tr.r-' i5P>; t<77i;* Q ' ^-OX^ P. >,v«v—. N 3NIOIQ3W JO A»V»9n TV NATIONAL LIBRARY OF MEDICINE v...fci >j<$* ? 4^ -i ^ NATIONAL LIBRARY OF MEDICINE o Q. NATIONAL LIBRARY OF MEDI< ^xA x £ _/ i J7^ 3NIDI03W JO Aava9H 1VNC 4# 7 j <% NATIONAL LIBRARY OF MEDI 1I1VN 3NOia3W jo Aavagi, IVNOUVN 3NiDia3w jo Aavagn ivnouvn \ ICINE NATIONAL LIBRARY OF MEDICINE XN oiiyn nidiosw jo Aavagn ivnouvn \ :./W « %/\ NATIONAL LIBRARY OF MEDICINE -J T tr--~ v ~7^<, a ;>&r > 3NI3IQ3W JO Aava9IT IVNOUVN 3NiDia3w jo Aavagn ivn< .' 1 vf JICINE NATIONAL LIBRARY OF MEDICINE -71 -^ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MED v >?^7 » T^J ■R/ sQ\0 NOI03W JO AMVaflll IVNOUVN \ LM r kV v 5 X -&;§-' c|Nt ATIONAL LIBRARY OF MEDICINE '■A.Au . 3NIDI03W JO AaV89l1 IVNOUVN - is °: /% NATIONAL LIBRARY OF MEDICINE /' ■—ss-K ; '/it- \ >ro,l S1 A/Tr* 3NIDIQ3W jo Aavaan wn NATIONAL LIBRARY OF MED #' 'iSlv"; PRINCIPLES OF PATHOLOGY, >, - r AND PRACTICE OF PHYSIC. BT JOHN MACKINTOSH, M. D., LECTURER ON THE PRACTICE OF PHYSIC IN EDINBURGH, &C, &C, He. CO ';j&y.? **ui VOL. I. FIRST AMERICAN FROM THE THIRD LONDON EDITION. WASHINGTON: STEREOTYPED BY DUFF GREEN, FOR THE REGISTER AND LIBRARY OF MEDICAL AND CHIRUBGICAL SCIENCE. 1834. % U Wd PREFACE TO THIRD EDITION. The original object of this work was to provide those gentlemen who did the author the honor of attending his lectures, with a Text-Book, in the hope that it might be found useful to them in prosecuting their studies. For some months the sale was confined to his own pupils, and the work was entitled " Heads of Lectures." But the author was subsequently advised to launch the result of his labors before the professional public, with the title changed to that of " Principles of Pathology, and Practice of Physic "—' trusting, that with all its faults and imperfections, it would be indulgently received as a humble at- tempt to-establish a pathological system of medicine.'—Preface to first edition. The success of this work has far surpassed the author's sanguine expecta- tions ; two large editions having been disposed of in the course of four years. In offering a third edition to the profession, the author, very sensible of the re- spect due to its members, and of the flattering manner in which the work has been received, has taken every precaution to render it worthy of a continuance of their patronage. It is considerably enlarged,—the import of every pa- ragraph has been well considered, and many errors have been corrected. He was so well aware of the imperfections of the work, that he courted the re- marks of several friends, well qualified, by their learning, experience, and ability, to undertake such a task; he has availed himself of their written and oral criticisms, and endeavored to turn them to the best advantage. The author stands particularly indebted, in this respect, to Mr. Marshall, Deputy-Inspector General of Hospitals, famed for a correct acquaintance with the literary, as well as the practical part of medicine; for being an accurate observer, an in- ductive reasoner, and an admirable critic. If all his suggestions have not been adopted, more particularly as to pursuing an abstract style of writing in this edition, it has not arisen from any want of respect for his opinions, but merely because the author entertains rather different sentiments. The author wishes his work to be regarded merely as a book of facts, care- fully collected and examined:—he lays no claim to be considered more wise, learned, or original than any other professional man in the enjoyment of similar advantages, and who has pursued the same patient method of investigating dis- w PREFACE. ease. He has been very sparing in the introduction of hypothetical discussions, and when he has attempted to explain or establish any point by reasoning, he trusts it will be found for the most part to be strictly inductive. Whatever feeling may exist as to the manner in which he has treated the opinions of others, the author knows that his efforts are perfectly sincere and well intended. In teaching the principles of a profession which is of such un- bounded importance to mankind, he has ever felt himself called upon, by the combined influence of reason and humanity, to deal with professional state- ments, theories, and practices, with that unreserved authority with which a judge is invested, when addressing a jury in a case of life and death. If it be necessary to exercise such a power, where one life only is at stake, how much more incumbent is it on a medical writer, on whose labors the lives of thou- sands may depend ! The author is not aware that he has ever been guilty of indulging in any expression which he would be afraid to repeat in the presence of the persons whose opinions he has impugned; neither can he be justly ac- cused of bestowing praise from personal friendship, or of condemning from personal animosity. He will never be ashamed or backward to confess an error, and he will feel no relunctance to give up every opinion he has formed. however long and arduous his investigations may have been, for others which may hereafter be proved to be more correct. He most heartily deplores the morbid sensibility and irritability which exist among medical men; no parallel to which can be found in the history of any other liberal profession. Few me- dical men can bear to know that the soundness of their opinions has been ques- tioned ; they regard any such attempt as a signal of deadly personal hatred, and view it in the same light as if their moral character were maliciously assailed. On what circumstances does this frame of mind depend? The author has al- ways attributed it to an overweening conceit, selfishness, and pusillanimity. Some may object to these statements, however true, being put in print, because they may think them calculated to injure the dignity of the profession, and to produce bad feeling. But the author cannot believe in the existence of real dignity and good feeling, where there is such a deplorable want of high-mind- edness and moral courage:—besides which, these pages are written exclusively for the professional, and not for the public eye. It cannot be denied, that prac- titioners in medicine stand too low in the scale of public estimation, and "some- thing is rotten in the state of Denmark." But the author trusts soon to see an important change in the profession, the first step towards which must be a greater care and discrimination on the part of those who teach the different branches of medicine, in exciting greater industry and zeal among their pupils PREFACE. v and inducing them, by precept and example, to regard the profession of me- dicine more as a science, and the blessed means of doing good, than as a cor- rupt trade. Much substantial good might be effected by examinators for me- dical diplomas, were they to feel that their own personal honor depended more on the high qualifications and superior mental endowments of the gentlemen admitted into the profession, than on the amount of fees received! No point connected with the medical profession stands so much in need of reform as the last alluded to; and the author is compelled by a sense of duty, to call the at- tention of Patrons of Universities, and Fellows of all Royal Colleges, and other medical bodies in Great Britain, to the example of disinterestedness on the part of the Royal College of Surgeons of Edinburgh. This is evinced by the liberality of their late regulations, the good effects of which have been already experienced ; for, although the qualifications required have been increas- ed, the number of students has not been diminished, and will in all probability be considerably augmented. Edinburgh, 31 Albany Street, "» 1st Nov ember, 1832. \ * Note.—The reader will be furnished with a full and complete table of con- tents at the endwf the volume. '» PART I. GENERAL HISTORY OF INFLAMMATION AND FEVERS—WITH THE PATHOLOGY AND TREATMENT OF INDIVIDUAL FEVERS. \ / f CHAP. L OF INFLAMMATION. HISTORY OF THE GENERAL DOCTRINES, CAUSES, PHENOMENA, AND EFFECTS CUT INFLAMMATION. In the history of Medical Science, we find that no subject has attracted more attention than that of inflammation; the minds of the most distinguished pathologists having been turned to the investigation with an ardour which has never been surpassed. This is to be attributed to the importance of the sub- ject,—to the frequent occurrence of inflammation,—and to the vast range of diseases which owe their origin to this morbid action. According to many au- thors, inflammation and fever are thought to be mere modifications of the same pathological state of the system, while others speak of them even as synony- mous terms; hence, a successful elucidation of the former, was expected to prove a triumph over the difficulties of the latter. This interesting subject still continues to command the attention of every new inquirer,—doubtless owing to the mystery in which he finds it involved; for it must be confessed, that, notwithstanding the indefatigable labors of John Hunter and others, it does not appear that any very strong light has been thrown on the true pathology of inflammation, while it could easily be proved that much obscurity has been produced by confounding cause and effect, and by regarding some of the phenomena as principal parts of the essence of in- flammation. A great mistake has also been committed, by medical inquirers following out an erroneous method of investigating diseases, forming false ana- logies, and attributing to inflammation of internal organs, all the phenomena and characters of those situated on the surface of the body,—thus drawing too largely from surgical pathology. But it may be stated, that the most deadly inflammation of important organs, may proceed to a fatal termination, some with few, others with none more of the symptoms hitherto universally attribut- ed to inflammation. In giving a history of the doctrines which have prevailed, it would be a waste of time to quote the opinions maintained previous to the time of Boer- haave, because they were inconsistent with the knowledge we now possess of the circulation of the blood. Boerhaave insisted that inflammation is produced by an obstruction to the free circulation in the capillary vessels. Obstruction, he conceived, might be occasioned by too profuse a flow of any of the excre- tions, and by heat, or the application of any other cause which dissipated the thinner parts of the blood, thereby producing viscidity. When this thickened 2 10 INFLAMMATION. state of the blood did not exist before the production of inflammation, he ima- gined that the larger globules of the blood found their way by some accident into the capillaries, and produced obstruction. But when the perspiration, the flow of urine, or any of the other excretions were suppressed, then he suppos- ed the capillaries became so much distended, as to allow the thicker parts of the blood to enter, creating a more permanent obstruction ; and this state he termed an error loci. Thus, it will be seen, that Boerhaave had two causes oi inflammation,—viscidity of the blood, and an error loci, either of which he supposed capable of producing an obstruction in the circulation of a part, giv-: ing rise to increased action in the heart and other vessels, and exciting a flow, of blood in the direction where the obstruction existed. He, however, felt the necessity of having the assistance of some other cause, to enable him to ac- count more satisfactorily for the morbid terminations which occasionally hap- pen, and therefore brought into play the humoral pathology, by stating that there is sometimes an acrimonious state of the fluids, which tends to produce gan- grene. That part of his doctrine relating to viscidity, cannot support the phe- nomena, the viscidity being more likely to produce a general than a local effect, since the whole mass of blood must be supposed to be in the same state. But there is rather more probability in the error loci; for it is a fact, that in inflam- ed parts, red blood enters into vessels, which, in a state of health, circulate only a colourless fluid. But here there is some difficulty in determining whether or not the error loci is an effect, and not a cause of inflammation; and the diffi- culty is increased, when we reflect, that vessels frequently circulate red parti- cles, which usually contain a colorless fluid, and yet inflammation has neither preceded, attended, nor followed this remarkable change. On looking at the history of medical opinions on this subject, we shall observe, that, as the hu- moral pathology declined, Boerhaave's doctrine began also to lose ground, al- though the phenomena of inflammation were, in many cases, ingeniously explained by their assistance ; and it must be confessed that we have abandon- ed this doctrine, which is far more ancient than the time of Boerhaave, without sufficient consideration. Stahl and Hoffman attempted to improve Boerhaave's doctrines, by bringing into account the influence of the nervous system on the capillary vessels in in- flammation. On this occasion, little need be said respecting the views of these celebrated men, as it will be necessary to resume the subject in a subsequent part of the work. But it may be noticed, that it has always appeared to me a strong proof of the close connection between the state termed fever, and that of inflammation, that almost every individual laborer in this field of investigation has adduced the same, or nearly the same doctrines, to explain both. Hence the pretty general belief as to their identity. But it will soon be my duty to offer some reasons for dissenting from this too sweeping pathology. This slight notice of the opinions of Boerhaave, Stahl, and Hoffman, is suf- ficient to enable me to connect their views with those of modern date. The doctrines which Cullen taught were founded upon those of the last three physi- INFLAMMATION. 11 cians. He admitted the obstruction so much insisted on by Boerhaave, but denied that it was produced either by error loci, or lentor of the blood. He also took advantage of the hint which had been given by Stahl and Hoffman, respecting the influence of the nerves, and insisted that the obstruction was produced by " spasm of the extreme arteries supporting an increased action in the course of them." Cullen maintained this doctrine even in those cases in which external inflammations are occasioned by the application of boiling water, blisters, and other stimuli. The only observation it appears necessary to maize, after giving this slight sketch, is, that all these illustrious physicians have been guilty of confounding cause and effect. When we place a ligature upon a large vessel, we do not find that general inflammation of the limb follows as a matter of course, which nevertheless ought to happen if mere obstruction were the cause of inflammation. This obvious objection has not escaped authors; and it has also been remark- ed by the acute mind of Allan Burns, that the effusion from the capillaries into the cellular membrane, which takes place so frequently as the effect of inflam- mation, cannot- be explained if the doctrine of spasm be admitted. Besides, Cullen has been guilty of a logical blunder, in attributing the proximate cause of inflammation to spasm of the capillaries, when, according to his own shewing, the spasm is occasioned by an accumulation of blood in these vessels. According to John Hunter, inflammation is to be considered only as a dis- tracted state of parts, which requires another mode of action to restore them to a state of health; or, in other words, that inflammation is a healthy action, which follows an injury of some tissue or organ. In another place, he states that active inflammation is to be considered as an increased action of the ves- sels, which consists simply, in the first instance, in a distension beyond their na- tural size. This he supposes to depend on the elasticity of the vessel, and a weakness of its muscular power. The whole of this he considers as a law of nature; and he seems to have believed, that the blood vessels possess within themselves an innate active power of dilatation. This leads me to state, that two modern opinions on this subject divide the profession. According to the one, inflammation depends upon increased action of the capillaries of the part. According to the other, it is produced by de- bility or weakened action of the same vessels, and increased action of the trunks. On each side of this intricate and difficult question, are ranged the names of very eminent men; but, as will be shown in the sequel, they might have spared themselves a great deal, of trouble. Both parties found their opin- ions upon miscroscopical experiments, performed on the web of the frog's foot. Each observed the same phenomena, but they have drawn different con- clusions. Dr. Thomson, for instance, applied salt to a frog's foot; the first effect was to increase the velocity of the circulation, and to make the vessels larger to the naked eye, and of a brighter red color. After the stimulant had been continued some time longer, the red globules became " less distinct than before the application of the salt, and obviously less distinct from the rapidity of their motion." 12 INFLAMMATION. Dr. Wilson Philip performed experiments prior to Dr. Thomson, on the frog's foot; and having first proved that he could create increased action in the capillaries without exciting inflammation, happened to meet with one unfortu- nate frog, who had already by some means contracted inflammation; and he found, upon applying the microscope, the vessels greatly dilated, and the motion of the blood extremely languid;—and he says, " It was at once evident, on ob- serving the part through the microscope, that where the inflammation was great- est the vessels were most distended, and the motion of the blood was slowest." Dr. Wilson Philip wetted the web of the frog's foot with distilled spirits, but although he continued to keep it moist for ten minutes, or a quarter of an hour, he could not perceive the slightest symptoms of inflammation. " The vessels, instead of appearing redder and more turgid, were evidently paler and smaller than before the application of the spirits." No wonder. Distilled spirits is the most deceitful application he could have used for such an experiment. In the first place, it might stimulate the circulation in the part, but its quick evapora- tion would necessarily produce coldness, which, no doubt, caused contraction of the vessels, and rendered them paler and smaller. Dr. Hastings has subsequently repeated these experiments corroborating those of the last named author. In all the experiments, whether performed by Thomson, Wilson Philip, or Hastings, the velocity of the blood is represented to have been increased in the capillaries, in the state of simple excitement; but it constantly happened, when inflammation commenced, that no globules could be seen in the blood of the affected vessels. Now, whether are we to join Dr. Thomson, in concluding that they cannot be seen because of the " rapidity of their motion," or Dr. Hastings and others, who state that the blood in an inflam- ed part becomes itself morbidly changed, so that no globules can be detected ? The point in dispute is thus brought within a very small space, and the reader is left to form his own opinions. The result of my investigations on the sub- ject shall now be detailed; and it may be stated, that this has not been done hurriedly, but after considerable experience, and a very careful review of all that has been written on inflammation. It appears to me, that the view taken by Mr. Syme, in an Essay on Inflam- mation,* is the most philosophical. He thinks that too much attention has been directed to the obvious signs of inflammation, viz. redness, heat, swelling, and pain, and too little bestowed on the altered functions of the part. Mr. Syme justly thinks, that "if this remarkable character of inflammation had been kept in mind, pathologists would hardly have spent so much labour in disputing about contraction and dilatation of the vessels, since it is obvious, that mere differ- ence of capacity, though it might, to a certain extent, account for the redness and swelling, could never enable us to explain the alteration of function, any more than a knowledge of the size of capillary vessels could instruct us as to the mode in which their secretions, &c. are performed during health." A A he maintains, that "redness and swelling ought to be secondary consideratio * Published in Edinburgh Medical and Surgical Journal, vol. 30, p. 316. INFLAMMATION. 13 in the investigation of the inflammatory state, in comparison with the grand dis- tinguishing character of altered function." Three points seem to have been much overlooked by writers on inflamma- tion. 1st. The influence of the nervous system ; 2dly. The changes in the qualities of the blood itself; and, 3dly. The disordered functions of the capil- laries. I have performed experiments upon horses, which prove most satisfac- torily the influence which the nerves have, even in chronic inflammation. It is well known that these animals are very liable to inflammation in the foot, from different causes ; and I have seen horses who had been lame for months, cured by dividing the nerves immediately above the fetlock joint, the effect being sometimes instantaneous, and occasionally permanent. With regard to the second point', there can be no doubt that the blood in the part affected becomes diseased; the red particles cease to be observed, and the blood assumes a floc- culent appearance, becoming darker and darker, and the vessels become in some degree obstructed. It is not improbable that this change on the blood may be found to depend partly, if not principally, upon the cessation of nutri- tion and exhalation, and at the same time a stop being put to the conversion of arterial into venous blood. It has been long known, that increased action of the vessels does not consti- tute inflammation, as we see every day illustrated in the act of blushing, and by the employment of friction to any part on the surface of the body. " In these instances, the vascularity soon subsides on the removal of the causes. But we can produce actual inflammation by a continuance of the friction; the blood will accumulate, and we shall have all the phenomena, and the usual effects of slight superficial inflammations. It may be produced also by obstructing the flow of blood in the limb for a sufficient length of time, by applying a ligature, and this is what actually happens in a case of strangulated hernia. Diminished action of the vessels may be produced and maintained for some considerable time, and the effect will perhaps be, not inflammation of the part itself, but of another part of the body at a distance. Again, if inflammation has been excited in an organ, an increased flow of blood takes place towards it, and all other parts must consequently suffer from a diminished supply of ar- terial blood; this increases the embarrassment in all organs, hence the general constitutional disturbance. In the practice of physic, this last circumstance is too frequently overlooked. Physicians are apt to expect a cessation of the con- stitutional symptoms the moment the original disease is subdued; this not being the case, they often push their remedies far beyond the proper point, and make matters worse. This is perhaps more peculiarly a British error, and we are justly condemned for it by our continental brethren. Other physicians, again, do very great mischief by stimulating and throwing in bark and other tonics too soon after convalescence has commenced,—they will be found in the morning ordering a large bleeding, and in the evening a stimulant. Cases no doubt oc- cur in which a more immediate change may be necessary; all that is wished to be impressed upon the reader in this part of the work, is, that such practice is 14 INFLAMMATION. too often had recourse to, more from an unfounded dread of the occurrence ot "typhoid symptoms," than from real necessity; and that sufficient confidence is not placed in the powers of the constitution to repair injuries which have been sustained. Physicians are too often found tampering with the human frame, as if it resembled a piece of machinery of their own construction. The essence of inflammation, pardy consists in more blood entering by the arteries than can escape by the veins, or than can be made use* of, as when the part is in a state of health, when its functions are actively performed; the con- sequence is an accumulation of blood, or congestion and effusion from partial obstruction ; and it is, I imagine, this degree of obstruction which produces the throbbing. The vessels of the inflamed part are greatly dilated, and the num. ber which contains red blood is greatly increased. It must be confessed, that in inflammation there is much undiscovered. Physiologists have to setUe several disputed points in the doctrines of the circu- lation ; and anatomists have to discover a great deal regarding the anatomy and physiology of the nervous system, before pathologists can be expected to ad- vance their part of the science of medicine in any remarkable degree. Considerable difference of opinion still exists among physiologists whether the circulation of the blood in the capillaries depends entirely upon the vis a tergo it receives from the heart, or whether these vessels have an impulsive power independently of the heart's action. Those who examine this subject without preconceived notions, and with no other view than to discover truth, cannot reject the vis a tergo which the whole column of blood is regularly re- ceiving from the heart. Neither can they reject the action which the vessels possess from their elasticity, in aiding other parts of the machinery, not to mention their power of contracting themselves even into milch smaller diame- ter than is natural to them, when circumstances require it for the preservation of life. With respect to the first point, it will be observed, that if one of the smallest arteries of the body, and at the greatest possible distance from the heart, be divided, the blood will be perceived to flow per saltum. As to the second, if the extreme vessels are quiescent, not possessing any po.wer of ac- ting within themselves, and depending entirely upon the action of the heart, how could irregular determinations of blood take place ? When any internal organ is inflamed, we are taught, by experience and observation, to apply blisters and other irritants to the surface of the body, as a part of the remedial process. These applications excite a temporary inflammation on the surface, sometimes to the complete relief of the internal disease. This translation, as it may be called, is not affected through the agency of the heart, by contractions of which the blood is propelled into the vessels generally ; it can, in all probability, have no power to send blood to one part, in preference to another. The results of Mr. Syme's experiments lead me to suspect that some nota- ble errors or oversights have been committed by Hunter and other experimenters upon the circulation. In the essay above alluded to, Mr. Syme, in endeavor- ing to refute the received notions respecting the circulation in the capillaries INFLAMMATION. 15 makes the following statements:—" In this case, also, we ought to discover, through the microscope, not only a change in the capacity of the capillaries, but an oscillatory movement of the globules passing through them. Instead of this, we see the capillaries apparently quite rigid and immoveable, while the globules shoot through them in such a free, unconstrained manner, as to con- vince every observer that they are not impelled by a vis a tergo." The results of one of Mr. Syme's experiments are worthy of being quoted in his own words.—" I have repeatedly seen the globules continue in motion through the capillaries of a frog forty minutes after the whole heart was excised. And this motion was not uniform,—either as to direction or velocity, in which case the gradual contraction of the vessels might have been supposed adequate to ac- count for it,—but sometimes this way, sometimes that,—at one time quick, at another slow,—and always continuing quickest as well as longest in the small- est vessels. While in health the motion of the blood is slowest in the capilla- ries." Having been an eye-witness to these experiments, I can add my testimony as to their correctness, and that every precaution was taken by Mr. Syme to guard against the possibility of any fallacy. Before concluding this subject, I beg to enter my protest against the em- ployment of the term " debility," as too generally applied to the capillary ves- sels of an inflamed part. If a man were able to walk three miles in an hour with an ordinary burden on his shoulders, it surely would not be correct to say he is in a state of debility because he could not go over as much ground if he had to carry an additional hundred weight. This is exactly the condition of the blood-vessels; they are well able to perform their natural functions, but when over-loaded, they are rendered incapable. Causes of Inflaanmation. In stating the causes of inflammation, it is my intention to avoid adverting to occult causes. In medical investigations, it is very injurious to the science to affect being over-wise, and it is surely more philosophical to confess our ignorance, than to attempt, by special pleading, to leap over difficulties, which, in the present state of our knowledge, are insurmountable. Instead of descant- ing at great length upon proximate, remote, exciting, and predisposing causes, it will be better to speak of common and specific causes of inflammation. The disease itself is improperly termed by Cullen and others, the " proximate cause;" this term will, for a considerable time to come, be fostered by sympto- matical physicians, who call the symptoms the disease, and the disease the proximate cause ; but there is no reason why it should be retained in this work, unless it were employed to denote the proximate cause of the symptoms. As to predisposing causes, it is more consistent to take them into consideration when treating of prevention of diseases ; but many writers have been guilty of great absurdities even with regard to their influence in the production of dis- ease. One author, with whose writings most medical men are well acquainted, 16 INFLAMMATION. in treating of the predisposing causes of hooping-cough, mentions, among others, «• a serous temperament,—a scrofulous constitution,—dentition,—a dis- position to contract catarrhal affections,—the retrocession of eruptive dis- eases." The common causes in the production of internal inflammation are, expo- sure to cold ; sudden vicissitudes of weather, particularly when the air is damp ; irregularity of bowels ; unwholesome diet; insufficient clothing; cold drinks, par- ticularly when the body is warm; depressing passions, &c. Almost all these causes tend to produce inflammation in the same manner, by inducing irregular distributions of the blood and venous congestion. The lost balance of the cir- culation is marked sufficiently well in the beginning of almost all acute diseases, by the accession of rigors, coldness, and paleness of the surface of the body. Some individuals are more liable to inflammatory attacks than others, and some to inflammation of a particular tissue or organ. Such persons may well be said to be liable to or susceptible of such disease, there can therefore be no objection to the term in this limited sense. Few persons escape inflammatory affections produced by specific causes. The contagion of small-pox is termed a specific cause, because nothing is capa- ble of producing the disease but its own contagion, in whatever way it is com- municated. Measles is produced by a specific cause. Scarlatina also, and perhaps hooping-cough. Erysipelas is not to be ranked with these specific dis- eases, because it is not produced by a specific cause, as is too generally ima- gined. If erysipelas were produced twenty times, by inserting matter taken from an erysipelatous surface, expressly for the sake of experiment, still it can- not be ranked as a specific disease, because it has also followed an injury pro- duced by a splinter of wood, a perfectly clean sewing needle, a rusty nail, &c. It has also occurred after a prick received in dissection. No one ever alleged that small-pox, measles, or scarlatina, were ever produced in this fortuitous manner. It may be also mentioned that there are other matters, the nature of which is unknown, but the effects of which are capable of producing inflamma- tory affections, viz., malaria, sometimes denominated marsh miasm, and human effluvia, together with another and still more mysterious agent, epidemic influ- ence. But it appears to me, the great agent in the production of inflammatory affections is the sudden application of cold to the surface of the body, particu- larly when the stomach and bowels are out of order, and the mind depressed. Cold wet feet, for example, will sometimes produce determination to the head, and phrenitis will be the consequence; or to the lungs, producing pneumonic in- flammation, &c. Dr. Thomson states that this cannot be explained upon any principle. The doctrine of determination of blood explains it so far, and in my humble opinion quite far enough for all practical purposes. It is not, however actual, but relative cold, which is so prejudicial to the human body; it is expo- sure to cold when the body has been previously much heated. An individual, alter sudden exposure to a cold damp atmosphere, may be at- tacked by inflammation of the lining membrane of the air passages. It becomes INFLAMMATION. 17 an interesting and important question to determine upon what part of the human frame the cold air acts. Dr. Thomson says, at page 57 of his work on inflam- mation: " In some instances cold, or a diminution of temperature, seems to act more directly upon the parts with which it comes in contact. We have proof of this in the inflammation of the mucous membrane of the nose, fauces, tra- chea, and bronchias, from the inhalation of cold air." This is a most unhappy illustration. It is apparently a matter of little consequence how cold the air is which passes into the lungs, provided the body be sufficiently protected by warm clothing. In cold regions, if Dr. Thomson's hypothesis were true, an indivi- dual ought never to be free from bronchitis. We are assured, however, that the sailors in the voyages of discovery, which were made by Captain Parry, to the North Pole, enjoyed remarkably good health. I There is another curious point which must be noticed. Extreme cold pro- duces exactly the same sensations and the same effects upon the living animal fibre as intense heat. Take a piece of frozen mercury in the hand, and it will cause a sensation similar to that produced by hot iron,—inflammation and vesi- cation follow; and if applied long enough, destruction of the part will take place. The hot iron destroys vitality by the addition of too much caloric; the frozen metal by abstracting it too suddenly. Division of inflammation into varieties. Inflammation has been variously divided and subdivided. The terms acute, sub-acute, and chronic, will be employed in the course of this work, as being sufficiently precise, and well understood. It is wished to avoid the use of the term " passive," because it is employed too vaguely, sometimes to express the existence of sub-acute inflammation, at others that of the chronic kind. John Hunter also instituted the terms healthy and unhealthy. Is inflammation a dis- ease^ If it be, it is certainly not proper to call it healthy. Other varieties of inflammation have been mentioned, as scrofulous, gouty, rheumatic, erythematic, erysipelatous, &c; but it is my belief, that as pathology improves, these terms will be less frequently employed. Another obvious division of inflammation depends upon the tissue or organ affected. Phenomena of Inflammation* External inflammation is characterized by redness, swelling, heat, and pain. All these taken together, leave no doubt as to the existence of inflammation. In this respect, surgeons have the advantage of physicians. They can see and feel the part affected, in addition to the power of judging from the constitutional symptoms, and the account the patient gives of his own sensations. Whereas in physic we have greater difficulties to encounter in forming a diagnosis. We observe local and constitutional symptoms also; but it does not always follow, because there are dyspnoea and fever, that the lungs are inflamed; the disease ; may be inflammation of the pericardium. There maybe violent vomiting, ten- derness in the epigastrium, thirst, with more or less fever, while the disease is 3 18 INFLAMMATION. in the head. There may be severe local and constitutional disturbance, without the existence of the slightest degree of inflammation, merely from a neuralgic affection of some tissue or organ, or from impeded function of some viscus. During life we cannot see the state of internal organs, to ascertain whether they are red and swollen; and a sensation of heat, pain, and fever, may exist without the least inflammatory action. It will be proved, in a subsequent part of this work, that the pulse cannot be depended on. With respect to buffy blood,* it may exist without actual inflammation; and, in inflammatory complaints, thfe blood does not always yield it. The shape of the dish modifies this appearance, so does the manner in which the blood flow's from the vein. Mental agitation and fatigue produce the buffy coat. Sometimes it does not appear on the blood till the patient has been largely and repeatedly bled. I am inclined to place considerable dependence, however, on the buffy coat, taken in connection with other circumstances, particularly when the surface is also concave, or " cupped," as it has been termed, and when the quantity of serum is proportionably large. It has often occurred to me to see dissections where great destruction of vital organs had taken place from inflammation, and yet there had been little or no pain complained of during life. Nay, I have seen instances of inflammation of the pleura to such a degree as to occasion death, where the symptoms were too slight to direct the medical attendants to the true seat of the disease. I feel convinced that no pathological physician will join Dr. Gregory, a modern writer on the practice of physic, in the following curious dogmas: " Delirium marks inflammation of the brain; impatience of light, ophthalmia ; hoarseness, inflammation of the larynx; and dijspnoza, that of the lungs." The practice of physic would indeed be simple and certain, were these things true. But this is not the proper place to enter upon a refutation of such arbitrary assumptions. The uncertainty of the pulse has been already mentioned. Inflammation may be going on towards a fatal termination, in an important organ, without any febrile movement. This was noticed long ago by Morgagni, Valsalva, and others, and it led them too hastily to conclude, that mortification of internal organs occasionally took place without the previous existence of inflammatory action. What occasions the redness, swelling, heat, and pain, in external inflamma- tions . The redness is occasioned, no doubt, by the enlarged size of the vessels, and the increased quantity of blood in the part affected. Vessels which former- ly transmitted a lymphy fluid, now circulate red blood. The swelling has been erroneously ascribed to the expanded state of the blood from increased heat; but it has been proved, that the blood contained in the vessels of an inflamed part, is not one degree hotter than that which flows from * Blood is said to be » buffy," when the surface, instead of being- of . refW;cK , presents a yellowish crust of greater or less thickness. There are v-irio„c • • 0r' the cause of this appearance. Some attribute it to the slower coajm'ktion of ^"l?* *? others to an increased quantity of fibrine; or merely to the hurried state of tfc . ood; tion. Of one fact I am quite certain, from repeated observations that blood Circula- to be buffed while it is yet flowing from a vein, and before the stream has reacted^ See" INFLAMMATION. 19 the heart; besides, a few degrees of caloric could have no effect in producing the swelling. It seems to be owing to the increased quantity of blood in the part, and the effusion of a lymphy fluid into the surrounding cellular substance,—the action of the absorbents being at the same time, in all probability, interrupted. Heat.—Boerhaave and others imagined, that this symptom depended on the friction of the red globules against the sides of the vessels; and that, in inflamed parts, the friction is greatly increased by the obstruction which exists. This, like all Boerhaave's doctrines, is too mechanical. It is difficult to determine on what cause the increased heat depends, and, fortunately for humanity, it is not of much consequence; but it is probably in part owing to a peculiar action in the nerves of the texture, partly to the increased volume of blood, by which the quantity of caloric is augmented, although it be not indicated by the ther- mometer, but perhaps principally to diminution or suppression of the natural functions of the part. Pain.—Pain in an inflamed part is not in general continued, it is most acute during the systole of the left ventricle of the heart. It would seem, that the state of the blood influences the sensibility of the body in disease; if the mucous membrane of the bronchial tubes be extensively inflamed, the circulating blood will be orincipally venous, in which case little complaint is made of pain. Terminations of Inflammation. Inflammation, (says John Hunter,) cceteris paribus, always proceeds more favorably in strong than in weak constitutions ; for, when there is much strength, there is little irritability. In weak constitutions, the operations of inflammation are backward, notwithstanding the part in which it is seated may possess, com- paratively speaking, considerable vascular activity. This observation, like many others by the same author, however true with regard to surgical pathology, cannot be made to apply so universally in the practice of physic. We more frequently see acute diseases of internal organs, gallop through a rapid course to a fatal termination, in robust, than in delicate individuals. Persons with delicate constitutions, frequently sink, while labor- ing under internal inflammations, not because the diseased action has any pecu- liar tendency to terminate badly, but because the patients are too weak 10 jear the necessary remedies. In another place Mr. Hunter remarks:—"It has been supposed that different species or varieties of inflammation arise from the difference of the nature of the part inflamed; but this is certainly not the case; for if it were, we should soon be made acquainted with all the different inflammations in the same person at the same time, and even in the same wound; for instance, in an amputation of a leg, &c. It is the adhesive in them all, if the parts are brought together; it is the suppurative, if the parts are exposed." This observation, no doubt, in some measure holds true in surgery; but it cannot be admitted in physic, as it is well known that inflammation terminates differently in different organs and tissues. The terminations of external inflammation are commonly styled " resolution; suppuration; ulceration; and grangrene." The first is, of course the most de- 20 INFLAMMATION. sirable; and fortunately for mankind, it is the most frequent. It is evinced by a diminution of pain and swelling—the fever gradually abates, pus does not form, nor does the structure of the part suffer permanent injury. The second termination is that termed suppuration. After the inflammation has existed for a certain time, which varies much in different persons, pus be- gins to be secreted in the cellular substance, and either collects in one cavity, as in common phlegmon, or is diffused very generally over a whole limb, as in phlegmonous erysipelas. Ulceration is the third termination mentioned. The most dreaded termination, and fortunately the rarest, is the entire death of the parts affected, which are then said to be mortified or sphacelated. This condition is recognized by the sudden cessation of pain; the part, from being of a bright red color, assumes a dusky hue ; it crepitates from the extravasation of air in the cellular substance, vesications arise, a very peculiar odour is per- ceived, the pulse sinks, and every appearance announces speedy dissolution. Death, however, does not always follow mortification of external parts, the dead are sometimes separated from the living parts ; and are ultimately thrown off, the patient surviving the injury. It is now necessary to mention shortly the effects of inflammation in the fol- lowing textures: 1. Skin. 2. Mucous membranes. 3. Cellular membranes. 4. Fibrous membranes. 5. Serous membranes. 6. Of inflammation of the solid viscera and glandular system. 1. Inflammation of the skin. The effects of inflammation on this part of the body are very various: such as the formation of rashes, as in scarlatina, roseola, &c; pustules, as in small-pox, porrigo, &c; vesicles, as in chicken-pox, herpes, &c; papulae, as in measles, lichen, &c; scales, as in lepra; ulceration with loss of substance; and also gangrene. 2. The effects of inflammation on mucous membranes, are, swelling and dryness ; effusion of mucus or of matter of a puriform character—a mixture of the two, appropriately termed muco-purulent; of a serous fluid, and coagula- ble lymph. These different products of inflammation are sometimes colorless at others yellow, and sometimes red like currant jelly. The mucous membranes are likewise liable to softening, thickening, passive haemorrhage, ulceration, contraction, sloughing, and tubercular formation. Some of these effects are common to the mucous lining of the air passages, alimentary canal, and urinary passages, as for instance, copious exudation of mucus, softening, thickening, and passive haemorrhage. Others are not so; tubercular formation, for instance, is more frequently met with in the alimentary canal. Ulceration is sometimes found in the air tubes, but more frequently in the stomach and bowels, particularly the latter, rarely in the blad- der. Some parts of the mucous membrane of the same canal are more liable to inflammation and ulceration than others; for instance, the terminations of the ilium and colon. Inflammation is more liable to terminate in the exudation INFLAMMATION. 21 of coagulable lymph in some parts than others; it is seen most frequently in the wind-pipe and rectum, although other parts are not altogether exempt. Considerable vascularity is not alone a certain proof of inflammation having existed in the mucous membranes before death, because it may be found only in depending parts of the canal; and congestions of this membrane may be occasioned by diseases of the heart and lungs, and by any other cause which obstructs the circulation of the blood. 3. Inflammation of the cellular membrane terminates in effusion of lymph, of serum, of pus, in induration, and gangrene. Inflammation in this tissue is generally termed phlegmonous, and although the cellular membrane is so ex- tensive and loose in its texture, the disease tends to circumscribe itself, and the effused matter to make its way to the surface of the body. Occasionally, though rarely, the inflammation has a tendency, from the first, to spread very extensive- ly, from peculiar circumstances which have never been satisfactorily explained. To express this condition, several new-fashioned names have been invented ; the one most applicable, is " diffuse cellular inflammation." Sometimes the death of a small portion of the cellular membrane takes place, then the affec- tion is called carbuncle. 4. Inflammation of fibrous membranes. This is the tissue which is gene- rally supposed to be affected in gout and rheumatism; the chief peculiarities are said to be, that it never terminates in suppuration, ulceration, or gangrene, and the functions of the brain are rarely disturbed during the course of the disease. It is said to terminate sometimes by effusions of a gelatinous matter, or depositions of calcareous matter. This subject ought to be held as being open to future investigation; it is by no means proved that the inflammation which attends gout or rheumatism is situated in such a texture; it looks to me more as if it were seated in the extremities of nerves. All the phenomena and the terminations of these diseases, tend to confirm this suspicion, more particu- larly when we reflect upon the sudden metastases. At all events, it is rather strano-e that so many authors should make the assertion, that inflammation of fibrous membranes never terminates in suppuration and ulceration. What do they call the periosteum ? But this question is too intricate and extensive, and too surgical, to be investigated in this work. 5. Serous membranes in a state of health show few red vessels, and their surfaces exhale a thin serous fluid, which is just sufficient to bedew them. When inflamed red vessels are seen during life, an effusion takes place either of serum or lymph, or of both. Sometimes the effusion is limpid, or turbid like whey: af other times it looks like pus, and occasionally it is greenish, or resembles lees of wine ; often large masses of coagulable lymph are discovered glueing the parts together. Adhesions between the different viscera of the thorax and of the abdomen seem to be affected by means of intervening portions of lymph, which subsequently become organised. The quantity of the effused matter is some- times small, amounting only to a few ounces, at others there are several pounds. It has occurred to me to see ten, twelve, and even twenty pounds in one side of the chest. 22 INFLAMMATION. A bloody effusion is sometimes found, more particularly in the abdomen. Echymosis not unfrequently takes place when the inflammatory action is very violent. There can be no doubt that tubercles form occasionally under a sub- acute and chronic inflammation of this class of membranes, more particularly in the peritoneum, pleura pulmonulis,* and arachnoid coat. Emphysema also occurs in the cellular tissue immediately under the peritoneum. It has been proved by experiments, that the peritoneum, however vascular under acute in- flammation, during life, loses its red appearance even during the act of death. In chronic inflammation, it is sometimes found very red in color, and thickened in texture. A great deal has been written during the last few years upon inflammation of the arachnoid, by which science has certainly been benefited; but it appears to me that considerable misconception has taken place upon this subject. Al- though red vessels are rarely to be seen in the arachnoid, so rarely that in my whole life two instances only have presented themselves, yet no one who has paid attention to the situation of effusions of matter in the skull, will deny the existence of inflammation in that tissue. But I apprehend it is comparatively rare. In my examinations (and they have not been few in number) to ascer- tain this point, it has not occurred to me above six times to find effusion exter- nal to the arachnoid membrane. If on examining the abdomen, we were to find no vascularity, and no adhesions, or effusions of serum or lymph, within the cavity of the peritoneum, but were to discover the effusion on the other side of the membrane, extravasated for instance in the cellular tissue which connects this serous membrane to adjacent parts, should we be entitled to say, from any thing we yet know, that this was a consequence of peritonitis? In the cases to which I refer, the effusion is between the arachnoid and the pia mater, which are united by fine cellular substance—the ivrong side, if it proceeded from diseased action in the former membrane, unless it has two serous surfaces, which has not been maintained by any anatomist. There is not, perhaps, in the whole body, a more vascular membrane than the pia mater, and I cannot avoid concluding that the effusions, not only on the surface of the brain, but also in the ventricles, depend more on diseased action in this membrane than the other. Ulceration is also to be considered as an occasional, although rare, effect of inflammation in serous membranes. It has presented itself to me three or four times only. There are two splendid specimens of this change in my one of ulceration of the pleura pulmonalis and costalis, the other, of the branes on the surface of one of the hemispheres of the brain. Gangrene is one of the rarest results of inflammation of serous membranes, and it is to be doubted whether it ever occurs when the diseased action is con- fined to this tissue. G. Inflammation of the solid viscera and glandular system. The first c' - cumstance generally perceived is the presence of an unusual quantity of blood * Tubercles are rarely seen in the pleura costalis. museum mem- INFLAMMATION. 23 in the affected organ. The first change in the structure of the viscus is soften- ing. Hardening is owing, in general, to chronic inflammation. With respect to inflammation of the solid viscera, it is to be remarked, that if the liver be excepted, the termination in the formation of abscess is rare. In the lungs, it is admitted by the best authorities to be rare ; I have seen it once only in the substance of the lungs. In the brain, it is probable that the peculiar change which has been denominated ramollissement, and the remains of old apopietic effusions, together with tubercular degenerations, have been often mistaken for abscesses. Tubercles are found in the substance of various organs, as in the liver, spleen, kidneys, lungs, and brain ; and there can be no doubt these are some- times the result of inflammatory action, but no one is warranted in asserting that they are invariably so produced. I have frequently found in the lungs, and in the substance of the brain, depositions of a tubercular character, which were certainly not caused by inflammation, and which, in all probability, had been in existence for years without exciting inflammation. This statement re- fers to persons who were either killed by accident, who died suddenly without any previous complaint, or who were carried off by other diseases. One of the finest preparations in my collection, is the heart of a woman, extensively and deeply tuberculated, who died in a moment without a previous complaint, and no other lesion could be discovered. Lastly, Inflammation affecting glands has an aptitude to terminate speedily in suppuration. Sometimes, however, they suppurate very slowly, and occa- sionally induration takes place. From this rapid sketch it may be thought that the subject has not attracted a sufficient share of my attention, and that several points have been altogether overlooked; such as the marked difference in the constitutional symptoms in inflammations affecting different tissues; and the general principles of treat- ment. The truth is, that the importance of these points is felt too deeply to al- low me to treat of them in a general description,—a description, moreover, which ought necessarily to be very short. These subjects will be fully entered into in subsequent parts of the work. CHAP. II. ON FEVER. HISTORY OF THE GENERAL DOCTRINES OF FEVER. The importance of the subjects which are to be discussed in this chapter is very great, from the frequent occurrence and often fatal termination of this class of disorders; and it will appear still more so, when we reflect on the vast ex- tent of our dominions abroad, where, it is believed, febrile diseases carry off four-fifths of those who die. If a person, after shivering, feels hot, restless, and thirsty, has a quick pulses and complains of languor, he is said to have a fever. Galen's notion of fever appears to have been, that an extreme degree of heat i.; formed in the heart, and from thence extends itself to the rest of the body. It is one of the oldest notions of medicine, that fevers are produced by a con- coction of something pernicious to the system, which is expelled by a critical effort of nature, as, for instance, by frequent and copious evacuations from the bowels, free perspiration, &c. This is the view of fever taken by the humoral pathologists. According to Boerhaave, fevers arise from the same pathological causes as inflammations,—thus ascribing them to viscidity of the blood, error loci, and an acrimonious states of the fluids. He conceived that the cold stage of fever was produced by the error loci, and all that followed was to be regarded as na- tural consequences. As has been mentioned in treating of inflammation, the first idea which appears to have been given to the world of the influence of the nervous system in the production of fever, originated with Stahl, and it was im- proved upon by his colleague, Hoffman. They supposed that fever consisted in a tonic spasm, produced on the extremities of the nerves by a deficiency of action in the brain. They also adopted the humoral pathology ; but insisted, that the sanative process was impeded by the spasm at the extremities of the nerves, thereby preventing the disease from being thrown off; and it appears to have been their opinion, that it was this resistance which produced the consti- tutional commotion which attends fevers. According to Cullen, the human body is composed of certain organs, whose actions are regulated according to laws peculiar to animal life, and superin- tended by a mobile and conservative energy which is situated in the brain act- ing wisely but necessarily for the general health, preventing mischief and re- pairing injuries, by a pre-established relation between the changes produced FEVER. 25 m and the motions required for the restoration of health, which actions are perform- ed by the nerves. According to him, the muscular filaments are merely the extremities of nerves. He supposed that fever is produced by a collapse or diminution of the energy of the brain, in consequence of the influence of con- tagion, miasm, cold and fear acting as sedatives. This dimished energy pro- duces an universal debility, and causes a spasm of the extreme vessels, and in this spasm the cold fit is supposed to consist. In fact, that fever is nothing more than diminished energy of the brain, and spasm of the capillaries. He conceived that the debility proves a stimulus to the circulating system, exciting increased action of the heart and arteries, which continues till it restores the energy of the brain; by removing the cause of the spasm of the extreme ves- sels, relaxation takes place, and health is restored by a copious sweat, or dis- charge of some of the other excretions. He divided the whole phenomena into three stages ; first, the stage of diminished energy of the brain, and con- sequent debility; secondly, that of spasm of the extreme vessels ; and, third- ly, all that follows till the commencement of the sweating stage. Perceiving his doctrines to be exceedingly weak, Cullen sought support from certain powers which are supposed to be inherent in the constitution, which enable it to resist and throw off disease, commonly called the vis medicatrix naluroz. But it is important that he should here speak for himself. " Upon the whole, our doc- trine of fever is explicitly this :—The remote causes, are certain sedative pow- ers applied to the nervous system, which, diminishing the energy of the brain, thereby produce a debility in the whole of the functions, and particularly in tho action of the extreme vessels. Such, however, is, at the same time, the nature of the animal economy, that this debility proves an indirect stimulus to the san- guiferous system; whence, by the intervention of the cold stage and spasm connected with it, the action of the heart and large arteries is increased, and continues so, till it has had the effect of restoring the energy of the brain, of extending this energy to the extreme vessels, of restoring their action, and thereby especially overcoming the spasm affecting them; upon the removal of which, the excretion of sweat, and other marks of the relaxation of excreto- ries, take place. This doctrine will, as I suppose, serve to explain, not only the nature of fever in general, but also the various cases of it which occur." It is remarkable that Cullen, who has insisted with so much pertinacity on spasm of the extreme vessels being a principal part of fever, should so com- pletely have forgotten himself, as to assert that atony, which is the very reverse of spasm, is also a principal circumstance in the pathology of fever. But he shall again speak for himself. " From the whole we have now said on the sub- ject, I think it is sufficiently probable, that the symptoms of anorexia, nausea, and vomiting, depend upon, and are a proof of, an atony subsisting in the ex- treme vessels on the surface of the body, and that this atony, therefore, now ascertained as a matter of fact, may be considered as a principal circumstance in the proximate cause of fever." " This atony we suppose to depend upon a diminution of the energy of the brain; and that this takes place in fevers we 4 26 FEVER. conclude, not only from the debility prevailing in so many functions of the body mentioned above, but particularly from symptoms which are peculiar to the brain itself." The meaning of " spasm of the extreme vessels," is morbid contraction ; mat of atony of the extreme vessels, is a defect of muscular contraction. Can a morbid contraction, and a morbid relaxation, co-exist in the same vessels at the same time? This contradiction appears'to me to be quite unparalleled,— it always surprised and disappointed me in the investigation of this subject; and it is astonishing that doctrines founded upon such statements should still be maintained. In the present improved state of pathology it is almost unne- cessary to enter into proof, for the purpose of shewing the error of attributing to spasm of the extreme vessels any part of the pathology of fever; but it may be mentiqned that, in some fevers, copious perspiration takes place through their whole course; and, even in the cold stage of intermittent, the surface is occasionally covered with moisture.* It appears to me, that Cullen and others have confounded debility of actual weakness, with oppression from obstructed action. The debility which depends upon obstructed action is very different from that produced by starvation, a pro- tracted disease, or great loss of blood, &c; it is mere oppression, occasioned by the loss of balance between the arterial and venous systems : and the proof consists in the well known fact, that upon the restoration of that balance, the overpowering sensations of weakness vanish, even when brought by blood-let- ting, which is a remedy directly debilitating If debility formed such a regular and indispensable part of fever, three circumstances ought to follow as neces- sary consequences. 1st. Weakness, produced in so many different ways, should invariably excite fever. 2d. Once a fever is lighted up in the system, it ought to be impossible to extinguish it, and particularly by any antiphlogistic means ; and 3dly. The longer such an action continues, the greater will be the debility, and therefore the febrile symptoms ought to become more and more intractable. The term " diminished energy of the brain," being a principal part of the foundation of Cullen's doctrines, cannot be allowed to pass without notice. It is one of those vague terms too often used by him to express a great deal more than we actually know, but which in reality explains nothing. It is one of those expressions which satisfies the youthful mind without affording instruc- tion or exciting inquiry. What is the natural energy of the brain ? how is it propagated ? It would also be very satisfactory if the living advocates of this system would inform us at what period of the disease the energy of the brain exists in its most perfect state, and greatest strength. Is it at the period of at- tack, or at its termination ? It appears to me to be most unphilosophical to treat of diminished energy of the brain as a principal part of any disease, be- cause it has no precise meaning. It can be of no use in explaining the nature and seat of fever, and of still less service in directing the plan of treatment * I have written more fully upon this subject, in a paper in the Medico-Chirureical R» view for January, 1828. e ^" tte" FEVER. 27 Cullen rejected the humoral pathology, and seems to have almost entirely disregarded the effects produced by outward causes, and inward irritations, in producing irregular determinations of blood, which, I shall hereafter attempt to shew, are the great agents in exciting diseases, and especially fevers. It may be noticed in this place, that Dr. Mason Good, in his late large and laborious work, advocates the truth of the chief parts of the Cullenian doctrines. According to Dr. Brown, man is made of organized materials, endowed with a principle of excitability or predisposition to excitement, by means of a great variety of stimuli, some of which are constantly acting upon the machine. This excitability, in point of fact, is nothing more than the nervous energy of Dr. Cullen; it is the principle of life, or life itself. It is, according to Dr. Brown, constantly varying in its accumulation and exhaustion; yet it differs somewhat from the nervous energy of Dr. Cullen, which is influenced by some- thing unconnected with the matter of organization, and which he terms " vis medicalrix natural "—whereas Brown's excitability is passively exposed to the effects of such stimuli as it may chance to meet with, and yields to their influ- ence. He divided all diseases into two classes : the first, caused by accumu- lated excitability, and marked by direct debility ; to this class he gave the name of sthenic. The second, produced by exhausted excitability, and marked by indirect debility ; this class he termed asthenic. And his treatment is as sim- ple as the arragement, viz. in the first case, to reduce the excitability by anti- phlogistic means ; and in the second, to increase the excitability by an opposite treatment. It can scarcely be believed that an author who acquired so much reputation, could have been guilty of publishing such nonsense on a point of such vital importance, as the following:—" In order both to prevent and cure diseases, we must always use the indication proposed, and stimulate or debilitate; never wait or trust to the supposed powers of nature, which have no real exis- tence."—Elements of Physic, vol. 1, p. 81. It is surprising, considering that his works abound with absurdities equally glaring, that Dr. Brown should have made any converts ; and it is not very creditable to the age in which he lived, that it should be told he had numerous followers,—but they soon began to fall off; and it is curious, that in proportion as they declined in number at home, they increased abroad, and are at this very moment, with some modifications, in considerable force in Italy. Dr. Darwin improved the Brunonian doctrines, in so far as he makes the brain the common fountain from which every other organ is supplied with sen- sorial fluid. He regards the sensorial fluid as a mere secretion, capable of being exhausted in four different ways, through the agency of four separate fa- culties which he ascribes to it. 1st. The faculty of irritability, exhausted by external stimuli, affecting sim- ple irritable fibres. 2d. Of sensibility, exhausted by stimuli affecting the fibres of the organs of sense. 3d. Of voluntarity, exhaused by stimuli affecting the fibres of those organs which act in obedience to the will. 28 FEVER. 4th, and lastly, of associability, exhausted by stimuli affecting organs associat- ed in their actions by sympathy or long habit. By each of these means, Darwin supposes the sensorial power becomes evacuated, as by food and rest it becomes replenished, often indeed with an ac- cumulation or surplus stock of power. He therefore considers the occasional causes of fever, (whatever they may be,) as inducing a torpor of the extreme arteries, and the subsequent heat, as an inordinate action of the sensorial pow- er hereby accumulated to excess. This subject might be pursued much farther, but a more minute detail does not consist with the plan of this work, particularly as the individuals whose names have been mentioned have bewildered themselves with theories, have substituted mere conjectures for facts to which they have given appellations, have replaced one mystery by adding another quite as inexplicable, and seem to have considered the subject without reference to morbid dissection, or to the habits and modes of living in different societies and climates. I still have to mention the doctrines of more modern pathologists, which are alleged to be founded on morbid dissection. Some of these contend that fever (or as they term it, the proximate cause of fever) depends upon inflammation of a particu- lar organ. Thus it has been attributed to inflammation of the brain—of the liver—of the digestive organs generally—of the mucous membrane of the stomach and intestines particularly—and of the arteries and veins. It is necessary to caution young practitioners, and more particularly those commencing the study of medicine, against implicitly receiving the arbitrary doc- trines of fever which divide the profession in the present day, viz. that fever is invariably produced by inflammation of one viscus, or set of viscera. Dr. Clutterbuck, a physician of reputation in London, has most ingenious- ly attempted to prove, that fever depends upon some degree of inflammation of the brain. In reviewing the merits of his system, it must be kept in view, that be practises in the greatest commercial city in the universe, among a people whose minds, generally speaking, are more actively employed than their bodies, who are exposed to intense anxieties, occasioned by extensive speculations and reverses of fortune, who are either in a state of considerable mental excite- ment or depression. If to these considerations we add the effects of heavy meals and sedentary habits, impeding the functions of the stomach and bowels, it will be seen, that there may be considerable foundation for the opinions this gentleman has been led to advance. But I object to the arbitrary application of his doctrines. Broussais, to whom the profession also stands greatly indebted, and whose merits, like those of many others, have been more justly estimated abroad than at home, asserts that all,fevers may be referred to. gastro-enteritis, simple or complicated. In France it is no wonder that Broussais should so frequently find the mucous membrane of the stomach and intestines altered both in appear- ance and structure, if the habits and modes of living of the people are recoU lected. The stewed meats, salads, oils, and sweets, consumed by Frenchmen FEVER. 29 among the higher ranks, together with the hard beer and acid wines which they drink, and the unwholesome food eaten by the lower ranks, all tend to produce irritation in the digestive organs. Sooner or later, these irritating matters pro- duce increased vascularity, which must frequently terminate in inflammation and ulceration. It is easy, therefore to account for the doctrines of Broussais, and for the tone in which he supports them ; and while I allow him every merit and commendation which is so justly his due, I cannot help objecting to the arbitrary manner in which he wishes to apply them. I have yet to mention, that there are many individuals of the present day who assert that fevers have never any connexion with inflammation, except in as much as they occasionally excite it in their progress; and in alluding to the ap- pearances so frequently found on dissection, they triumphantly but erroneously allege, that such appearances are the effect, and not the cause of the disease. Change of structure is certainly only a consequence of previous disordered action, but in fever it is not difficult to trace the progress of the* local disease, from the beginning of the disordered action till the structure of the part is in- jured. But I cannot dwell upon this point in this part of the work, as I shall have to allude to it more fully hereafter. I shall* however, take the liberty to observe, that there are many persons who cannot imagine that inflammation can exist in any organ or tissue of the body in any degree without a strong and a quick pulse, thirst, restlessness, and considerable pain. Fatal error! The war of opinion in France, respecting the pathology of fever, is at pre- sent too* great to entitle us to expect candor from all the combatants. Much ta- lent is already in the field, and when the stage of excitement is over, the science of medicine will probably be found to have gained very considerably. Some are ready to assert the universal truth of the new doctrines at the point of the sword, while others as strenuously, and apparently as sincerely, deny them. New advocates are daily coming forward on each side; and while wt may express our admiration of the zeal, ability, and assiduity, displayed by so many individuals, still I cannot avoid stating my conviction, that their services would be more useful to suffering humanity, if many of the authors thought more, and wrote less. From this reflection, I would beg to exclude the truly valuable works of Broussias, Andral, Laennec, Boisseau, Bailly, and many others ; but even with respect to these, if that of M. Bailly is excepted, it is melancholy to reflect upon the little practical benefit they have themselves de- rived from pathological investigations. They have filled large volumes with cases and dissections, but their pratice is too expectant on most occasions, and generally weak and vacillating. Having already expressed myself candidly re- specting the views of authors of our own country, I may be permitted to do the same with respect to those of the French school; and I must further add an ex- pression of surprise at the little acquaintance with British medical literature, which even their best writers display. Frequent opportunities will occur, in the course -of this work, to quote with benefit to my readers, many important facts from French works, but in this doctrinal history, it would be of little ser- vice in general, and occasionally would make " darkness visible." 30 FEVER. It is now time that I should state the views which I have been led to form on this important subject. First. Fevers may depend on inflammation of an acute, but more frequently of a sub-acute nature, of some organ or tissue of the body. If the inflam- mation be acute, the febrile symptoms will be correspondingly high; but if sub- acute, they will assume a slighter form. Secondly. Fevers very often depend upon mere functional derangement of some organ, having as yet no connexion with inflammation. Thirdly. Fevers sometimes depend on the mere loss of balance in the cir- culation, producing local congestions ; fevers arising from these last two causes are generally called idiopathic. After having watched the progress and termination of fevers in various climates, I have been led to conclude, that the nature and seat of fever, (which may be called its essence,) is pretty much the same in all constitutions, in all climates, and under all circumstances ; the leading difference being in intensity, and the rapidity with which some run through their course. Some have supposed, from the tenor of the papers which have been publish- ed by me, that I deny the influence of the nervous system in the production of fever; but this is far from being the case. It would as soon occur to me to question the laws of gravitation. I have always maintained the strict connex- ion between the vascular and nervous systems, in producing and keeping up fe- brile and inflammatory diseases. There can scarcely be a doubt, that a disordered state of the functions of the brain, and other parts of the nervous system, occasionally gives rise to febrile action. It is impossible to deny to the brain, as an organ, that it may be dis- ordered, like other viscera, in function, as well as diseased in structure. My ideas of fever may be summed up in the words of Dr. Fordyce, one of the best and most original writers upon the subject. " A fever," says he, " is a disease that affects the whole system; it affects the head, the trunk of the body, and the extremities; it affects the circulation, the absorption, and the nervous system ; it affects the skin, the muscular fibres, and the membranes; it affects the body, and affects likewise the mind. It is, therefore, a disease of the whole system in every kind of sense. It does not, hoivever, affect the various parts of the system uniformly and equally; but, on the contrary, sometimes one part is much affected in proportion to the affection of another part."—Dissertation on Simple Fever, Part I. p. 27. It appears to me, that certain general views closely touching this question are admitted by all writers whose opinions are of any value, although the same facts have been called by different names, and have led observers to draw op- posite conclusions. 1st. That the functions of almost all organs are embarrassed in fever from the very beginning, and often for days before the sense of cold is felt by the affected person. 2dly. That the Mood leaves the surface of the body, and accumulates m in- ternal organs, and that, unless they are overwhelmed, the system makes an ef- FEVER. 31 fort to relieve herself, and certain combined phenomena take place, which are designated by the terms " re-action, fever." A question has arisen to deter- mine by what means this is effected. There can be no doubt that it is owing to the principles of life. There are two circumstances, in following which in- vestigators have bewildered themselves ; one is, the vain attempt to ascertain the first link in the chain of diseased action ; the other is, the still more hope- less endeavour to discover the principle of life, which perhaps no man will ever be able to unravel. 3dly. That inflammation of all parts of the body will give rise to fever. 4thly. That inflammation may supervene during fever, without being the pri- mary cause of the febrile commotion. 5thly. That the nervous system is involved as well as the vascular; and 6thly. It follows as a consequence, if all these things be true, that the blood itself must be in a diseased condition. This outline of my opinions must suffice at present,—it will be best filled up when treating of the pathology of individual fevers,—when at attempt will be made to account for the discrepant histories which have been given of fevers, and for the varieties of treatment recommended by different authors. Division of Fevers. Fevers have been divided into various kinds. Dr. Mason Good has four or- ders, thirteen genera, and each genus has several species. This is a very er- roneous plan in writing as well as teaching; for every individual case has some peculiarity, so that this very learned author might with as much propriety have made many millions of species. It was the opinion of the celebrated Dr. Rush, that it is " not more impro- per to say that men are of different species, because some are tall, and others short, or because some are long, and others short-lived, than that fevers are of different species, because they vary in their symptoms and duration. Cullen has divided fevers into intermittent, remittent, and continued, and this last is sub-divided into synocha, typhus, and synochus. It is my intention to reject the term " idiopathic,"* as applied to fevers, which I consider a most unhappy term, being one respecting which no medical man with whom I am acquainted can give a satisfactory definition ; it seems to be a disease beyond the pale of pathology, having neither nature nor seat. It is defined by some to be a fever without a cause. Fever is alleged to be a certain combination of symptoms, but it cannot be said that this is the disease. The symptoms are to be regarded as evidences of a diseased condition of some part or parts of the system; whereas, those who speak of idiopathic fever, will be found very frequently to do so, either from habit, or from a dislike to change terms, they themselves having a particular meaning for it. But the schoolmen who are in the habit of using this term, I verily believe, do so from * The fevers said to be " idiopathic" are " intermittent, continued, and exanthema- tous." 32 FEVER. an erroneous impression tnat the symptoms are the disease, and it is undersi oo that some of them even go the absurd length of treating of idiopathic hectic. The terms adynamic and ataxic have been also avoided in this work, because there seems to be no good practical reason for their employment. None of the arrangements which have been hitherto laid before the profes- sion, exactly meet my views; and in so far as I have been able to observe the phenomena of fever, I believe they may be advantageously arranged under the following heads : 1st. Intermittent fever. 2d. Remittent or yellow fever : infantile remittent. 3d. Continued fever, sub-divided into four orders, viz. Fever from functional derangement. ----from inflammation. ----from congestion. A mixed form of fever between these three last, but in which conges- tion predominates, commonly denominated typhus or synochus. 4th. Hectic fever. 5th. Fevers attended with eruptions, subdivided as follows : Scarlet fever. Measles. Small pox. —-------modified. Chicken pox. MUiary fever. Roseola. Urticaria. 6th. The Plague. General description of the phenomena of Fevers. The following are Cullen's definitions of febrile diseases, and of fevei : First, of Pyrexia. " After shivering, succeed a quick pulse, increased heat, with interruption and disorder of several functions, diminution of strength, particularly of the joints." Secondly, of Fever. " After languor, lassitude, and other signs of debility, pyrexia, without any pri- mary local affection." There are the strongest objections to all medical definitions. The following may be urged against the two above quoted; they are symptomatical defini- tions, and it is well known by physicians of experience that the symptoms vary much according to constitution, climate, and habits of living. They vary even in different individuals belonging to the same family, and during the same epidemic. The symptoms develope themselves also in various degrees ; one symptom, when exceedingly severe, frequently conceals or disguises the others. A definition, to be useful either to the student or the young practitioner, should embrace such phenomena as are peculiar to that particular disease, and which FEVER. 33 never attend any other,—phenomena which may be therefore said to be pa- thognomonic of the affection. As has been already stated, there is no case of fever, or indeed of any other disease, which has not some peculiarity that dis- tinguishes it from another; in truth, the symptoms of diseases have a very wide range of character. A definition, giving a sketch, not of the symptoms, but of the nature and seat of the disease, would be a most useful introduction to the practice of physic ; but pathology, unfortunately, is not yet sufficiently advanced to enable me to adopt such a plan in the course of this work. It may be asked why Cullen, in his definition of fever, has taken no notice of pain in the head and in the loins, delirium, and coma, of oppression at the praecordia, of nausea, want of appetite, thirst, and the state of the tongue? The reason appears to me to be evident; the mention of these phenomena would have led to the suspicion of local affection, which was contrary to his own dogmas. " Fever," says Dr. Fordyce, " of all other diseases, is that one in which a pathognomonic symptom is least to be depended upon; that is to say, an ap- pearance which does not take place when there is no fever, or a fever does not take place when there is no such appearance."* Febrile diseases sometimes commence without any rigor, and go through their whole course without any unusual heat of skin, quickness of pulse, or thirst. The rigor is not always followed by increased heat. Languor, lassi- tude, and other signs of debility, are symptoms common to almost all diseases, and therefore should not be ascribed to fevers in particular. It is impossible to give a good general account of the phenomena of fevers, because, in addition to the objections urged above, they vary every day in the course of the disease. The symptoms which appear in the accession of fever, differ from those which manifest themselves in its progress; and these again from those which are observed in the decline and termination. These differ- ences have given rise to a division of every fever into stages: 1. That of accession. 2. ------increase. 3. ------declension. 4. ------collapse. These stages have been differently named; the first is sometimes called the stage of oppression and depression ; the second, that of re-action; the symp- toms occurring in the third and fourth stages have too frequently been called typhoid. The symptoms vary also according to the organs chiefly affected. In some cases there are decided cerebral symptoms, from the very beginning, indicated by headache, intolerance of light and sound, tinnitus aurium> and delirium, or stupor with low muttering delirium, and sometimes coma. In other cases the viscera of the thorax are principally affected, indicated by dyspnoea, cough, expectoration, and tightness in the chest. In a third set of cases, some of the viscera of the abdomen are implicated, announced by nausea or vomiting, un- 5 • On Simple Fever, Part I. p. 7. 34 FEVER. easiness increased on pressure, obstinate constipation or diarrhoea, a mor 1 state of the alvine evacuations, discovered both by their appearance and odour; a tympanitic state of the abdomen, and the peculiar appearances of the tongue. Occasionally in the course of the fever there are evidences of acute or sub- acute action in all the three great cavities, and this is what occurs in the worst forms of yellow and malignant fevers. In fever the functions of every organ are more or less disturbed, so that there is the best proof of universal disorder, and the appearances so frequently seen on dissection warrant this inference. True it is that we now and then, on examining the body of an individual, find no decided morbid appearance.* This is by no means peculiar to the practice of physic; for, in that of surgery, people sometimes die after capital operations, where there has been no loss of blood, and no organic lesion found upon dissection, to explain the cause of death. They are said to die from the shock, by which term I understand that the principal functions of the body become suddenly impeded to such a degree that life can no longer be carried on. In the same way, in fevers, individuals die before any alteration of structure has taken place; from peculiarity of con- stitution, they cannot stand the shock produced by the embarrassment of so many organs in the performance of their functions ; and farther, many indivi- duals cannot bear the remedies which have been thought necessary for the subduction of the disease. Some cases of fever commence with shivering, quickly followed by increase of heat and other symptoms of pyrexia, and terminate in a few hours, after considerable suffering, by copious perspiration ; this is the simplest form of fever, and is termed ephemeral; but when there is a regular succession of paroxysms, it is called intermittent. Other cases commence in the same manner, followed by heat of skin, &c; continue for a day or two, when the symptoms decline ; and there is sometimes a state of complete apyrexia, which continues only for a short time, when they recur with perhaps increased violence; this kind of fever has obtained the name of remittent. When it occurs in infancy and childhood, it is called " infantile remittent." When the skin becomes yellow, the term yellow fever has been applied. Another kind of fever goes on for days, or weeks, without intermission, and is therefore called a continued fever. It has several varieties, of which the following are brief sketches. First variety.—An individual feels his appetite impaired, his bowels out of order; his urine perhaps scanty and high colored; he passes restless nights, and at length is sensible of increased heat of skin ; towards morning he gene- rally falls into a gentle perspiration, and enjoys a few hours sleep, from which * This is seldom the case however. The only places in which the physical traces of disease can be investigated with due care and deliberation, are public hospitals, and the indifference which generally prevails is shameful. If a physician has the ability he is too much occupied, and some, unfortunately for science, have neither the ability nor inclination. FEVER. 35 he rises somewhat refreshed ; he finds his tongue loaded, his breath more or less foetid ; he feels unwell, but still is able to pursue his ordinary affairs. In the course of the day he is sensible of frequent slight chills, and flushes of heat; he becomes rather languid, has a little headache, but hopes to be better after dinner; he returns home, and although he has no appetite, forces himself to eat and drink, and passes rather a worse night. This goes on for several days, till at last he shivers pretty severely, and feels so much oppressed that he is com- pelled to confine himself to bed. Then for the first time medical advice is sought; the physician can find no symptom which can be attributed to inflam- mation; there is considerable restlessness, but no great degree of sufferingj except that which proceeds from a sense of oppression in the precordial region, fulness in the stomach and bowels, and pain in the loins ; the appetite is gone, and the individual loathes food of all kinds, but has considerable thirst. The mental faculties are commonly quite sound, but there is perhaps slight aliena- tion during the night. Abstinence from solid food, and a steady perseverence in gentle laxative me- dicines, soon produce an amendment. This is the form which I have denomi- nated " Fever from functional derangement." Second variety.—A person is sometimes seized with a shivering more or less severe, followed by severe pain in the head, chest, or abdomen ; accompanied by considerable heat, thirst, full pulse, and every symptom which announces a sub-acute attack of some structure, within one or other of the three great cavi- ties; and this is the form all writers term a pure inflammatory fever. Bui when the inflammation of any part runs high, it is then said to be an inflamma- tion of a particular tissue or organ. It must be recollected, however, that in- flammation of internal organs may go on to a fatal termination without strong- ly marked symptoms. Third variety.—Another individual, without being sensible of any previous complaint, may be suddenly seized with shivering; the sense of coldness soon becomes intolerable ; he is unable to support himself in a standing or even in a sitting posture ; his intellectual faculties are soon observed to be impaired, his features shrink, a deadly coldness gradually spreads over the whole surface of the body, his pulse sinks, he makes little complaint, and dies without the ap- pearance of any of the symptoms usually termed febrile. This is a form of disease which is certainly not very frequently met with in this country, but which is often seen in warm climates, and it occasionally attacks women in child-bed. This is the purest example which can be given of what has been termed congestive fever,* but it is not that form of it which we most frequent- ly meet with in these latitudes, where it generally developes itself in the fol- lowing manner :—A person, after feeling more or less unwell for some days, or perhaps for some weeks, experiences chilly sensations, alternating with un- * This is the form of fever which occurs in Rome and other places where intermittents prevail, and is termed fievres intermittentespernicieuses, the pathological elucidation of which has been so fully pointed out by M. Bailly. 36 FEVER. dsual warmth ; he is disposed to sit over the fire ; feels weak, and after being in this situation for some time longer with changes from heat to cold, the cold predominates to his sensation, while another person will pronounce him to be hot; but upon careful examination, his extremities, more particularly the hands and feet, will be found cold; he makes little complaint, and is often thought to be asleep, when in fact he is comatose. Occasionally, however, the head is quite free, he suffers from slight dyspnoea, is unable to take a full inspiration, but has no pain. The tongue is generally moist, sometimes loaded, white and shrunk. The pulse is soft, sometimes quick, at others not above the natural standard. Even when to all appearance he is in a complete state of coma, he can be roused, when his expression of countenance will be vacant, and appear as if he were in a state of intoxication. If questioned as to what he com- plains of, he will answer, " of nothing," or he will move his hand towards his head, or place it on his breast signifying some uneasiness, but he quickly falls into a comatose state again. Fourth variety.—The next form of fever of which it is my duty to give a sketch, is that in which the patient is seized much in the same way as in the last described variety. He complains, however, from the first of pain in his head, chest or abdomen ; has frequent attacks of chilliness followed by heat; with symptoms characteristic of diseased action in the head, thorax, or abdo- men. But this state is quickly succeeded by more or less insensibility, slight delirium, rapid weak pulse ; the surface of the trunk of the body feels hot, while the extremities are rather cold; the delirium which manifested itself only during the night, now becomes permanent; it is not of the furious kind, but that which is appropriately termed " low muttering delirium ;" the tongue, which was moist for the first few days, is now observed to be dry and glazed; he passes his urine and feces in bed; is always found upon his back, and, how- ever often he may be moved, will soon shrink down again towards the foot of the bed, which is a sign of complete prostration of strength, and perfect helpless- ness, a bad symptom in any disease. In this state it is imposible to rouse the patient, and it may be evident that he is also blind ; the pulse being quick, and so weak as scarcely to be felt, while the action of the heart may yet be very strong, and a considerable pulsation felt in the carotids, or abdominal aorta. Recove- ry is rare when the symptoms are so very severe, although the fatal period may be protracted to the end of the third week. Occasionally in this form of disease, instead of the cold predominating, there is considerable heat, and the symptoms are pretty sharp, but at the termination of a few days they become such as have been described above. This is the disease generally called typhus. But when the symptoms run very high at first, and subsequently become low, then it is usually called syno- chus. And this is precisely the form of disease which will be more particular- ly described hereafter, under the denomination of " a mixed form of fever," for want of a better appellation. The term typhus is objectionable, because it is sometimes used to denote a malignant, or a outrid fever ; at others it, is cm- FEVER. 37 ployed to signify a nervous fever. The term synochus is also objectionable, for this reason, that it is stated to be of an inflammatory nature, but there is a supposed union with a typhoid state of the system, which although present re- mains latent in the first stages, and subsequently developes itself; and we are told that the appropriate remedies for imflamniation are not to be employed, from a dread of typhus, which must inevitably follow. The term hectic fever is used only to signify febrile symptoms consequent to some previous disease, and restricted to symptoms which are produced by the formation of pus in some organ or tissue ; in fact, whatever doubts have been entertained with respect to the nature of all other fevers, this is almost the only one which is universally allowed to be symptomatic. It is considered unnecessary to offer any general explanation in this part of the work respecting the fifth class, viz. Fevers attended with eruptions ; or the sixth, the Plague. Causes of Fever. The causes of fever are marsh miasm, contagion from human effluvia, and epidemic influence. These causes, together with cold, fear, &c. are called in medical language remote ; but I shall continue to employ the terms common and specific. Cullen resolves all remote causes into sedative, in order to sup- port his dogma of debility ; he could not consistently allow a cause of a stimu- lating and exciting nature. Marsh miasm, he supposes capable of producing intermittents and remittents only, and he restricts the term contagion to human effluvia, capable of producing continued fevers only. He considers the com- mon causes scarcely capable of producing fevers. Some authors assert that there is only one species of infectious matter peculiar to all febrile diseases. No one who has attended to this subject, can deny the influence of contagion, and the air of marshes, on the human body; but I conceive that too much has been attributed to them, too little to the previous state of the constitution, and also by far too little to the common causes of fever, and to internal irritations. A weighty argument in favor of contagion, is sometimes drawn from the well known fact, of fever spreading not only from one to another in a family, but also in the same tenement; but the similar circumstances under which the in- habitants are placed should not be forgotten. The anxieties, the hopes and fears, which alternately effect individuals attending others whom they love, the exposure to cold and fatigue, the night-watching and want of rest, the irregu- larity in taking nourishment, and the neglected state of the bowels, all tending to produce loss of balance in the circulation, will go far to account for a num- ber of individuals in the same neighborhood, and more particularly in the same family, being affected one after another. Neither should it be forgotten, that all these individuals residing in the same locality, and living in a similar man- ner, may have been exposed at the same period with the person first affected, to the miasm or epidemic influence, or some of the common causes which pro- duce fever. Why one individual should be sooner attacked than another, and 38 FEVER. have the disease perhaps more severely, it is difficult to determine. An inter- esting question here arises,—What length of time does the contagion remain latent in the body, before it shows its effects? This is an intricate question, and one which has never been satisfactorily investigated. Some say it can be for a few days or weeks only, while others state with great confidence, that it may remain many months. Dr. Gregory used to assert that contagion might lie frozen for any length of time, and resume its virulence upon being thawed. There are other interesting facts, which are not sufficiently attended to in con- sidering this subject. It" is my belief, that contagion will not produce fever, applied* a thousand times to a person, if he be in a good state of body and mind. Dr. Gregory stated, that he must have been exposed to the influence of contagion some 20 or 30,000 times, without affecting him once. The con- tagion of fever, to produce its effects, must be applied to a person ill fed and clothed, or to one whose stomach and bowels are out of order, or who is labor- ing under the effects of some mental depression. From the evidence before us in the records of medicine, it appears that in- dividuals residing in low marshy countries, are peculiarly liable to fever which has been termed intermittent. The air of a marsh, however, does not differ in its chemical properties from that of the most salubrious situations, it supports combust'on, and therefore cannot, as some have supposed, be deprived of much of its oxigen. If its constitution were changed, it would affect all who breath- ed it, bucks as well as whites ; but this is not the fact, for there are very many people, who live in the centre of marshes for years, withont being attacked by intermittent fever. I have myself had many attacks of this disease during a residence in a marshy district, therefore it has been in my power to investigate this subject minutely, not only with regard to the phenomena of the disease and its causes, but also the sensations produced during the proxysms. From personal observation thus acquired, the first circumstances which attracted my attention, were, that men were more liable to the disease than females,—whites than blacks,—the dissolute than sober steady-living men ; and that agues were most prevalent at new and full moon. Women are less liable to the disease than men, because they are less exposed to vicissitudes of weather, their habits are not so dissipated, and they keep more regular hours. Blacks born in the West Indies, are less liable to this disease than whites, partly, no doubt, from the nature of their constitutions, but principally because they have neither the means nor the liberty to indulge themselves like their masters. But I am convinced that difference of consti- tution, enabling blacks to resist the causes of fever better, has been very much overrated, and that diseases which destroy so many Europeans, are owing more to licentiousness than to the effects of climate. The dissolute are more liable to this disease than others, because they often expose themselves during the night, when the system is in a state of collapse ; and the disturbance which is created and kept up in the functions of important organs, by constant ex- cesses, must not be lost sight of. FEVER. 39 Moisture alone has a great effect in producing disease, and its influence is speedily observed on the mind as well as the body. But moisture aione will not produce intermittent fever, the influence of excessive heat must be super- added, and then there is a rapid evaporation from the earth's surface. It is this evaporation, I imagine, which is productive of so much mischief to Euro- pean constitutions in warm climates, particularly where there is any tendency to collapse. Agues are not commonly prevalent during the rainy season, when the surface of the earth is more or less covered with water; but they become so after the dry season sets in, when it is alleged " the sun acts upon the soil itself, producing deep rents, whence it is supposed the miasm emanates." This, however, can be more satisfactorily accounted for in a different manner. During the rainy season, white people take greater care of themselves, and are^ less exposed ; the sun is obscured from the eye by dense humid clouds ; there is consequently a pretty constant deposition of moisture, but little or no evapo- ration. The sun's influence becomes very great when the rainy season ceases, and the extent to which evaporation goes on, exceeds all belief. It is then that severe fevers and dysenteries generally prevail. Dr. Fergusson has obseved, that " the same rains which made a deep marshy country perfectly healthy, by deluging a well-cleared one, where there was any considerable depth of soil, speedily converted it, under the drying process of a vertical sun, into a hot-bed of disease. With regard to the apparent influence of the planetary system in interroit- tents, it must be observed, that in localities where this disease generally prevails, the surface of the earth is scarcely above the level of the sea at high tides; so much so, that to prevent inundations, dikes are thrown up. At new and full moon the tides rise, the marshes become covered with water, the drains become charged, and the daily effects of evaporation produce the disease. I am indeed aware, that in the interior of Ceylon, and above the Ghauts, in the peninsula of India, where the tides cannot have the slightest influence, agues are very pre- valent, both among natives and Europeans at certain periods of the moon's age. [ am informed by Mr. Marshall,* that in the interor of Ceylon, he has seen the mercury in the thermometer rise from 60° to 90° in the shade: and in the sun's rays even to 142.° The difference of temperature to which the troops were exposed from 5 o'clock A. M. till mid-day, amounted sometimes to 82 Jegrees. Some have attempted to account for the occurrence of remittent fevers by the effects of excessive heat; but I believe that heat alone, unless the empera- ture be very high indeed, will not produce fever in any climate, till moisture be superadded, or sudden changes of weather take place, when the thermometer will suddenly fall twenty or thirty degrees, as I have myself observed in un- healthy seasons. It will be seen that it is not my intention to deny the existence of some invi- sible substance suspended in, or mixed with the air of the atmosphere, and which * The well-known author of Notes on the Medical Topography of Ceylon—Hints to Young Medical Officers, &c, &c. 40 FEVER. may produce intermittent fever.* A fact may be mentioned on this side of the question, which must carry considerable weight with it. It has occurred to me to see a good deal of intermittent fever in situations far remote from marshes, but in every one instance the individuals had been at some period of their lives in marshy districts; yet it is certainly very strange that some of them never had a paroxysm during the period of their residence in these places, and not till months, and in some instances years, had elapsed. Some contagious diseases are communicated from person to person, by breath- ing the air in the apartment where the sick person is confined; others require that actual contact should take place; and some diseases are communicated in either way. In the plague, it would appear that actual contact with the affected Individual, or with his apparel, is necessary; whereas, in small-pox, the conta- gion may be received merely by coming into the same room, and it is also con- veyed by inoculation. Contagious diseases spread slowly from one person to another, and from house to house, and may often be concentrated within a cir- cle, where it will attack all, or almost all, who are exposed to the contagion, particularly those who have not had the disease before. When we say a disease is epidemic, it is understood that we mean one, which is produced by a certain state or condition of the atmosphere at present unknown, and which has baffled the exertions of every one who has entered upon its in- vestigation. The term implies that a great number of people are suddenly seized at the same period. An epidemic, after continuing for a longer or a shorter period, suddenly ceases, at a time perhaps when the greatest number of patients are affected with it. These are facts which appear to have confounded those who assert that yellow and other fevers are invariably contagious. It appears to me that intermittent fever is never contagious: but I am of opinion the yellow fever, and that which has been termed typhus in this country, are so, under particular circumstances, in a very high degree. Observation and experience have induced me to conclude, however, that this cause of fever has been very much overrated. In the year 1793, Dr. Chisholm made an attempt to prove that the fevei which then prevailed in the West Indies, was highly contagious, and imported from Bulam, on the coast of Africa, by a ship called the Hankey. Similar attempts have since been made in many places in America, as well as in Eu- rope, to account for the severe fevers which have prevailed from time to time. The favourers of importation have invariably failed in proving the disease to have originated in that manner, and have not been able to show that it had not a local origin. In the town and garrison of Gibraltar there are always cases of fever, particularly in sultry weather ; many are severe, attended by yellow- ness of the surface of the body, and vomiting of a dark-coloured matter com- monly called black vomit. These cases are considered by all candid observ- ers to be the ordinary remittent fever, common to this and all other places un- • Some writers go the extraordinary length of speaking of the specific gravitv of Marsh Miasm. 6 ' FEVER. 41 der similar influences. The majority of the cases are found to occur in the lowest, worst ventilated, and filthiest parts of the locality. But in 1S04-I810- 1813-1814, and 1828, Gibraltar was visited by a fever more severe in its symptoms, more fatal in its results, and attacking a larger proportion of the troops, as well as the inhabitants. On each of these occasions attempts were made to prove its importation, and that it spread by contagion, and had no trace of local origin. Considerable doubts were, however, entertained upon this subject; but in 1814, the supporters of importation and contagion failed so completely in showing the foreign origin of the fever which then prevailed, that many sensible people were led to doubt, and others to deny, the truth of such views. I wish at present to confine my observations to the source of the fever which prevailed in the town and garrison of Gibraltar in 1828. A host of medical men, with the late lamented Dr. Hennen at their head, maintain that the disease was of local origin, for which there were abundant sources, and that there is no proof of its having been imported. One or two others, with Sir William Pym, Superintendant General of Qua- rantine as their leader, not only insist that it was not of local origin, but that it was imported in a particular ship called the Dygden, which sailed from Ha- vanna on the 12th May 1828, and arrived at Gibraltar on the 28th June. I have carefully perused all the evidence produced through the medium c/ the medical periodical press, and published by the following gentlemen :—Mr. Frazer, late Surgeon to the Civil Hospital at Gibraltar; Dr. Smyth, Surge®;. 23d Regiment; Mr. Amiel, Surgeon 12th Regiment; Mr. Wilson, late of Medical Staff", who I believe retired from the service, partly from disgust, and partly from the persecution to which he was subjected, and would not submit; Dr. Barry, Physician to the Forces : also, Sir William Pym's replies to que- ries put to him by the Royal Medico-Chirurgical Society of Cadiz,—together with the opinions of the Board of Commissioners, and certain documentary evidence respecting the annual occurrence of fevers of a similar character at Gibraltar, as extracted from the books of the Civil Hospital, and authenticated by the signatures of a number of highly respectable gentlemen. After the most careful perusal of these productions, duly considering all the facts adduced in evidence by all parties, my deliberate opinions are as follow: 1st. That the fever of 1828 was of local origin, and for which there were unfortunately abundant sources in the bad state of the drains, the crowded con- dition of the poorer inhabitants, and the exceedingly filthy and badly ventila- ted state of their abodes. 2d. That there is not a tittle of evidence to show that the disease was first propagated by communication with the Swedish ship Dygden. Indeed, it does not appear that there was any cause to suspect this ship of bringing the seeds of the disease with her from Havannah. In the first place, we see from her clean bill of health, signed by the authorities there, that " this city and its neighbouring towns are free from all plague or contagious epidemic disease; as likewise the said captain, with the fifteen men of his crew, are in a perfect 6 42 FEVER. state of health, according to the muster by his roll," &c. In the second place, we find the declaration of the captain, and the report of Dr. Hennen to the Governor, the first of which bears that he "sailed from Havannah on 12th May, with a crew of fifteen men, all in good health. A few days after, two men of the Swedish part of the crew complained of severe headache, and pains in the limbs, which increasing, they had to go to bed. Through sudori- fics and purging medicine, they got well in eight days, so as to be able to at- tend their duties. During that time, five others had been taken ill of the same complaint, but recovered in a few days, under similar treatment. A lapse of ten or twelve days followed, during which the whole crew were in perfect health ; but upon getting into a higher latitude, I met with gales and rain, when the greater part of the crew suffered much from wet, and immediately after, those who had till then been well, were taken ill, probably from cold produced by the weather, yet the symptoms which appeared were the same as in the others. The youngest recovered in a short time, but the eldest two died, one after five, the other four days' illness, which took place on the 27th May, and 1st of June. The old clothes they had worn, together with hammocks, and what was in them, were thrown into the sea with their bodies." In Dr. Hennen's report to the Governor of Gibraltar, dated 2d August, 1828, we find it stated, that he had minutely inspected the captain and crew, " whom I found in perfect health, and I shall repeat my inspection before the expiration of their quarantine, on the 6th of the present month. In my letter of the 29th July, I mentioned, as the reason for putting the ship in quarantine for forty days, that two men died on the passage. It is now sixty-six clear days since the first man died, and sixty-one since the death of the last, and nothing like disease has since appeared, nor have I the most distant reason to apprehend danger to the public health, from any circumstance connected with the Dygden." 3d. If the disease were contagious, it does not appear from the evidence to have been so in any high degree. - 4th. It is an undoubted fact, known to every medical man who has been upon the rock, that remittent fever, attended by yellowness of skin and black vomit, is a very frequent occurrence during the autumnal months. I am in possession of an authentic document, containing a history of the symptoms and appear- ances on dissection, observed in cases of remittent fever treated in the Civil Hospital at Gibraltar in 1821, and the five subsequent years. Having com- pared these with the cases of 1828,1 can discover nothing different. The two symptoms pitched upon by Sir William Pym, as pathognomonic of true yellow fever, viz. yellowness of the surface and black vomit, were present, and the morbid appearances found after death were perfectly similar. The superior medical officers have had a heavy charge made against them in the following statement by Dr. Smith. " At one period of medical rule in this garrison, every variety of fever was ordered to be returned under one head. Such, indeed, was the thraldom of the military medical press (if I FEVER. 43 may so use the expression) at Gibraltar, from the termination of the epidemic fever of 1814, until the arrival of Dr. Hennen in 1826, that it was considered a most wicked heresy for a surgeon of a corps to return fevers under any other ncad than simple continued fever.- The consequence is, that although febrile diseases are the most frequent of the numerous cases treated both in the Mili- tary and Civil Hospitals, no correct table of fevers can be now formed from the returns of these establishments; no distinction whatever being drawn between the different species of remittent and continued. The authors of such a mea- sure can best answer for themselves." Was this done to deceive the Governor, or did it receive his approbation to mislead the authorities in England? This calls aloud for serious investigation, in order to prevent the repetition of such disgraceful management. That it could have been endured, can scarcely be believed, except by those who, like myself, have been exposed once or twice to the tyrannical conduct of ignorant and obstinate medical superiors. 5th. That Sii William Pym's answers to the queries of the Spanish physicians, are highly discreditable to him as a scientific man, and calculated to injure the public interests, however much they might be intended to fix him in the receipt of the salary derived from his sinecure office of Superintendant-General of Quarantine in Great Britain. These answers are for the most part vague as- sumptions—some being drawn from insufficient evidence—others from no evi- dence whatever—while many of them are at complete variance with fact, of which last, the following is a notable example :—Answer to question 3d. " The first cases were, as I have said, in a house of 24 district, the situation of which, is healthy, very well ventilated, and 200 feet above the level of the sea." Now it was in this district of the town that the fever avowedly first appeared, and was for some time confined. Whether it was such a healthy, well-ventilated spot, or one, tho air of which was saturated with febrific poison, the reader is left to draw his own conclusions after the perusal of the following statement, copied from a document which I received from Gibraltar. It was not written to contradict Sir William Pym's answer, as it never entered the writer's imagi- nation that the Superintendant-General of Quarantine, or any other gentleman who had resided at Gibraltar, could have hazarded such a statement. , The district in question (No. 24) " is situated in a natural gorge of the moun- tain, and is rendered still more close by a high wall raised for the military pro- tection of the town. The wall is called ' Charles the 5th wall,' and is situated on the south of the town. The rear of the district, (24) together with the whole town, is impenetrably shut out from the influence of east winds by the rock itself. The district itself is particularly cut off from the beneficiar effects of perflation by a high and impending semi-circular bluff of the mountain, in some degree insulating it from the rest of the town, on the north side. Charles the 5th wall is higher than the tops of the buildings in this district. This locality is therefore excluded from the influence of every direct wind, unless that which dIows from the west, which was not the case when the fever broke out. Be- sides, it is deserving of particular attention, that the superficial soil was filthy, 44 FEVER. that the district is intersected with numerous collateral drains, and gives origin to several others which unite on the level below, and these form one main sewer which disgorges itself into the sea at water mark, directly in front of this part of the town. The wind enters the mouth of this sewer on the beach, rushes upwards through the drains, and escapes through gratings (which are closely concentrated in this district) loaded with offensive and noxious exhalations, and diffused within a limited circle among the houses erected round the mouths of the great branches. There is also a deep and large common soil-pit in this district, which at the commencement of the epidemic was filled with impurities of every kind. In this situation a drain burst about the beginning of September, in the barrack-yard of the 12th regiment, and when I saw it, its contents had broke up the solid pavement, and was boiling over. The atmosphere of this part of the town was consequently noxious, and contained within itself a suffi- ciency of putrid matter to have disseminated a febrific miasm over the whole garrison. Now, it is a remarkable fact, that the two first cases of the fever originated on the ground floor of a badly ventilated house in this district, and in the close neighborhood of one of the openings of the drains; and abtiut 50 of the cases in the beginning of the epidemic were distinctly traced by several medical officers to come from the vicinity of the openings of the drains and privies of this district, or in the course of the drains." We find the following statements made by Dr. Hennen, in his official com- munications, which I have copied from Dr. Smith's paper : " That so many cases of a fever of a very serious nature have appeared in the barrack of the Sappers and Miners, on Hargrave's parade, which I woukTobserve to your ex- cellency is in the line of the drains, crossing from district No. 24 that I feel myself called upon to submit the propriety of immediately encamping that corps and totally evacuating the barracks." In another letter to the Governor, Dr. Hennen further stated, " In reference to my letter of this day's «late, I have minutely inspected district No. 24, in company with Mr. Wilson, of the civil hospital, Mr. Woods, the medical officer attached to that district, and other staff- officers ; and it is with much regret that I have to state to your Excellency, that at every step I took in that district, I had reason for surprise, not that fever had broken out there, but that it had not extended farther. From whatever causes it may have proceeded, the pauper population is dense to a degree incredible, except to those who have seen it. In sheds without ventilation, without .drain- age, and generally composed of the slightest materials; in tiers of beds as close as in a crowded transport, numerous individuals sleep. They go out to their work at an early hour, and return at gun-fire, locking up their miserable places of nocturnal shelter during the day, and leaving them saturated with the steam of their bedding, their food, and the overflowing receptacles of their ordure. The detail would be too disgusting to enter into; but I most respectfully submit to your Excellency, the indispensable necessity of sweeping away the whole of these sheds, which I have every reason to suppose are unauthorised by the go- vernment." A commission was subsequently appointed by the Governor's or- FEVER. 45 ders, to inspect the different districts of the town, which was composed of mi- litary as well as medical officers, and I copy the following statement from their report: " In the course of our inspection, we were struck at every step-we took, with the density of the population." So much for Sir William Pym's answer to the 3d question, in which he has given a confident assurance of the healthy situation and well-ventilated state of No. 24 district, where the first cases of fever occurred in 1828. Both statements cannot be true, and I am sorry to say there are many other points in the same predicament. I wish it were possible for me to reconcile them with each other, not only on account of the reputation of Sir William Pym, as an old officer, but for the credit of the department to which he belongs, and the judgment of the authorities who appointed him to the lucrative situation of Superintendant-General of Quarantine in Great Britain. 6th. It is my opinion that the Board of Commission was not happily cho- sen by Sir George Murray. No medical officer should have been nominated, or any other individual, however exalted his rank, who had previously express- ed decided opinions on the subject to be investigated. 7th. I humbly conceive Sir George Don, the governor, acted contrary to his orders, and certainly he did not act wisely, by delegating his authority as President of the Commission, to any individual, and more particularly to Sir William Pym, the Superintendant-General of Quarantine, who immediately nominated his newly-acquired partisan, Dr. Barry, to be Secretary to the Com- mission. That Dr. Barry is an ingenious gentleman is well known 'r that he changed his opinions very suddenly at the time of Dr. Hennen's death is al- leged, and has not been satisfactorily disproved ; and that he immediately adopt- ed the opinions of his new chief is undoubted. That Dr. Barry, in his capa- city of Secretary, gave colouring to the evidence produced before the Com- mission, or improperly put leading questions to the parties examined to favour the views of his chief, I do not mean to state. But it will be admitted, that such functionaries as President and Secretary should not have been chosen from a class of persons to whom the slightest suspicion could be attached. On the list ol the commission, I find another name as exceptionable as those of Sir William Pym and Dr. Barry, viz. that of Dr. Broadfoot, Superintend- ant of Quarantine at Gibraltar. Besides these, there are also the names of tw» official gentlemen, the Captain of the Port, and the Town Major, who were thus improperly placed in a situation either to accumulate or reject evi- dence, which might show inattention or dereliction of duty to such an extent as to compromise their situations! The only unexceptionable appointments on the Commission were those of Colonel Chapman, Civil Secretary, and Judge-Advocate Howell, and the coincidence of their opinions is quite re- markable. Colonel CI lapman's opinion is as follows :—Judging from the evidence pro- duced before the Board, the manner in which it has been given, together with the description of persons' who have been brought forward as witnesses, I am decidedly of opinion that the late epidemic disease is of local origin. As to 46 FEVER. the importation of the late epidemic, I am of opinion that the attempt to prove the introduction of the disease, after many months of fruitless inquiry by those rvho tcish to prove it, has totally failed." Judge-Advocate Howell gave the following opinion : " Upon a careful re- view of all the proceedings before the Board, I am of opinion, that the evi- dence brought forward has totally failed to prove that the late epidemic disease was introduced from any foreign source, either by the ship Dygden, or by any other means ; and I am further of opinion, that the late epidemic had its ori- gin in Gibraltar." From Botta's history of Tuscany, the following statements are extracted respecting the epidemic yellow fever which prevailed in Leghorn in 1804. "It was occasioned, as it appears, by the prevalence, during the summer of that year, of south winds, unusually warm and rainy; this sickness was by some termed the yellow fever, by others the black vomit; both names which agree well with the symptoms which mark it. It began to rage in the lowest quarters of the city, and those most crowded and filthy, to such a degree that some were cut off in seven days, some in five, others in three, and even in the short space of one day." " The disease was most violent in robust young men, more mild with the weak, the old, and with females; but almost all those last, at- tacked when pregnant, died ; almost all the children escaped." Speaking of the remedies, it is remarked, " On the other hand, it was found, that from the air being impregnated with animal exhalations, the disease was more easily propagated, and the person infected was more violently attacked ; and a con- firmation of the argument was found in the circumstance, that the quarters of the city most filled with filth, and the houses of the poor, were the chief seats of the disease. On the contrary, the airy quarters, and where the houses were neat and clean, and enjoyed open and free air, were either exempted, or did not become worse, or the infection did not spread from one body to .-mother." " It did not extend into the country, although persons in numbers, and goods in quantities, were transported and spread from district to district, and from the city to the country." On this occasion, also, an attempt was made to prove the importation of the fever from Vera Cruz, but was not successful. When the yellow fever prevailed in Philadelphia in 1794, the celebrated Dr. Rush was most shamefully persecuted by the authorities, to whom many of his medical brethren lent themselves, for having proved that the yellow fever ex- isted in that city—that it was generated in the place, and had not a foreign origin. It is now nearly thirty years ago ; and after reading thr report made on the subject by his opponents, I can readily join Dr. Rush in his conclu- sion, that " it is impossible to review this report, without blushing for the shameful submission made by the Science of Medicine to the commercial spirit of the city." It may be useful to my readers to know the evidence which 1 >r. Rush pro- duced to shew the local origin of the fever, and it will be observed that an attempt was made on this occasion to fix its importation on a ship, u jt wag FEVER. 47 produced," says Dr. Rush, " by the exhalations from the gutters, and the stag- nant ponds of water in the neighborhood of the city. Where there was most exhalation, there were most persons affected by the fever. Hence the poor people, who generally live in the neighborhood of the ponds in the suburbs, were the greatest sufferers by it. Four persons had the fever in Spruce street, between Fourth and Fifth streets, in which part of the city the smell from the gutters was extremely offensive every evening. In Walter Street, between Market and Walnut Streets, many persons had the fever; now the filth of that confined part of the city is well known to every citizen. On the 25th August, the brig Commerce arrived in the river from St. Mark. After lying five days at the fort, she came up to the city. A boy who had been shut out of his lodgings, went in a state of intoxication and slept on her deck, exposed to the night air, in consequence of which the fever was excited in him. This event gave occasion for a few days to a report that the disease was imported; and several physicians, who had neglected to attend to all the circumstances that had been stated, admitted the yellow fever to be in the town. An investigation of this supposed origin of the disease soon discovered that it had no foundation." Vitiated air,* and the effluvia which proceed from the bodies of individuals crowded together in jails, hospitals, and ships, have always been abundant sources of fever. Dr. Fordyce mentions instances where sheep and hogs were transported during the American war, from England to America, in the holds of ships, in which many were confined in a small space ; an infectious fever frequently broke out among them, which destroyed great numbers. History affords many melancholy examples of the baneful effects of vitiated air and human effluvia, and the speed with which they destroy animal life. The best example is to be found in the occurrence which took place last cen- tury in the black hole at Calcutta. One hundred and forty-six unhappy indi- viduals were forced into a dungeon, about eighteen feet square, at eight o'clock at night, and at six next morning, when released, only twenty-three came out alive ; most of these were in a high putrid fever, and subsequently died. It becomes an interesting question, but one too extensive for this work, how contagion propagates itself, and to which part of the body it is first applied ? In this inquiry, we shall be much assisted by the circumstances which are ob- served to take place after inoculation with small pox. The mucous membrane of the lungs seems to be one of the first parts in which the diseased action is to be detected; and careful observation has induced me almost to believe, that in diseases produced by contagion, the bronchial membrane rarely if ever escapes. Fourcrois tells us, that in several of the burial grounds in France, in which the graves were dug up sooner than they ought to have been, the persons em- ployed have occasionally been asphyxiated ; those who were standing at a little distance, were often affected with vertigo, fainting, nausea, loss of appetite, &c. * It is to be regretted that the term Malaria is not restricted to foul air, according to its literal meaning. 43 FEVER. History affords us remarkable instances of the occurrence of diseases decidedly epidemic; the most ancient are those which will be found in sacred writ, in which we find, that on one occasion seventy thousand persons were destroyed by pestilence in three day's time; and we are told, also, that one hundred and eighty-five thousand persons were destroyed in the Assyrian camp in a single right. The most remarkable epidemic of modern times, is the Cholera of the ' East, which extended itself in the very teeth of tempestuous winds. Pythagoras first started an opinion respecting critical days, and he had an unlimited belief in the occult powers of certain numbers. Hippocrates seems to have entertained similar opinions, and it is an essential part of the old doc- trines of concoction, according to which it was supposed that a separation of the morbific matter had a tendency to take place on one of the critical days, by a discharge from the skin, bowels, kidneys, or blood-vessels. I have no belief in the influence of critical days, although I admit that the crisis frequently takes place in some of the ways mentioned. When an organ is affected with disease, there is a constant effort of nature to throw it off; this effort is, in truth, one of the great principles of life, and its object is effected by a determination of blood to another organ; occasionally a spontaneous dis- charge of blood takes place. From the time of Hippocrates, it has been generally believed that fevers had a tendency to remit on the 3d, 5th, 7th, 9th, 11th, 14th, 17th, 20th days, and even on the 21st. Many modern physicians have adopted this doctrine ; but I doubt much whether it has not proved more injurious than beneficial in the treatment of disease. Often may physicians be seen prescribing a placebo, because the critical day is at hand, when they ought to be actively employed in eradicating the disease. When attending to this point, J have very often found the calculations made erroneously; and not unfrequently I have seen physicians disagree as to which was the proper critical day—one calculating from the period when the rigour took place—another from the period when the heat of skin occurred— and 1 have seen a third calculation made from the time when the patient confined himself to bed. There can be little doubt, that fevers and other diseases have a tendency to run through a regular course, and when they terminate favorably, this happy event generally takes place upon the occurrence of an eruption, or of some discharge, as by diarrhoea, copious perspiration, flow of urine, expectoration, &c, It cannot be denied, however that in some diseases there is a strong tendency to periodicity, but far more so in the accession than termination. Thus, in intermittent fever, the attack may come on regularly at the usual period, but each stage may occupy a shorter or a longer space of time in one paroxysm than another. Sometimes an indivi- dual dies in the cold fit, but much oftener the hot fit is not relieved by sweating and his disease becomes a continued or remittent fever, or inflammation of a particular organ takes place. But it is of little importance whether the doc- trine of critical days be true or false, if the physician acts wisely, and neglects nothing which can tend to reduce the diseased action.. INTERMITTENT FEVER. 49 INTERMITTENT FEVER. Of all the febrile diseases, intermittent is generally the simplest in form. It is composed of three stages, beginning with a cold fit, followed by heat, and terminating in profuse perspiration. It has been known from the earliest ages, and is most prevalent in some parts of North and South America ; the Pontine marshes near Rome ; in Holland; and in the fens of Lincolnshire and Cambridgeshire in England. We are told, that in the sixteenth century, this fever was very prevalent, and proved fatal to a great number of people in London; and in the year 1558 it raged like the plague, and was also very fatal; but it has become less frequent in Great Britain, which is to be ascribed to the in- creased comforts of the people, to their habits of cleanliness, and to the im- provement which has taken place in the climate, owing to the draining of lands, and cultivation of the soil. It has been stated, but, I believe, without founda- tion, that a miasm producing intermittent fever is generated in London in the neighborhood of St. James's Park. Intermittent fever is of very frequent oc- currence in all warm countries, and is one of the purest specimens of a disease depending upon an irregular determination of blood, in which the system is of- ten relieved by the unaided powers of the constitution. Cullen's definition is, " Fevers arising from marsh miasmata, consisting of many paroxysms, with intermission, or at least with an evident remission inter- vening, returning with remarkable exacerbation, and in general with shivering ; one paroxysm only in a day. Like most symptomatical definitions, this is very exceptionable. Paroxysms of intermittent have taken place from sudden change of atmosphere in sitations where no miasm ever existed; and the most severe cold stage which ever came under my notice, and which lasted twenty-six hours, was produced by exposure to frost after the individual had got wet on the top of a coach. Mr. John Hunter informs us, that two children had ague from worms; they took bark, but it did them no goo^; but the worms were destroyed, and they got well. We have in like manner, says he, agues from many diseases of particular parts, more especially of the liver and spleen, and from an induration of the mesenteric glands. Many instances are also recorded from repelled eruptions, the drying up of old discharges, as well as from the application of cold. Sir George Baker has given an account, in the Medical Transactions, of an intermittent that prevailed in 1780; it affected the inhabitants who lived in the higher parts of the country, while those in the marshes escaped. Sir Gilbert Blane informs us, that while the village of Greenhythe, nearly on a level with the marsh at Northfleet, is unaffected with intermittent fever, the adjacent hills suffer considerably from them. There are usually reckoned three kinds of intermittents, the tertian, the quo- tidian, and the quartan. But they ought strictly to be regarded as the same disease, with a longer or a shorter interval; and the one frequently runs into the other. We often, however, see a double quotidian. I have observed, that 50 INTERMITTENT FEVER. the longer the interval, the more severe is the paroxysm, and vice versa; but there are many exceptions. Tertian is employed to express that form of dis- ease in which there is an interval of forty-eight hours from the commencement of one attack to that of another; quotidian, twenty-four; and the quartan, seventy-two. Phenomena of Intermittents. When an individual has once had an attack of intermittent fever, he is after- wards more liable to the disease, and is sensible of its approach some time before any one suspects him to be ill; the toes and the last joints of the fingers feel cold and benumbed, and the nails have a blueish color; he has sensations of languor, and long fits of yawning; occasionally at this period there is head- ache, sometimes stupor, and pains in the back and loins. Cold stage.—When the paroxysm actually commences, the patient feels the extremities cold, with a sensation as if a small stream of very cold water were flowing down the spine, which extends itself to the thorax and abdomen. He has great desire for warm drink, and to cover himself with as many bed-clothes as can be procured; the prostration of muscular power is considerable; the sense of cold very soon becomes insupportable; the teeth chatter, and there is an universal tremor over the body; and if I can trust my own sensations, and the accounts of others, the tremors affect internal as well as external parts. These tremors sometimes terminate in convulsions. The respiration is al- ways laborious, short, and hurried, and the individual is unable to take in a deep inspiration when desired; a short hard cough frequently attends, without ex- pectoration ; there is great oppression at the praecordia. Some individuals com- plain most of headache, some of pain in the back, in the lumbar region and lower extremities, and others of universal pain. In almost all cases the patient is incapable of attending to any thing. Sometimes there is stupor, and at others, coma or delirium. The features are much shrunk and pale; the eye looks dull and hollow, while the cheeks and lips are more or less of a livid hue- The pulse is oppressed and weak, sometimes slow, at others quick, and fre- quently intermits; but the violence of the tremors renders it often impossible to feel the pulse distinctly. The tongue is moist. It is a curious circumstance that while the patient complains of intense cold, the heat of the body every where, except in the extremities, is sometimes above the natural standard. The paroxysm occasionally comes on without any rigor, instead of which the patient feels a slight sensation of cold, or severe head-ache, is lethargic, or af- fected with languor and yawning. Sometimes the paroxysm is announced by violent articular, lumbar, and frontal pains; and sometimes a patient falls into a profound sleep for several hours, and awakes in a violent hot stage. These various forms are called by the vulgar the dumb-ague. It sometimes happens, that af>the next attack, instead of a regular paroxysm, a violent pain is felt in the situation of the supra-orbitary foramen, and extends to the brow, affecting the nervous twigs of the frontal branch of the fifth pair; this pain often con- INTERMITTENT FEVER. 51 tinues for many hours, and seems to resemble the tic douloureux. But it would be vain to attempt a description of all the appearances which this disease occa- sionally assumes. The duration of the cold stage is very various, rarely less than half an hour, and seldom exceeding four. It sometimes happens that an icy coldness steals over the whole surface, and in aguish countries it is not an uncommon circum- stance for persons to die in the cold stage. Hot stage.—After the cold stage has continued for a longer or shorter period, the hot stage commences ; the one gradually runs into the other, there being no distinct interval between them. The change is attributed by patients themselves to the treatment which has been employed, or to the effects of vomiting which sometimes accompanies the cold stage. The skin becomes hot and dry, some- times pungent; the face flushed and swollen; the thirst urgent, the tongue parched; there are restlessness, general uneasiness, and oppression at the prae- cordia; the respiration is hurried and anxious; and almost invariably, the patient complains of acute pain in some region of the body, generally in the head and lumbar region, very often also in the thorax, and left hypochondrium; there is frequently a slight degree of disturbance in the mental faculties, sometimes in- deed delirium. On some occasions there are symptoms, which announce cere- bral disturbance, viz., severe headache, tinnitus aurium, and throbbing of the carotids. The pulse is frequently quick, sharp, and bounding, even in patients whose health and strength are already much impaired. I have seen the thermometer, the accuracy of which had been well ascertain- ed, rise in the hot fit, even in this country, to 110c, and in warm climates it is stated to rise as high as 112°. The duration of this stage varies more than the former; in general it continues from four to twelve hours, and terminates in perspiration; but on some occa- sions the febrile symptoms continue for several days or weeks, when the disease is termed a continued fever; now and then there are marked remissions follow- ed by exacerbations, when it is called a remittent: in addition to the last-men- tioned circumstances, there are sometimes considerable irritability of stomach, black vomiting, and a yellow tinge of the skin, then the case is termed a bilious remittent, or yellow fever. Sweating stage.—After the hot stage has existed for some time, it terminates in the sweating stage; the perspiration appearing first on the forehead, arms, and legs, soon becoming general and profuse. It is difficult to calculate the quantity of this excretion in any case ; but it is admitted by all who have at- tended to the phenomena of intermittents, to be very great. From the moment the perspiration begins to appear, the uneasy sensations, and other symptoms above described, begin to subside, and generally vanish after it becomes copious.* * M. Andral, in the first part of his very excellent pathological writings, p. 477, men- tions a very curious case. A young man, who had been hemiplegic on the left side of his body from his infancy, was attacked with tertian intermittent. He only perspired on that half of his body which had not been paralysed. He stated that in his best health he never perspired but on one arm and leg, and one side of his face and neck. 52 INTERMITTENT FEVER. Many patients fall into a profound sleep for several hours, and then awake quite refreshed; others complain much of weakness, while some whose consti- tutions have not been previously injured, are able to resume their ordinary duties almost immediately. When this disease continues for some tune, the patient not only becomes weak, and loses flesh, but he has no interval of ease; each paroxysm increases his sufferings, and he feels comparatively little relief from the perspirations, which he often prolongs, in the vain hope of alleviating his symptoms. He com- plains of head-ache, intolerance of light and sound; or he has a cough and dys- pncea, whicn will almost always be found to depend on inflammation of the lin- ing membrane of the air passages; or he has constant thirst, flatulency, consti- pation, or diarrhoea, with griping pains in the bowels, a dull pain and sense of weight in both hypochondriac regions, generally in the right; the skin is hot, and feels harsh; the feet and legs frequently become cedematous; the abdomen tumid; the urine scanty; the tongue dry at the tip, the rest of it being furred; the patient passes restless nights; and perhaps in the very next paroxysm he may die in the cold stage; or the sweating stage may not succeed the hot, and1 he may die in a few days of continued ji remittent fever; or decided marks of inflammation of the brain, liver, lungs, &c, take place, and he is cut off, from the effects of disorganization in these organs. Such circumstances are of fre- quent occurrence in warm countries, where intermittents prevail; many such melancholy examples will be found, by referring to the works of Sir John Prin- gle and others ; but more particularly to Sir James Fellowes's reports of the destruction occasioned by this fever among our troops employed in the expedi- tion to Walcheren. The history of the fever which annually prevails at Rome, and which has been so ably and faithfully described by M. Bailly, also corro- borates the above statements. This fever sometimes attacks individuals when laboring under internal dis- eases, such as dysentery, hepatitis, &c, and I have frequently seen a remittent converted into an intermittent. It may also be mentioned, that enlargements of the parotid take place during the course of intermittents. The gland increases in size and hardness during each cold fit, and it seems, in the first instance at least, to owe its enlargement to sanguineous engorgement; subsequently the gland suppurates. It has already been mentioned, that when intermittents have continued for some time, the lower extremities frequently become cedematous, the belly tumid," and sometimes even ascites takes place. The first does not denote danger, but the last always occasions an apprehension of an organic lesion of some impor-' tant viscus. Nevertheless, both may be occasioned by mere functional derange- ment. In these cases, the thirst is considerable, and the secretion of urine scanty, and sometimes dysenteric symptoms manifest themselves. Appearances found on Dissection. ■ The following appearances have been observed in the bodies of those who died in the cold stage.—The vessels of the brain gorged with venous blood • INTERMITTENT FEVER. 53 and the carotids, after passing into the skull, may sometimes be seen greatly distended with black blood.—The lungs much congested, of a dark colour, which is the condition described by the older writers, by the term " putrid state." In the very few instances which have fallen under my own observation, I have not observed any structural disease in these organs; for, upon making sections, and squeezing them in water, they have resumed their natural appearance and buoyancy.—The heart, and veins near it, are gorged with blood; and sometimes an effusion of blood, or bloody serum, is found in the cavity of the pleura. In the abdomen dark-coloured patches are sometimes seen on the peritoneum, oc- cupying a considerable extent of the intestinal tube; and, upon cutting through these portions, all the tissues are found highly injected, and it is probable that this appearance has often been mistaken for mortification.—The liver is some- times gorged with blood and discoloured ; but when treated, like the lungs, in water, this organ is restored to its natural colour, unless it has been altered in structure by previous diseased action, when it is easily broken down, like coa- gulated blood. I have seen the spleen in the same state; but was not able, by washing, to restore it to its natural appearance. The stomach and intestines contained, in one instance, a dark, sanguineous-looking matter, like the black vomit. In corroboration of the above statement, as well as in proof of the patholo- gical and practical views yet to be detailed, I beg to subjoin a short account of some of the interesting cases and dissections described in the excellent work of M. Bailly,* whose zeal in the cause of science, led him to Rome in the sickly season, for the purpose of investigating the nature and seat of intermittent fever. " Case I.—Benoit Simouelli, set. 30 years, of a strong constitution, affected for some time with a tertian fever, came to the hospital on the 2d July 1822, " 3d, Had a slight febrile access, afterwards took !| ij. of bark. " 4th, Towards mid-day, he walked in the ward, -felt very well, and laughed with the other patients. All of a sudden, he was seized with violent shivering, to which succeed- ed a very high fever, during which he had alternate flexion and extension of the fore arms, and profound coma. He died ih six hours after the commencement of the attack. "Dissection the following day at 2 o'clock p. m.—Vivid injection of the whole of the arachnoid; color of the cinerititious matter of the brain much deeper than natural, ap- proaching a dark reddish grey; a little water in the ventricles. No false membrane on the arachnoid. Great inflammation of the stomach, especially towards its great curvature, which was every where of a deep, generally diffused red. Many worms in the small intestines, which presented also inflamed portions, epecially where the ascarides had collected. " Case in.—Pierre Donati, at. 28, of a good constitution, was brought to the Hospi- tal of Saint Esprit on the 2d August 1822. " An hour and a half after mid-day, he was seized with an accession of fever, which commenced by excessive coldness, followed by intense heat, and stupor. He lay upon his back, with his eyes half open. He awoke when any one spoke to him, and feU • Entitled Traite" Anatomico-Pathologique des Fievres Intermittentes, Simples et Per- nicieuses 1825. 54 INTERMITTENT FEVER. again into the same state of coma. His pulse was frequent and strong; the skin burn. ing. In the night copious sweating appeared, the intellectual faculties returned, and m the morning he was in a state to answer concerning his health. Took several ounces of bark. " 3d, The fever returned half an hour after mid-day. Commenced with a very vio- lent coldness, followed by heat, and stupor; but nevertheless he always awoke when any one called him, and he opened his eyes. The fore arms were bent upon the arms, and could not be extended; the teeth were clenched, which prevented the state of the tongue from being seen. Sensibility of the skin diminished. He lies upon his back. There is no pain upon pressing the belly. At half past two o'clock, general perspira- tion, but not so abundant as the firsti In the evening, return of sensibility and intelli- gence. Cessation of contraction of the arms. But the ideas are less clear. Other doses of bark. "4th, The morning of the third day after his arrival, at half past 7 o'clock; the pulse was frequent; stupidity; together with a drunken appearance. At 11 o'clock, a return of the cold, subsequent fever more violent; stupor more profound, coma, return of the rigidity of the limbs; subsultuse tendinum ; he always lies upon his back ; pulse full and strong. At half past three o'clock, sweat appealed, but less copious. After the sweat, he could not give an answer, and he was unconscious of his own state; ces- sation of the contractions. Died at 10 o'clock in the evening of the 5th. "Dissection 12 hours after death.—Lively inflammation of the whole of the arach- noid ; serosity between the circumvolutions, with engorgement of the vessels ; injection of the vessels of the lyra. The brain being raised, there escaped half a pound of blood. Some points of a red color in the stomach and intestines; liver gorged with blood ; spleen voluminous and easily torn. No morbid appearance in the chest. " Case IV.—Francois Lauretti, shoemaker, set. 60, of a lean constitution, fell sick on the 17th August 1822. He had the fever every day, beginning with shivering, and terminating in the night by sweating. At the same time he was constipated, and had pain in the epigastrium. Was brought to the Hospital of Saint Esprit on the 24th Au- gust. In the evening, the surface of his whole body was1 of a deep yellow citron color; said this color appeared during the last paroxysm; extremities cold, while he had a feel- ing of internal heat; tongue red and dry; pulse 108, like a thread. He had still so much recollection, that he smiled on seeing us approach him, for we had already spoken to him when he was brought to the hospital, and before he was yet put to bed. He complained of nothing, appeared quite tranquil, and replied perfectly to all that we asked him. " 25th.—In the morning he was found in a state of coma; and died at 10 o'clock, a. m. « Dissection -The body was of a lemon yellow color. On opening the head, the dara mater was tinged as yellow as the skin; by repeated washing this tint could in part be removed ; but on holding it to the light, the diminution of color was scarcely percept- ible ; injection of the arachnoid ; cortical substance of a deep color ; yellowish serosity between the convolutions. On slicing the brain, a number of red points were seen ; a little water in the ventricles : the cerebellum natural; the lungs healthy; the cavities of the heart appeared to us larger than usual; in the right ventricle, was a clot entirely formed of albumen, as yellow in color as that of the skin and dura mater. The belly, before being opened, was concave, and resting on the vertebral column ; the stomach contracted on itself; it was every where of the color of lees of wine: Although it was well washed, there adhered to its surface a thick mucus, similar to the tenacious ex- pectoration of patients laboring under pulmonary catarrh. The smaller curvature and INTERMITTENT FEVER. 55 a portion of the greater, presented that kind of eruption described at No. 30. When examined with a lens, it offered nothing more remarkable than to the naked eye, only instead of appearing to consist of small perfectly round elevations, and entirely separa- ted from each other, they communicated by their bases. The redness of the stomach was less lively towards the pylorus but it began immediately at the duodenum, where it was very intense, and continued without interruption in the small and large intestines. The gall bladder was green externally, and filled with a black and thick bile; on press- ing it strongly, only a few drops could be made to pass into the duodenum; the orifice of the ductus choledochus could not be distinguished, in the midst of the red, bloody, and swollen folds of the mucous membrane of the duodenum, but by this means. The ductus choledochus being opened, presented nothing remarkable, except that its mouth was drawn into the duodenum, in consequence of the swelling of the inflamed tissue of the latter. The liver was of ordinary consistence; its color was of the yellow of pow- dered bark: this is the only time I ever saw it in ^this state. The spleen was of the usual size, and quite diffluent. " Case V.—Jean Oliver, set. 40, of a good constitution, was brought to the hospital on the 6th July. He was then without fever. In the evening the fever came on, pre- ceded by shiverings, and followed by violent heat. Pulse strong, 120; coma. He lies upon the back. Right arm immoveable. The left arm bent and carried towards the head. Sensibility every where. When an attempt is made to open the left eye, he ap. pears to experience pain, and contracts the eyelids. Belly painful. "7th, in the morning.—Coma; lies upon the back; pulse strong. 108. He died at seven o'clock, p. m. " Dissection.—Injection and thickening of the arachnoid; engorgement of the vessels which run on the convolutions, which are separated by watery exudations; the left lyra greatly injected; watery effusion at the base of the brain; phlegmonous eminences in the stomach, which were of a grey slate color; invagination of the small intestines; spleen voluminous and pulpy. «' Case VI.—Vincent Orsini, aet. 60, came to the hospital the 3d July 1822, in the fol- lowing state: Coma; pulse insensible; extremities cold; demi-flexion of the two thora- cic extremities; when an attempt is made to extend them, a resistance is felt on the part of the flexor muscles. Left eye half shut, right eye open, pupils dilated, immo- veable; tongue dry, lying in the very bottom of the mouth. He manifests pain when pressure is applied to the belly. Died the same evening. " Dissection.—Vivid inflammation of the arachnoid, with great injection of its vessels. There escaped some serum, which was situated between the dura mater and arachnoid. A fibrous tumor of the size of a large nut, adhered to the dura mater, under the poste- rior angle of the parietals, and compressed the brain; although the injection of the arachr noid was very lively on both sides, it was, however, greatest on the left. Hydatid in the choroid plexus, the size of a small pea. The water that was between the arachnoid and dura mater was more abundant on the left side than on the right;, brain pretty soft. General inflammation of the stomach; the S. of the colon was of a brownish red., " Case VII.—Donato Fanti, a collier, xt. 50, was brought to the Hospital of Saint Esprit, in a comatose state, which continued even till death. Pulse strong, beating 80 times in a minute; when the extremities were pinched, the patient manifested pain; his skin was hot and moist; when they opened his eyes, he did not direct them to any ob- ject. It was impossible to see his tongue, because his jaws could not be separated suf- 56 INTERMITTENT FEVER. ficiently. He only complained of pain when he was pressed in the region of the hver, and did not appear to suffer any thing when pressed on any other part of the belly. "Dissection.--On opening the cranium several ounces of blood escaped; the arach- noid was strongly adherent to the dura mater by granulations resulting from old inflam- mation; the vessels of the brain were very much engorged, on slicing it drops of blood escaped from the divided vessels, which reappeared even after wiping. The liver was blackish; it appeared composed only of black blood, slightly coagulated, and of cellu- lar bands, which alone offered some resistance to the finger: where this weak resistance was overcome, the liver was but of the consistence of thin jelly; for the blood appeared effused in its tissue, which resembled a pulpy mass. The intestines were inflamed in several points, and each inflamed portion corresponded to some knots of worms which were still alive. The lungs, the spleen, and the stomach were healthy. " Case IX—.Joseph Totti, horse doctor, of a sanguine bilious temperament, strong constitution; was accustomed to go down every year to marshy situations, to direct the workmen in seed time, or at the harvest, which occasioned obstructions in the spleen and liver. In 1811, in the time of harvest, being then aged 40, and working with great activity, he was affected with an intermittent fever, which continued till the third pa- roxysm. At last he returned home; the fatigue of the journey procured for him a very short sleep. I saw him in the fifth paroxysm, when he was in the following state; Agi- tation; impossibility of finding a position which procured rest; pain under the right false ribs, mounting to the top of the shoulder, and extending to the left hypochondri- um; pains in the articulations; head heavy; tongue covered with a white crust, bitter taste in the mouth, vomiting, thirst; face livid; pulse irregular, neither soft nor hard; great difficulty in respiring; urine red and clouded. He got an injection to loosen the belly. He had little repose during the night, for the fever returned, preceded by a general coldness over all the extremities, and the pain in his side was aggravated. " 6th day.—A frequent dry cough without expectoration. The emulsions had eased the thirst. Had no appetite. The bitter taste in the mouth had disappeared. A pound of blood was drawn from the arm, the coagulum was almost soft; the serum wis livid. At the return of the fever, the cold only attacked the extremity of the feet. " 7th day.—The pain worse and worse; the difficulty of respiring still greater; fre- quent eructations; urine always the same. As the tongue was white, and as he had had no stools after the lavement, he took |ji of manna, which produced a bilious stool. In the night he had no sleep; delirium. " He became gradually worse, and died on the fourteenth day, when in the act of raising himself to speak to his confessor. "Dissection.—The body offered nothing remarkable but tension of the belly. In the abdomen, there was a sanious effusion mixed with a little blood. The liver was pu- trid and tuberculous; this affection commenced towards the convex part, extending it- self on all sides, and descending towards the concave part; nevertheless, the greatest destruction was on the convexity; the rest was engorged and inflamed; its volume was natural. The gall bladder contained a little thin clear bile, not viscid. The inferior face of the diaphragm was erysipelatous; the stomach and small intestines were full of water; the spleen double the ordinary size, and of a black color ; the exterior surface of the right lung was covered with a white crust, the inferior part adhered to the pleura costalis. •«Case X.__Dominique de Marco, at. 30, of a good constitution, was affected with a simple tertian fever since the 24th June 1822. On the evening of the 7th July, he was seized, according to the report of his parents, with an accession of the pernicious, comatose intermittent. He arrived at the hospital on the morning of the 8th July, and INTERMITTENT FEVER. 57 he was in the following state: Coma; decubitus on the back; face red; fore arms bent and contracted; pulse 112; convulsive trembling of the fingers; legs stretched and im- moveable; sensibility every where. They made him swallow three ounces of bark in six hours. " At 2 o'clock.—Pulse 100; sinapisms to the feet. " 9th, in the morning.—He is in a sweat; remission of the fever; pulse 88 ; a watch- ful coma ; he hears, but does not answer, although he looks ; two hours later, pulse 92, very full; several ounces of bark. " Evening.—Pulse full, strong, 96 ; profound coma; resisting stiffness of the right arm ; he cannot shew his tongue ; skin hot, and always moist with sweat. To make him swallow the bark, it was necessary to pinch his nose, and hold his mouth open with a key ; afterwards water was poured in, which he kept in his mouth, and finished by re- jecting it. He has taken seven ounces of bark through the course of the day. "10th, in the morning.—Pulse, 140, strong and full; coma; flaccidity ; general im- mobility ; mouth open ; blood was taken from the jugular; respiration stertorous. Died towards mid-day. " Dissection.—Injection of all the vessels of the arachnoid, even to the very smallest ramifications, and on both sides ; but on the right side, and upon the anterior lobe, it was of an intense red, without any distinction of vessels ; when it was torn away from the convolutions, the pia mater was also removed; it adhered so intimately to the arachnoid, as to resemble one membrane, red, very thick, and in the tissue of which blood was effused, which appeared immediately to coagulate ; little water in the ventri- cles ; the brain of the ordinary consistence ; when it was cut, there appeared a great number of red points, which immediately became the seat of large drops of blood ; the arachnoid of the cerebellum was also highly injected, the consistence of that organ was natural. Stomach grey, externally, contracted, slightly inflamed; small intestines pre- sented two invaginations ; a portion of this intestine white, transparent, distended with gas ; the rest grey and contracted ; in three places all the circumference of the tube is red, both within and without, occupying the space of three inches in length ; all the large intestine is white, &c. &c. Liver gorged with blood ; spleen weighed between two and three pounds, and reduced into a grey, pulpy state. " Case XI.—Paul Tossini, set. 30, of a good constitution, was taken on the morning of the 29th June with a fever, which commenced with heat, and which returned every day until the 6th July, when he arrived at the hospital. . He had had thirst, bloody stools, tenesmus, enlarged spleen ; and he had taken cooling drinks and a purgative He is now in the following state : His appearance is stupid ; somnolence rather than coma ; general pain of head. The patient only appears to be drowsy, for he is easily awoke, and understands sufficiently well what is said to him ; decubitus on the back, the knees are drawn up, but he cannot extend the thighs without experiencing pain ; during his slumbers the right eye is partly open, the left shut; it is impossible to de- press the lower jaw, without producing suffering ; the tongue is dry, red, covered with a black crust, which extends from the point towards the middle, the breadth of which is not more than half an inch ; the, tongue is drawn a little to the right; at intervals, slight convulsive movements of the hands ; pain of belly upon pressure ; skin hot, dry, pulse 120. When the right arm is extended the flexor muscles contract, and the pa tient seems to suffer much pain ; but when once extended it continues so. " In the night, bloody dejections, extremely fetid; declination of the paroxysm, which returned on the 7th in the morning ; at seven o'clock the patient complained of cold. I did not see him till six o'clock in the evening, when the paroxysm was begin- ning to decline ; the skin was hot and moist; the lips were encrusted ; the pulse was 58 INTERMITTENT FEVER. not to be felt; respiration hurried; the two fore arms bent, when it was wished to ex- tend them, above all the right, violent pain was produced ; preservation of sensibility, every where ; sometimes the right eye a little open, the left being shut. He had seve ral convulsive movements this morning and towards mid-day. He took kino before the accession at the moment when he already felt the cold. Increase of coma-; died at hall past seven o'clock in the evening. " Dissection—General injection of the arachnoid, particularly that part which coven the cerebellum and the lateral part of the commencement of the spinal marrow. The injection of the right side was a little more intense than that of the left, although it was otherwise as vivid as it is possible to imagine, for it was not a simple injection, which merely shows the smallest vessels. The arachnoid was of a deep red, as if all its tissue were penetrated with blood. The brain presented nothing remarkable. The intestines were injected in the same manner, from the oesophagus even to the anus ; their whole thickness appeared to be impregnated with blood ; they were not either thicker than natural, nor contracted; on the contrary, they were distended with flatus. Spleen weighed from eight to ten pounds ; when it was put upon the table it became flat like a. bladder half filled with water ; its tissue was reduced to a pulp. '•Case XIII.—Francois Pompeii, eet 19, was seized on the 1st July 1822 with an ac cession of fever, in consequence of a sudden chill which he experienced on entering a cool grotto when his body was covered with sweat. He was brought to the hospital on the 2d July at six o'clock in the evening. Before he arrived, he had a considerable epistaxis. He was in the following state ; profound coma, eyes widely opened, directed to the right, fixed ; expression besotted ; general immobility ; decubitus on the back; insensibility of the extremities when pinched, they were quite flexible. He did not answer the questions which which were put to him ; the direction of the eyes did not change even when one approached him. He manifested pain when his stomach was compressed ; skin burning hot; a white cedematous swelling of the face ; his parents said that this tumefaction had come on since the disease, for previously he had rather a thin face. This access continued until Wednesday morning the 3d July ; he then took an ounce and a half of bark. " 4th July, Thursday morning.—The paroxysm returned, at the commencement of which, he could still give answers to the questions put to him, but the coma went on in- creasing, and with it all the symptoms above described ; the pulse was strong, vibrating, full, beating 84; the same direction of the eyes to the right, the same immobility of these organs, and of the extremities ; respiration short. Eight leeches to the ears; died at ten o'clock in the evening. "Dissection.—Several ounces of blood flowed from the nose in the dead room ; in cutting the scalp, more blood escaped ; the whole might have weighed a pound. Gene- ral engorgement, of all the vessels which ramify upon the convolutions ; the brain, still covered by the dura mater, gave a feeling which made us believe that there was a fluid in the interior, nevertheless there was only a little serosity in the ventricles; the sub- stance of the brain was of the natural color. All the intestinal tube, without any excep- tion, presented a red appearance, which was owing to a general injection of all the vessels, even in their smallest ramifications. It would be difficult to inject so perfectly the vessels either of the intestines or of the mesentery, as they were in this body. The intestinal tube, although a little transparent, was penetrated with this congestion through- out its whole thickness ; every thing indicated the first stage of a violent inflammation that is to say, of a sanguineous congestion. "Case XV.—Thomas Adami, set. 20, was brought to the hospital on the 23d August, 1822. He was delirious ; they were obliged to secure him. After mid-day the delirium INTERMITTENT FEVER. 59 subsided. A profound and intense coma succeeded ; the pulse was strong, hard, and beat 85; the extremities were flexible, but motionless; decubitus upon the back; pupils immoveable; features swollen and intensely hot; general insensibility. Body covered with a clammy sweat. In the evening the respiration was more hurried, and very much embarrassed ; pulse not to be felt; froth was discharged from the mouth ; he was insensible even when his skin was pinched ; died at one o'clock in the morning. " Dissection, eleven hours after death.—General inflammation of the arachnoid, of which the very smallest vessels were injected; no serosity ; the cortical substance was of a deep red, compared with that of a subject dead From a shivering fever, (Jafi6vre algide,) which we shall notice by and bye, &c. &c. " Case XVI.—Antoine Turianne, aet 12, of a good constitution, was brought to the hospital on the 23d July, 1822, at four o'clock in the afternoon. He was in the follow- ing state : Commencement of stupor, his answers are slow, and not quite correct; the questions put to him made him discontented and unhappy ; agitation ; he turns himself on all sides in his bed ; eyes open and stupid ; skin hot and dry. (Bled to 8 oz.; lave- ment; tisane.) In the evening, increase of stupor, in consequence of the accession of another paroxysm, coma profound, eyes open, pupils contracted and immoveable, the fore arms bent upon the arms, no pain on pressing the belly. Sinapisms to the feet. " 24th July, in the morning.—Continuation of coma ; pulse 124 ; head intensely hot; flexion of the fore-arms ^ it is impossible to depress the inferior jaw. Bled at the feet to 8 oz. In the evening, remission of die fever and of the convulsive symptoms : skin slightly moist; it was necessary to pinch his nose to make him swallow ^ij. of bark. " 25th, in the morning.—Return of the fever, and the flexion of the fore-arms ; con- tinuation of the stupor ; does not reply to questions ^ insensibility of the skin of the legs, that of the arms sensible i head intensely hot; decubitus on the back ; eyes open. Boiling water applied twice to the feet; the patient did not feel it very acutely. Pedilu- vium during six minutes; snow applied to the head; the pulse fell to 82. Return of intelli- gence, he swallowed voluntarily the bark $ but a httle afterwards, violent agitation of all the body came on ; the inferior extremities, which from the commencement were cold, were neither heated by the bath, nor inflamed by the application of boiling water and sinapisms. Of the four ounces of bark, which they made him take, he vomited more than two ; neither could he retain the bark injections which were exhibited. He re- mained in this state till 6 o'clock in the evening; the coma returned, and he died at 7 o'clock. " Dissection.—A very vivid injection of all the arachnoid; between its folds there was a membrane produced by the coagulation of effused blood; much serum between the convolutions, and at the base of the cranium ; the cortical substance very red. The stomach natural; the small intestines contained a prodigious collection of worms ; the inflammation was sufficiently intense in this part. The colon was contracted, its walls very thick, and the internal membrane much inflamed, of a dark red color. " Case XXX.— Joseph Maoloney, set. about 60, came to the hospital on the 21st Sept. 1822. He had been sick for five days. His answers were so confused, it was impossible to find out what had been his previous state, further than that he said he had vomited some bitter stuff, that he was tormented by thirst, that he had suffered great distress, and had pains in the epigastrium. In the evening, tongue dry, vividly red round the edges; constipation, nausea without vomiting, heat natural over the extremities and the thorax ; a burning heat in the epigastrium ; anguish; severe pain in the stomach under pressure ; pulse small, frequent; lavement of barley water—gum-water"—fomentations to the belly. During the night, vomiting, and had a stool. 6t> INTERMITTENT FEVER. " 22d, in the morning—Pulse more expanded ; the ideas still confused, diminution of agitation, heat natural every where ; tongue dry, thirst. Same treatment. About half- past 9 o'clock he had vomited the tisane with mucus, bile, and several lumbrici. About half past 11 o'clock, stupidity, pains in the epigastrium increased. At 3 o'clock p. s. lancinating pain of belly ; pulse small, frequent; extremities cold, and bathed in cold clammy perspiration ; inferior extremities bent up upon the belly. Bled from the arm, died in half an hour afterwards. " Dissection.—Injection of the vessels which ramify upon the convolutions of the brain ; substance of the brain presented an infinite number of small drops of blood; three or four ounces of water at the base of the cranium ; lungs natural, crepitating In the belly there were fifteen or sixteen ounces of dark blood, running like oil ; spleen ruptured at its inferior part, not by a fisssure as in other cases, but presenting an open- ing the size of a dollar, out of which came a dark and putrilaginous substance ; it was impossible to raise the spleen without breaking it, it was so diffluent; it separated in the hand into two portions, of which one when placed on the table became flattened like jelly, and the other portion remained attached to the diaphragm, which they were obliged to cut out to expose the spleen completely ; it was not much increased in volume. The stomach was of a reddish brown in the greatest part of its extent; inflammation of all the rest of the intestinal tube ; rose colored within ; bladder natural; liver gorged with blood. " Case XXXVIII.—Angelo Galetti, act. 18, of a good constitution, was brought to the hospital on the evening of the 29th July. The patients who were near him said, that during the night, he complained continually of sharp pains in the belly. Took an ounce of bark ; the whole of the body was as cold as ice. " 30th, 8 a.m.—Legs, thighs, fore arms, arms, cheeks, of an icy coldness; the belly, chest, and forehead were of rather a lower temperature than other parts of the body ; pulse insensible at the wrists ; I could feel it but very feebly in the crural arteries, it beat 100; the patient trembled and complained continually ; his most common position was on the left side, with the thighs bent on the belly. He understood what questions were put to him, but not sufficiently well to give proper answers ; he never entered into any detail; and died at half-past nine. " Examination three hours after death.—The small intestines slightly distended with gas, were externally of a purplish red. " The internal membrane was of the same color, so that the violent injection of which they were the seat, had existed through the whole thickness of the substance of the intestine. This injection was recent. Inflammation of the upper half of the caecum. The whole of the great intestine was white external- ly ; on being opened, it presented an inflammation, the violence of which was greater towards the rectum, where the mucus membrane was so intensely inflamed, that some blood had been effused, wliich mixing with the mucus formed a thick coating, which ad- hered to the whole of its surface. The colour of all the interior of the colon, and es- pecially of the rectum, was of a lively, intense red : in a word, the most violent degree of inflammation that can exist without disorganization. The stomach was pale • after being washed, it presented, near the pyloric extremity, an infinity of little depressions, from half a line to a line in diameter, and some of which contained in their bottom a small spot of blood, which was easily removed. The folds of the mucous membrane were, besides nearer each other, and more numerous than ordinary. The mucous coat itself was thickened. The liver was healthy. The spleen krge and pretty hard but of a redness of the lees of wine. Slight adhesions of the right lung ; the same between the whole surface of the heart and pericardium ; they were easily destroyed. Injection of the arachnoid, engorgement of the vessels which ramify on the convolutions and of those which compose the choroid plexus. INTERMITTENT FEVER. 61 *« Case XXXIX—Vincent Crescenzi, set. 60, of a thin but healthy habit of body, feil sick on the 19th of August, 1822. He was attacked with fever, which set in with shi- verings, followed by extreme heat, pain in the head and belly, vomiting of bilious matter. During the night, the paroxysm terminated in sweating. He was brought to the Hos- pital of Saint Esprit on the 19th August, 1822. The fever returned in the morning, preceded likewise by shiverings, and accompanied by the same symptoms as in the eve- ing; the stomach was painful on pressure ; the patient experinced a great heat in the inside ; anxiety ; depressed countenance, the features were as if flattened to the bones of the face ; the colour of the face was natural, the expression dull.—(Half an ounce of bark on the decline of the paroxysm.) " Evening.—Decline of the symptoms ; skin wet with a cold clammy sweat; pulse small, frequent; general shivering ; pain at the epigastrium ; tongue red, but moist; no thirst. (Half an ounce of bark.) " Night.—The skin remains moist and cool. The patient has vomited the bark. " He had several paroxysms afterwards ; became worse, and died on the night of the 23d, sensible .to the last. "Dissection.—Slight injection of the arachnoid; engorgement of the vessels which' ramify upon the convolutions ; an effusion of yellowish serum between the foldings of the arachnoid; cerebrum and cerebellum natural; heart and lungs healthy. Stomach grey externally and contracted. Inner surface of a bright red, deeper still towards the pylorus. Foldings of the mucous membrane better marked than usual. Small intes- tines grey externally and contracted. Internally their redness was brighter than that of the abdominal muscles, which afforded us a point of comparison. To give an idea of this inflammation, the colour of the large intestines could be compared to that which they would receive were they soaked in black blood. This inflammation increased as it approached the S. and the rectum ; liver healthy ; spleen of a middling consistence, be- tween the state of degeneration and health. This inflammation could be compared only to that of the 30th case. " Case XL.—Vincent Cola Paolo, of Rimini, jet. 40, of a good constitution, residing at Roma Vecchia, entered the hospital on 7th July. Had been attacked with a pa roxysm of fever on the previous evening. On the morning of the 7th, his state was the following :—Hands colder than those of a dead person ; pulse 108, small, contracted ; hiccup regular in its returns fourteen times in the minute ; position supine ; sighs drawn easily ; answers pretty correctly, he experiences pain in the region of the liver. In the evening, the fit declined, and the hiccup disappeared. " On the morning of the Sth, senses completely restored, with his natural expression, which, during the paroxysm, assumed that particular aspect, which characterises those labouring under the fever ; but the hands have always an icy coldness Which extends half way up the fore arm ; he is not aware of their being cold; but on placing them on his belly, he at once becomes sensible of it; he speaks as if he were in a state of health. At nine o'clock, his appearance became as if besotted; he replied with hesitation and re- luctance. Has an inclination to sigh. He lay on the side, with the legs bent upon the abdomen ; the fit commenced, the cold gained upon the trunk, respiration became short, some tendency to hiccup ; in short he died at three in the afternoon. He took some bark during the apyrexia. " Dissection.—General injection of the arachnoid, which is thicker than natural, red, and as if doubled by a sanguinolent false membrane ; the vessels distributed upon the circumvolutions of the brain are engorged; the stomach is much inflamed in its pyloric half, the rest of the intestinal canal healthy. 62 INTERMITTENT FEVER "Case XLI.—Angelo Donni, of Milan, set. 35, weak, lymphatic constitution ; prepar- er of macaroni. On the 5th July, 1822, he entered one of the grottos of Monte Te9- taccio, when he experienced a general sense of cold, which he attempted to shake off by drinking seven or eight glasses of wine ; but could not however warm himself. He then felt a great weakness, which was the predominant symptom during the six days previous to his entering the hospital. His state had so little of a decided febrile cha- racter, that according to his account, the medical man could not tell him if he had had the fever. He had a sense of general uneasiness ; took an emetic and a purgative, and returned to his work; but the general state of disease and uneasiness increasing, as likewise the weakness, on the I lth of July in the morning he came to the hospital of Saint Esprit, on foot, supported by a man on each side. Being arrived in the 1st ward, where I first .saw him, he seated himself upon a form, and appeared to feel ill. He let himself fall down upon the right side, but the expression of his countenance was not that of a person fainting. There was something in the motions of his head, of his eyes, resembling those symptoms produced by drunkenness, and not that want of power oc- casioned by the cessation of the motions of the heart. He was merely supported, and recovered, and he was then enabled to ascend more than 30 steps, in order to reach the clinical ward. When in bed, the following was his condition ; pulse frequent, weak; temperature of thighs, legs, hands, and arms, cold ; tongue moist and not red. He was able to give a history of his previous state, nevertheless he begged the physician to question his companion, who accompanied him to the hospital, for although he had neither delirium, nor coma, nor syncope, he appeared so confused, so little master of his ideas, that he declined to give any account of it. All he assured us of was, that he had never had the fever. In the afternoon he was twice ill. " Evening.—Pulse scarcely perceptible, great pains, extremities cold, the left hand more so than the right; it is of a livid colour. Temperature of the belly, and the chest, almost natural; face pale, delirium, agitation, inquietude. (Decoction of bark 3j viij. Extract of bark, theriaque, a a. 3 ij. Laud. liq. anod. camph. emuls. a a gr. xx. blisters to the thighs.) " 12th July.—At half past one in the morning, sweat general and copious, but cold. In the morning at the visit, weakness the same; pulse insensible at the arms, which are cold, as also die thighs ; the belly is a little warmer, but it is also below the natural temperature ; pulse at the temples 114. The blistered surface pale, no water under the epidermis, which remains only detached. He has lost no part of his judgment, but manifests a tendency to drowsiness, complains of no pain, the belly is not tender on pressure ; the principal ailment is great weakness. (Blisters to the arms. Bark £ ij. in wine.) " A little later, return of the same symptoms, alternating with delirium and drowsi- ness ; general and intense sense of cold ; died at half-past five in the afternoon. " Half an hour after his death, the. body was warmer than during life. " Dissection.—Stomach highly inflamed between its great curvature and the pyloras. Intestines presenting traces of inflammation in some points. Spleen soft and pulpy, liver healthy, old adhesions of right lung. Before opening the cranium, the head was separated from the trunk, when there escaped by the occipital foramen a great quantity of bloody serum. Injection of the arachnoid in its minutest ramifications, but a little more on the left than on the right side. Great engorgement of the vessels distributed On the circumvolutions, more marked on the left side. Grey substance of the brain, of a pale, rather than of a deep hue ; choroid plexus pale ; serosity between the circumvo- lutions ; brain of a soft consistence." INTERMITTENT FEVER. 63 From these and other cases it appears, that M. Bailly found in thirty-three dissections, more or less extensive disease in the brain: in twenty-two of these there was thickening, and other marks of inflammation, in the arachnoid coat; and in eleven, inflammation of the substance of the brain. In twenty cases there was gastro-enteritis. In four cases gastritis by itself, and also four of en- teritis, uncomplicated with gastritis. In eleven the spleen was softened; in some instances enlarged; one weighed from two to three pounds, and another from eight to ten pounds. In two cases the spleen was large and hardened. In three cases the spleen was ruptured, and in one it was gorged with blood. In two cases the Uver was softened; in four gorged with blood; and in one case inflamed. In one case the gall-bladder was inflamed. In two cases there was pericarditis. In three, peritonitis. In one, pneumonitis. In one case there was inflammation and enlargement of the parotid. These statements respecting the appearances on dissection in intermittent fever, will be found fully corroborated in the works of Morgagni, Pringle, Cleg- horn, Chisholm, and Fellowes. Causes of Intermittents. In point of form, I ought now to treat of the causes of intermittent fever, but having explained myself so fully on this subject, when treating of the causes of fever in general, at page 44, it is unnecessary to do so in this place, further than to repeat my conviction, that the effects of internal irritations, sudden va- riations of temperature, and of evaporation, as causes producing intermittents, have hitherto been too much overlooked. Pathology of Intermittents As there are three distinct stages in this disease, it will be proper to treat of the pathological condition of the body during each. Cold stage.—Perhaps, the first link in the chain of morbid action may be in the nervous system; there is decided evidence of its being involved from the beginning to the termination of the disease. But as there is nothing to guide us in the investigation, I shall not enter into it. The first circumstance which we distinctly perceive, is diminished circulation of blood in the extremities, then a sense of coldness, and with it a feeling of weakness. These are evidences of an irregular determination of blood, by whatever cause produced; and in proportion as blood accumulates in the vessels of internal organs,* their func- tions become impeded. The lungs shew their gorged state, by the dhort, diffi- cult, and anxious breathing; by the impossibility of inflating them beyond the least degree; and by the violent dry cough which occasionally takes place. The livid appearance of the cheeks, lips, and mucous membrane of the mouth, is an * This is the state termed congestion, which implies, that the balance between the ar- terial and venous system is deranged for the time, the latter being overloaded or con- gested with blood, and not that the circulation in any organ, or set of organs, is ent'uelj obstructed, which nevertheless does actually happen in those extreme cases in which re action does not take place, and the individuals die in the cold stage. 64 INTERMITTENT FEVER. additional proof of the embarrassed state of the lungs, shewing that the blood is not properly de-carbonized. The disordered functions of the brain in this stage, depend, I imagine, principally upon the gorged state of the lungs, and also upon the overloaded state of the right side of the heart, preventing the free return of blood from the head. The disordered functions of the brain may also be produced by a change in the balance of the circulation of the vessels of the head, independently of the state of the lungs and heart. The tremors may pro- bably be attributed to congestion of the vessels of the brain and spinal marrow. The sense of cold seems to be owing partly to the state of the nervous system, and partly to the state of the lungs. The pain in the head and loins, and op- pression at the praecordia, may be fairly attributed to the same causes. The muscular prostration, and feeling of sinking, are not owing to actual debility, but to obstructed action, in consequence of the above-mentioned condition of organs. The proof of all which circumstances is to be found in the fact, now well known, that abstracting blood, in the cold stage, will immediately remove not only the difficulty of breathing, the pain in the head and loins, the disorder- ed functions of the brain, (when these exist,) the oppression at the praecordia, &c, but will also stop the rigors, restore the strength of the pulse, increase the heat of the whole body, and cause the sensation of cold to vanish in an instant. Cullen and others believed, that all the subsequent phenomena of fever depend upon the cold stage, which, although a mere hypothesis, is now for the first time proved to be true. The pathological views which are still taught in most of the schools of Great Britain may now be stated, and this shall be done in the words of the late very celebrated professor of physic, Dr. Gregory : " The languor and debility depend upon diminished nervous energy ; the uneasy feelings, on muscular debility ; the paleness of the face and extremities, and shrinking of the features, are owing to spasm of the extreme vessels; the coldness is to be explained by the blood being propelled from the surface by debility, or prevented from entering the ves- sels by the spasm; thus the cold may be produced either by the spasm or by the debility; the tremors depend upon debility of the muscles, but there is also some irregularity of nervous energy; the breathing during the cold stage is small, frequent, and anxious, owing to debility of all the muscles that serve for respiration, while, at the same time, the congestion of blood produced by the weakened action of the heart, would require the breathing to be often repeated, and the respirations to be fuller than natural, which circumstance tends to in- crease the uneasiness; the heart partakes also of the debility; this debility of the heart produces an accumulation of blood in the great vessels, and this oc- casions that unusual motion of the organs of respiration, termed yawning Want of appetite, nausea, and vomiting, are owing to debility of the fibres of the stomach. Costiveness is produced partly by spasm. Failure of attention and memory, and also delirium, are owing to debility." On perusing these statements, the reader will observe sufficient proof of the pathological condition of the body, which I have described, but instead of attri- INTERMITTENT FEVER. 65 buting it to the same state of organs, he places spasm and debility as the cause of each phenomenon ; thus most unphilosophically, like the rest of the disciples of the Cullenian school, he makes the facts to suit the doctrines. Influenced/ as this distinguished man's mind was, by such erroneous pathology, it is no wonder that he should have pronounced the following dogma: " I have no doubt, therefore," said he, " that the causes producing fever, act first by inducing de- bility ; and accordingly we find, that stimulants employed at this period have produced good effects in checking this disease, while evacuations, as blood-let- ting, which, at another period of the disease, might have been proper, if em- ployed in the first stage, never fail to be attended with most dangerous conse- quences ; or it is, to use the words of Celsus, " hominem jugulare." I shall now show that this is a statement which Celsus never made with refer- ence to the cold stage of intermittent. On a careful reference, I find no allu- sion made to such a practice in his works; but in treating of the danger of bleeding in vehement fevers, he expresses himself thus,—"Quod si vehemens febris urget, in ipso impetu ejus sanguinem mittere, hominem jugulare est." Lib. ii. cap. 10. It appears to me that Dr. Gregory was led into this error by a statement made by Sir John Pringle, who, in allusion to the good effects of bleeding in the camp fever which he describes, observes at page 210, (Obser- vations on Diseases of the Army, Ed. 1768,) " A person unacquainted with the nature of this disorder, and attending chiefly to the paroxysms and remis- sions, would be apt to omit this evacuation, and to give the bark prematurely, which might bring on a continued inflammatory fever. A vein may be safely opened either during the remission or in the height of the paroxysm; for besides that I have observed the remission to come sooner and fuller after hemorrhage, I have repeated experience of the safety of bleeding in the hot fits; and not only in this, but in the marsh fever, even after it had come to almost regular inter- missions. In order to make Celsus's maxim (he quotes the above passage from lib. ii. cap. 10,) consistent with this practice, we must interpret his terms impe- tus febris in the sense of that dullness or cold fit which preceded the hot one in the fevers which he describes, for then indeed bleeding would be improper." This is straining an author's statement to suit other views with a vengeance. The meaning of Celsus is clear and precise,—he makes no allusion to the cold stage. This shows how liable we are to be misled by the authority of a name. Hot stage.—Acting upon the principle of not inquiring into occult causes, very little need be said respecting the circumstances which produce the re-action; but there has long existed a pretty general belief that the blood accumulated about the heart, in the cold stage, proves a stimulus to that organ, and produces re-action. In this manner Dr. Gregory and others make the spasm of the ex- treme vessels the cause of the diminution of blood on the surface ; and then he observes,—" The blood thus driven upon the internal parts, must accumulate in, and prove a stimulus to, the heart and great vessels." The next question comes to be, how is this effected? The truth is, that we know nothing of the matter; and, after all, it is perhaps best to attribute it to 9 66 INTERMITTENT FEVER. " the principles of life," or, in the language of Cullen, to the " vis medualrtx nature," which is ever in action, to prevent injury, and to remedy the evil after it has occurred. The phenomena which are ascribed to the state of re-action, are those, the combination of xohich is denominated fever; namely, hot and dry skin ; quick pulse; thirst and loss of appetite ; restlessness and anxiety; head- ache, and occasionally delirium; hurried respiration; dry, furred tongue, &c. With respect to the heat and dryness of the skin, the old opinion of Boerhaave need scarcely be alluded to, who attributed this condition to the friction of the globules of the blood against the sides of the vessels ; neither is it necessary to dwell upon the still older opinion, which attributed the heat to fermentation; nor is it requisite, after what has been previously stated in this work, to say a word more respecting spasm of the extreme vessels. The heat and dryness of the skin in the second stage of intermittent are, no doubt, owing partly to the sup- pression of the secretions and excretions ; also, probably, to some change in the nervous system, but principally to the increased quantity of blood driven to the surface of the body. Sioeaiing stage.—it has been stated that, in general, in cases in which no or- ganic lesion exists, the pains and uneasy feelings begin to subside after the com- mencement of the sweating, and soon afterwards disappear. An interesting question here presents itself: how does the perspiration produce the effect? It appears to me that it acts in two ways ; first, cooling the body by evaporation; and, secondly, it moderates the force and frequency of the heart's action, by de- pleting the system. It is impossible to state the precise quantity of fluid per- spired in such cases ; but, if I can trust the hasty, and far from accurate obser- vations made respecting this point, by placing oil-skin on the outside of the bed- clothes, I am inclined to believe that it amounts to considerably more than two pounds ; and it must be kept in view, that this discharge comes directly from the blood itself. Treatment of Intermittents. It was formerly a matter of high dispute among physicians, whether an inter- mittent fever ought to be immediately cured, or allowed to run its course. Many believed that the system is benefitted by the disease,—that the febrile symptoms, in fact, are the natural cure of some other disorder in the constitu- tion,—and they argue that curing it must be hurtful. Some still assert that the disease will cure itself; and therefore, that it is improper to apply any remedies, except laxatives, to keep the bowels open. The best maxim in physic is, to get rid of diseased action as quickly as pos- sible, there is no saying what mischief is to follow in the train of consequences. •* There could not be a moment's hesitation," says Dr. Fordyce, " in deter- mining to restore the patient to perfect health at once, were tliere any remedy or mode of treatment that would certainly prevent the returns of the paroxysms of a tertian intermittent, and take off the symptoms remaining after the crisis, so that no other disease should follow. But there most undoubtedly is no me- INTERMITTENT FEVER. 67 dicine uniformly efficacious, or that always leaves the patient in tolerable health, and secure of not being destroyed by the remains of the disease, or by any other disorder arising in consequence of it."—" Were there any such, why should different practitioners attach themselves to particular varieties of bark; recom- mending the brown, the yellow, or the red, with such decided preference? Why should they prefer arsenic or zinc, if any one were uniformly successful ? The discovery of such a remedy has always been a great desideratum ; and although no one remedy has yet been found out, I believe bleeding, in the cold stage, conjoined with the occasional use of the sulphate of quinine, and laxa- tives, to be as certain a mode of treating intermittents, as any other set of re- medies can be said to be certain in the treatment of any other class of diseases. Treatment in the Cold Stage.—As the cold stage demands different manage- ment from the hot, and both of these from the sweating stage, and all these from the intervals between the paroxysms, I shall treat of the means to be used in each stage, and then describe the plan which ought to be adopted in the in- tervals, to prevent a return of the complaint. In the cold stage, which gene- rally lasts from half an hour to two or three hours, the first tiling to be done is to endeavor, by every means in our power, to restore the heat of the body, and to relieve uneasy feelings, with a view to shorten its duration, and bring about re-action. Hot applications ; additional bed clothes ; warm drinks; stimulants ; opiates and aether, have been strongly recommended,—with how little success, every experienced man can testify. The best method of applying heat is, to surround the patient with bottles filled with hot water; and it affords consider- able relief when a sufficient degree of heat can be applied to the epigastric re- gion. It appears to be more efficacious than the general warm bath, in which I have seen a patient shiver, and complain loudly of cold, when the bath was heated above 100°. It is a common plan to give a bumper of gin or brandy, with some pepper, to create re-action, and cut short the cold stage ; and there can be no doubt that it has sometimes succeeded ; but I have seen much in- jury ensue in many cases. This enables us to account for the horror entertain- ed by the older writers, at cutting short the cold fit, because it was never at tempted by any other means than by ardent spirits, large doses of opium, and aether. Dr. Gregory used to mention, in his lectures, two cases of violent epistaxis, succeeding to doses of brandy and pepper, which reduced the patients to great weakness. In the instances which fell under my own observation, and to which I have already alluded, fever and violent cerebral symptoms suc- ceeded, and, in two or three instances, local inflammations. Bleeding, in the cold stage, will in a great majority of instances, cut it short; in fact, it will rarely fail in stopping the existing paroxysm, and on many occa- sions, it has prevented a return of the disease to which the patients had been long subject, and by which they where nearly worn out. It is difficult to de- termine what quantity of blood it will be necessary to draw in any given case; sometimes it requires twenty-four ounces; I have known three ounces suffice, and, in one case, an ounce and a half produced the full effect. The larger the 68 INTERMITTENT FEVER. orifice in the vein is made, the greater is the chance of arresting the disease at a small expense of blood; but, in many cases, the operation is attended with considerable difficulty, from the convulsive tremors which affect the whole body. I was once successful in arresting the disease by bleeding, in a cold stage which had continued twenty-six hours ; but I regard this as an extreme case. The blood sometimes only trickles down the arm, and, as the system is relieved, the stream becomes larger and stronger, till at last it springs from the orifice, and frequently before six ounces are taken, the patient will express relief from violent pain in the head and loins, and it will soon be observed that he breathes more freely. The tremors become slighter and slighter, and, by the time a few more ounces are abstracted, they will cease altogether, and with them will vanish the painful sensation of cold. The pulse will be found strong- er, and a gentle moisture will be observed on the body. If the patient be pro- perly managed with respect to bed-clothes, neither hot nor sweating stage will in general follow. Most of the patients who have been treated by myself, or by my pupils under my immediate inspection, have fallen asleep immediately after the operation; but some have even got up and dressed themselves. The best testimony which can be offered in favor of bleeding in the cold stage of intermittents, is to annex a condensed history of some of the cases treated by myself and others in this country. Indeed, I have been blamed by many for not having done so in the first edition, but time has enabled me to perform this duty with more confidence, for I have now the satisfaction of add- ing an account of the happy results of the practice in India. "Case I.—James Ward—admitted into Royal Ordnance Hospital in November 1823. Has had several attacks of intermittent annually, since the year 180°, when he served in the expedition to Walcheren. Of late his indispositions were long, and left him more and more debilitated. He was bled twice in the hot fit, to relieve the severity of the symptoms, and with considerable temporary relief, but without preventing or miti- gating the violence of the subsequent paroxysms. He was afterwards bled from a vein in the arm, during a very severe cold stage ; the rigors were violent, and the sense of cold insupportable. He complained much of his head and loins, the face was of a livid color, and the vessels of the conjunctiva turgid with blood. Pulse 100 or 105, and oppressed; breathing short and anxious, and to use his own expression, he felt "a heavy load about his heart." When the vein was opened, the blood trickled slowly from the wound, but it soon came in a jet. When 8 ounces were taken, the rigors ceased, and he expressed great surprise at the suddenness of the relief; when 12 ounces were abstracted, he was free from all complaint, and his skin had a comfortable moist feel. He enjoyed a good night; he had no return of the intermittent; and his reco- very was rapid. " I had an opportuuity of seeing this man daily for some months afterwards, and his constant tale was, that he •' had not felt so well, or so much of a man," since he went to Walcheren. The only remedies used after the bleeding were laxatives and infusion of quassia. " Case II.—James Atkinson, aged 33, had formerly had repeated attacks of Was seized with severe rigors when on the top of the Carlisle mail, travelling to EdT burgh. The paroxysm was evidently produced by exposure in bad weather fi tt" i INTERMITTENT FEVER. 69 rain, and then to a keen frost, with wet clothes. When I visited him in hospital, he had labored under the rigors for no less a period than twenty-six hours,—in truth, it was the most severe cold stage I had ever seen in any country, with severe pain in the head, back, and loins ; oppression at prsecordia. Warm drinks, stimulants, and hot applications, had been employed without benefit. The agitation of his body was so great, that it shook the very bedstead on which he lay, and threatened to terminate in convulsions. Tongue loaded, but moist; breathing hurried and laborious ; pulse 65, oppressed ; skin not below the natural standard over the trunk, but all his extremities were cold, and he complained of a sensation of extreme coldness. Fortunately, I made a good orifice, and the blood flowed in a good stream ; the first pound was abstracted in three minutes, with very trifling relief, except to his breathing; but during the flow of the second pound, which occupied three minutes, he became more and more easy, and the rigor ceased completely. His body, and even the extremities, became of a proper temperature, and his skin felt moist < the pulse rose from 65 to 106 ; he passed a good night; had several stools during the next twenty-four hours, and was found perfectly easy next day. On the following day he was convalescent, looked well, asked for more food, and had no return of the disease. "Case III.—Thomas Bullock, a strong healthy young man, reports that he had the disease in the tertian form for twelve days. Attributes it to exposure to cold when on sentry in the arsenal at Woolwich. He was in the sweating stage when brought into the hospital at Leith Fort, on the 4th March 1826. " On the 6th had another paroxysm. " 8th.—Cold fit came on at three a. m. After it had continued half an hour and was well formed, his pulse beating 84 and oppressed, a vein was opened in the arm by Mr. Marshall, (now assistant surgeon of the 87th regiment) in the presence of several other gentlemen. When 15 ounces of blood were abstracted, the rigor ceased ; the pain of head and loins, and the oppression at prxcordia, vanished ; the breathing became natu- ral ; the pulse rose to 95. In half an hour after the operation, said he felt quite well; no hot fit followed ; a very gentle moisture appeared on the surface, but there was no sweating stage; pulse 95. " 18th.—Was again attacked with rigors a quarter of an hour before the visit. He is now in a severe well-formed cold fit ; breathing hurried and laborious; the whole body is in a tremor; tongue rather loaded ; passed a bad night; pulse 120, oppressed. Attributes this paroxysm to cold when in the privy. A vein was opened in the arm, and 14 ounces of blood were abstracted before the fit was subdued; there was no ten- dency to syncope ; pulse 110, full, and of good strength. No hot stage ; no sweating stage followed. "19th—Yesterday, for some time after the bleeding, he appeared free from all com- plaint ; but towards evening was attacked with violent head-ache and pain in the belly. Blood was again taken from the same orifice, to the amount of 12 ounces, with com- plete relief, since which he has been easy and slept well; bowels slow. " 20th.—Slight chill this morning, which appeared to be cut short by a warm drink; no fever followed ; passed a good night; bowels not moved. 22d.—Had a slight sensation of cold this morning, but there was no hot stage , says he feels quite well; bowels slow. "23d, 24th, and 25th.—Reports state that he went on improving. " 26th—Says he does not feel so well; but there has been no tendency to rigor ; bowels bound. 70 INTERMITTENT FEVER. "31st—He went on improving in health, and without any return of the disease till this day. He was found at the time of the visit in a slight hot stage, after having ex- perienced a slight rigor, which lasted for twenty minutes ; tongue white and loaded. "April 2d—Had a severe rigor at 10 a. m. which was followed by fever and sweat- ing ; at 2 p. m. he was found quite free from complaint. "His health went on improving gradually till the 25th, when he was discharged the hospital cured. " The same individual reported himself sick on 30th May following, and was taken into hospital, after a severe paroxysm of intermittent. On his admission he stated, that since his discharge, his health had been very good, and his strength increasing, but that he has had three slight rigors ; his appearance, however is much improved. "31st___Says he expects the paroxysm to-morrow morning at nine o'clock ; bowels regular ; appetite good. " Was ordered to take three grains of sulphate of quinine every half hour, commen- cing three hours before the expected time of attack. " June 1st.—He took six doses of the quinine ; escaped the pardxysm ; had no re- turn afterwards, and was discharged on the 4th. " Case IV.—Robert Smith, a stout man, whose health had formerly suffered from a residence in a warm climate, states, that he had had an intermittent fever five years ago when stationed at Woolwich, but has not had a return of the disease till now. Was taken into hospital at Leith Fort on 7th March 1826, laboring under febrile action, which he said succeeded to a severe rigor; the febrile symptoms continued with disturbed sleep till the 13th day, with little variation. He was then seized with a severe rigor, attended with sensations more than usually distressing ; above all, he complained acute- ly of his head. He was bled during the cold stage to twelve ounces, when the tremon and the other symptoms ceased all at once ; he soon after fell into a profound sleep, his skin having a gentle moisture ; there was no hot stage. " Escaped an attack till the 22d, when he had a severe paroxysm, followed by intense head-ache, for which he had leeches, cold applications, and a blister. He afterwards took sulph. quininx. "CaseV.—William Macauley was admitted into the Royal Ordnance Hospital on Wednesday 31st May, laboring under a severe hot fit, attended with the usual symp- toms. "June 4th.—The paroxysm took place at 1 o'clock p. m. this day; about 12 o'clock the pulse was counted, and was found to beat 84, and oppressed ; the precursory symp- toms had just commenced; at half past 12 the pulse was 66, and still more oppressed This rigor was very severe ; the tremors of his body shook the bed, and his sense of cold was insupportable, at the time that a thermometer placed under the tongue stood at 100. He complained of great oppression ; pain of back and loins ; difficult and hur- ried respiration. The rigor was allowed to be formed for^ 10 or 12 minutes before a vein was opened, 24 ounces of blood were then drawn, the rigor ceased, and all its un- pleasant symptoms. «' He had about eight alight paroxysms after this, and was subsequently cured by the use of quinine. , Case VI.—Alexander Clark, a stout well-made young man with a florid complexion. "Came into hospital at Leith Fort on 26th May 1826, with the fourth paroxysm upon him. He was attacked at 7 a. m. with rigors ; the fit was very severe. The hot stage had given way to the sweating when I saw him. He could assign no cause, except that he had done duty at Woolwich a few months before. Tongue foul; fever diet. INTERMITTENT FEVER7 71 '• 23d.—Was free from complaint yesterday ; had six stools from the laxative. The rigor came on this morning at half past six, and went through the regular stages with the usual distressing symptoms. Tongue much loaded ; B. regular; no appetite; urine scanty. " Experienced severe paroxysms on the 24th and 26th, attended with head-ache and a severe pain in right hypochondrium. "28th—Rigor came on at 11 a. m. Five minutes after it was well formed, a vein was opened, but the operation was badly performed, owing to the violent tremors ; 20 ounces of blood were slowly drawn, when the rigor ceased, together with tremors, the difficulty of breathing, the oppression at prxcordia, and the head-ache, &c. The pain- ful sense of cold gave way all at once to a pleasant feeling of heat, and the pulse be- came natural. The bleeding was not carried the length of producing syncope. No hot stage followed, and the skin was covered with a gentle moisture. In half an hour his only complaint was of slight nausea. " He had several slight returns of the disease, and ultimately recovered under the use of quinine. " Case VII.—Mr. Marshall, assistant surgeon of the 87th Regiment, when on a visit in the west of Scotland, was called to see a middle aged man who had served in the army in a warm climate, and who had suffered most severely for some years from inter- mittent fever. Every kind of remedy had been tried in vain, and he gladly submitted to the treatment of bleeding in the cold stage, which Mr. Marshall had seen so success- fully performed in similar cases. " 12th.—The cold fit is very severe ; the feet cold; heat of the superior extremities rather above the natural standard and moist; pulse very small, not easily perceived ; pain of head excessive ; great thirst; pain in back considerable ; complains of distressing sense of weight at the prsecordia. A vein was opened, and the blood trickled down the arm, but shortly came in a full stream. When ten ounces of blood had flowed the shivering ceased, and all the bad symptoms vanish- ed. Half an hour after the bleeding, says he is quite well. On the 14th, 16th, 18th, no return of fever." Mr. Marshall assured me that he had no return of the complaint when he last visited him, which was several months after the bleeding, and that the cure seemed to be as sudden, and apparentiy as permanent, as that which took place in Ward's case. " Case VIU.—George Scott, aged 36, a native of Eyemouth, was seized with an in- termittent of the quartan type when in Lincolnshire in August last. He had used various remedies, and among the rest bark, without relief. The paroxysms have con- tinued with such regularity, that he has not escaped a single attack since the commence- ment of the disease. His health and strength have suffered so much, that he has been unable to work for a considerable time, and came to Edinburgh almost in despair, to seek relief. His look is meagre and emaciated; and he appears the wreck of a strong and active man. " On Thursday 28th December, 1826, at 2 p. m. the rigor commenced, and when it had continued for half an hour, I opened a vein in the arm, having placed him in the sitting posture ; his whole body was affected by violent tremors, his teeth chattered ; he complained of intense cold ; dimness of sight; severe pain in the back part of the head, and in the left side, loins, and inferior extremities ; his pulse was quick and flut- tering, so as not to be counted, and the countenance expressed great suffering. Owing to the violence of the tremors, a bad orifice was made in the vein, and the blood flowed slowly. When about twelve ounces were abstracted* the rigors diminished, the uneasy feelings began to subside ; and by the time 16 ounces were taken, he was free from. tremor and pain, and said he felt quite well. The pulse was now a good pulse, but! 72 INTERMITTENT FEVER. neglected to make a memorandum of its number at the time. He showed some ten- dency to syncope before the arm was tied up. Several gentlemen were present when the operation was performed. He was again visited in an hour, when he was found breathing naturally, in a sweet sleep. Pulse 84, and of good strength. I was told he had been very faint, and had vomited immediately after wc had left the house. " Saturday 30th—He came to the dispensary at the visiting hour, and said that he felt himself 'a new man.' "Sunday 31st.—He came to the dispensary again, and was there seized with a pa- roxysm a little after the hour of visit. The fit was preceded and accompanied by much slighter pains and general disturbance than any former attack. In about ten minutes after the fit could be said to be well formed, the rigors were very severe, the tremors violent, and the feeling of debility was so overpowering that he declared he could not support himself longer on a chair ; his breathing was quick and laborious, and his teeth chattered ; I tied up his arm and opened a vein, and before three ounces were abstracted, the paroxysm ceased, and with it all the other unpleasant symptoms. Although a minute before he had declared that he could not sit up a moment longer from debility, yet he now said he felt his strength restored, and had no wish to lie down ; in less than ten minutes, I had the pleasure of seeing him running home. There was no subsequent heat of skin, and no sweating ; his pulse, before he left the dispensary, was 86, and of good strength ; whereas before the bleeding, it was 100, and so weak as scarcely to be counted. "Monday; 1st January.—I sent to inquire how my patient felt; the messenger was told that he had had a good night, and was out making merry with some friends. " On Wednesday he had a slight chill without subsequent fever or sweating; he afterwards got the sulphate of quinine, and had no more of the disease. " Case IX.—A woman, 27 years of age,4he mother of several children, experienced repeated paroxysms of irregular intermittent for several months, till at last her general health became much impaired under the disease in the tertian form. She was bled by Mr. Drever, one of my pupils, towards the termination of a slight cold stage. About 12 ounces were abstracted ; neither re-action nor a sweating stage followed ; and there has since been no return of the complaint, although several months have elapsed. She had neither bark, sulphate of quinine, nor arsenic. In fact, no medicines were pre- scribed but those of a laxative nature. " Case X.—David Lambert, actat. 36, sailor, residing at No. 9, Couper Street, North Leith, states that he was attacked with intermittent for the first time on the 9th May 1827, when on his voyage from Bourdeaux, in the ship Enterprize of Newcastle. At the time of attack they were off Dover in very bad weather, ten days from Bourdeaux. Since then the paroxysms have returned daily, the cold stage continuing for tliree quar- ters of an hour, often for upwards of an hour. It has always been severe. His general health soon gave way. He left the ship, disabled, and arrived in Leith on the 30th May. When I visited him, he appeared to be very unwell, feeble, feverish, restless, and anxious about his fate ; fearful of the consequences of the approaching cold stage, which he expected in a few hours. Says he sleeps little ; has constant thirst and diarrhoea ; pulse 100 ; tongue white and loaded, but moist; has a bad cough with ex- pectoration ; slight difficulty in breathing ; and constant dull pain in the chest and loins, appeared much debilitated ; lies much in bed, and when he sits up complains of swelling of the feet and legs, which are cedematous ; stethoscope announced bronchitis generally in both sides of the chest. The captain of the ship gave him something in. treacle which he supposed to be bark. Mr. Henbestand Mr. P. Mackintosh, two of my pu- INTERMITTENT FEVER. 73 pils, volunteered to watch the case, with a view to bleed in the cold stage. The re mainder of the history is taken from their report. " ' June 7th.—Found him very unwell; coughing incessantly and violently ; com plaining of sense of weight in the chest; pain of head and giddiness ; cold extremi ties; pulse 95, and oppressed. At 20 minutes before 8 p.m. he was seized with rigors, which soon became very severe. The breathing was hurried and laborious ; his cough and other symptoms greatly aggravated. The whole body was in violent agitation, and his teeth chattered. When in this state, a vein was opened in the right arm, and four small tea cups of blood abstracted, (about 16 ounces.) He was so suddenly and so perfectly relieved, that he declared he felt quite well, his body became warm, and he soon fell into a quiet slumber. Pulse natural. After regulating the quantity of bed clothes, we took our leave.' " «9th —By account had a very slight chilliness last night; the whole paroxysm be- ing of short duration ; there was scarcely any heat, and very little perspiration. In fact, he said there were none of the bad attendants of the previous attacks. He was again visited at 9 p. m. and found in the cold stage, which lasted only ten minutes. The •hivering was so very slight, as scarcely to be perceptible. Passed a good night; was able to sit up a considerable part of the day ; strength improved to his own feelings. The cough still continues with the expectoration. Passes dark and fetid.stools. Calo- mel and rhubarb. A blister to the sternum. Milk and farinaceous diet. " ' Had an attack on the 10th, and another very brief one on the 11th ; from which date until the present day, June 29, there has been no return of the disease. There is no affection of the chest; his aspect and motion bespeak health, and his strength is perfectly restored, without the use of bark, quina, or arsenic.' My reporters state, that on the 19th, the patient expressed himself in the following terms : ' If any man had told me, twelve days ago, that I should be so well as I am now in six months, I could not have believed him.' " Case XL—Corporal Geo. Webster, Royal Artillery, has served thirteen years, three of which were in the West Indies, where he enjoyed excellent health ; but since his return, has shown a tendency to chest complaints ; has been once in this hospital with a bad catarrh, from which, however, he recovered. He presented himself again at the Leith Fort this day, June 24, 1827, and stated, that he had for some days past suffered from rigors, alternating with flushes of heat, and attended by pain in the loins and belly, diarrhoea, and slight nausea. His pulse was quick, and tongue loaded. He got an emetic, and daily laxatives, and was discharged on the 29th, supposed to be cured. He reappeared on Thursday, 5th July, and reported, that since his discharge on 29th ulti- mo, he had experienced three regular paroxysms of intermittent, with a day interve" ning ; the last attack was this morning. The cold stage was very severe, and contin- ued for two hours ; it was succeeded by the hot fit, and terminated in sweating. Com- plained much of general pains, but suffered distressingly from head-ache during the pa- roxysm. He got nothing but laxatives; and had attacks on the 7th, 10th, 12th, and 14th. He escaped from the 14th till the 20th, when he had a very violent paroxysm ; and on the 22d, he was bled in the cold stage, and the following report was made at the time : The cold fit severe, accompanied by violent pain in the head and belly, and and oppression at prsecordia, heat; 95°, pulse 105, weak and irregular, respiration hur- ried and difficult When the cold fit had continued for ten minutes, a vein was opened, the blood trickled down the arm at first, but afterwards came in a good stream. When about eight ounces of blood were taken, the pains every where ceased, the tremors be- came slighter and slighter, and were completely stopped before sixteen ounces were abstracted. He then felt a slight tendency to syncope, and the arm was tied up. He 10 74 INTERMITTENT FEVER. spoke much of the sudden and complete relief he had experienced, and contrasted hi? present situation with the pains and oppression he had had in previous paroxysms, which always continued tdl the sweating stage had gone on for a considerable time. His pulse now beat 75, strong and full, heat 100°. No hot or sweating stage followed the bleeding. Four hours after the bleeding, he was again visited : pulse 110, of good st'-ength, skin hot from pressure of bed clothes, which were now carefully removed, to his great relief. " 23d.—Says he has not been so well since first attacked ; feels, if any thing, rather stronger, slept well, bowels open, appetite pretty good, and had no return of the dis- ease. Had no medicines but laxatives and infusion of quassia. "Case XII.—Bombardier James Armstrong, aged 19, is tall, spare, and pale ; says he always enjoyed good health till fourteen days before he left Woolwich, when he was seized with intermittent fever. After the first fit, he had no return for nine days, which he attributes to the use of bark, which was prescribed for him in the General Hospital. But when taking the bark, and while yet in hospital, he was again attacked, and had a paroxysm every day for four successive days. He still continued to take the bark in the intervals. He was removed from die hospital on Wednesday the 11th July, to em- bark with his company for Leith Fort. He escaped a paroxysm on the following day, but had one on Friday the 13th, and every day since. "20th July 1827.—Presented himself at the hospital at Leith Fort, this morning. States, that the paroxysm came on at 7 a. m. which was very severe, particularly in the cold stage. Says he suffered most from headache, and a trembling feeling, together with a tightness at his breast. Feels now considerable prostration of strength ; has no appetite, tongue white, not much loaded ; thirst; bowels have been very open for four or five days ; pulse 100, and full. " 22d.—Paroxysm came on at 7 this morning. Was bled in the cold stage, after it was well formed. He says the fit was very violent, and that his sufferings were produced by severe pain of head, difficulty of breathing, and tightness across the chest. Pulse so quick, irregular, and small, as not to be counted. When about an ounce of blood was abstracted, he felt much relieved ; immediately afterwards the rigor ceased suddenly, the sense of cold gave way to a comfortable feeling, and all the other painful sensations va- nished ; and not more than eight ounces of blood were drawn. In the course of a quar- ter of an hour, said he was sensible of a little heat and slight thirst. Was visited four hours after the bleeding. Says he feels quite well, and declares lie never felt so well, or so free from uneasiness in so short a time after any previous attack, and that he has no feeling of debility, which lie used to have. Heat under the tongue in the cold stage was 105° ; heat taken at this visit 100", pulse 76, full and strong. He had no stool to-day. "23d.-At twenty minutes before eight this morning felt a slight chill, succeded by a flush of heat; but, to use his own words, he had " no fever to speak of," no sweating, and he was not ill above three quarters of an hour; in former paroxvsms, the cold fit alone lasted two or three hours, and the whole attack occupied five or six. Savs he now feels uncommonly well. Appetite much improved. Took a laxative. "24th.—Slept well, had a slight sensation of cold this morning, but no fever or per- spiration. Physic operated thrice. « 25th -Feels better and stronger. Slept well, but perspired copiously during the night. Appetite very good. Bowels regular. At the same hour this morning he ex- perienced a shght sense of cold in his loins, but tiiere was no general chilliness and no heat followed. ' "26th.-Had another slight sense of cold at the same hour this morning, but no heat or perspiration followed; strength and appetite improving; bowels regular; slept welL INTERMITTENT FEVER. 75 "27th.—At the same time this morning was sensible of a feeling of lassitude, but no chilliness. "August 3d.—Continues well. Discharged to attend as an out-patient. " 10th.—Came to hospital during the hour of visit in a very severe cold stage, which had been on him for-about half an hour. He complained of intense pain of head, as if some one had been beating it with a hammer, accompanied with pulsation. The tremors were violent and universal; the surface rather cold, the extremities very cold ; pulse 140, and oppressed ; heat under the tongue 97°; breathing hurried and oppressed, and when he attempts to take in a full inspiration, by desire, he finds it not only impossible, but makes much complaint of a pain in the left side of the chest, in the region of the heart. A vein was opened, and before four ounces of blood were drawn, the rigor diminished in violence, and the pain of head became relieved ; after the loss of eight ounces, the head was quite free from pain, and the tremors subsided ; the heat of his extremities was re- stored, and a general warm glow was felt over the whole body. When eleven ounces of blood were abstracted, he was found to be free from complaint, and the arm was tied op. Heat under the tongue at this moment 107°, and the pulse beat 126, and very full. The bleeding occupied five minutes. In about ten minutes after the bleeding, the head- ache became so intense that he entreated to lose more blood, and eight ounces were taken with complete relief to the head. This quantity, was discharged in three minutes. His body was now universally warm, indeed rather hot; the additional blankets were removed, and he felt afterwards cool and comfortable. Pulse 120 ; feels drowsy. "11th.—In an hour after the second bleeding yesterday, the headache returned, but in a much slighter degree ; it was completely relieved by the application of cold water. Passed a good night, had a copious perspiration towards morning. Feels now quite well; has no pain, and says he does not feel weak. Appetite good. Had three stools last night, and one to-day. "17th.—Has continued to mprove since last report. Has had no return of the dis- ease, and is discharged to attend for a few days as an out-patient " Case XIII.—John Loyd, aged 20. Has been eleven months in the service, and was three times in hospital at Woolwich with intermittent fever. " July 27, 1827.—By account, he had regular paroxysms of tertian intermittent lately on the voyage from Woolwich to Leith Fort. When he presented himself at the hospi- tal to-day, his countenance was much oppressed, and his gait tottering. Says he has had a rigor all night on guard, and that he has felt colcftbr the last twenty-four hours. Com- plains much of headache, pain in the loins, general uneasiness, and difficulty in breathing. Heat under the tongue 100°; thermometer held in the hand 78°. The feet and legs also cold to the touch. Pulse scarcely to be felt, and not to be counted. He appears to be between the cold and the hot stage, the cold predominating, with so much con- gestion about the heart and larger vessels that re-action is prevented. Upon this view of the case, a vein was opened, and although a large orifice was made, the blood only trickled down the arm, which was proved to depend on a want of sufficient force in the circulation ; for when the orifice was pressed by the finger, so as to stop the flow of blood for a moment, allowing time for the vein to fill, a stream took place on the remo- val of the pressure; this was repeated a number of times, and with the same effect. The blood itself was thick, and coagulated imperfectly; it looked of different tints. Twelve ounces of blood were taken in fifteen minutes. The patient felt somewhat re- lieved after the bleeding, but complained of debility. " 28th.—Became very hot and restless in an hour after the bleeding, but has had no perspiration. Passed a bad restless night, with headache and sore throat. Pulse 106, distinct and easily compressible. Skin hot. Thermometer placed under the tongue T6 INTERMITTENT FEVER. 102°; held in the hand 99°. On looking into the throat, there appears to be no inflam- mation. Breathing almost natural. Is affected w'tfh slight startings. A vein was opened in the arm, and although a large orifice was made, the blood only trickled, and present- ed the same black appearance as yesterday ; as soon as four ounces were taken, a small jet took place, which increased at last to a tolerable stream. The arm was tied up on the approach of syncope, when eight ounces were abstracted. Expressed himself much relieved by the bleeding, particularly with regard to his head. Heat under the tongue after bleeding 100°. Feels disposed to sleep. "Vespere. Complains of headache, heat of skin, and considerable thirst. Pulse 100, and strong. Blood drawn in the morning has not separated any serum : it is like treacle, and, together with that taken at the last bleeding, has all the appearance of what the old writers called "dissolved putrid blood." " 29th—Feels better in every respect. Slept well. No stool since yesterday morn- ing. Pulse 100, less oppressed. Heat natural. Tongue rather foul and dry at the tip. "30th.—Continues to feel better, and to sleep well, but complains of weakness. Three stools. Pulse 92, of good strength ; great thirst. " 31st.—Complains of general uneasiness, sore throat and difficult deglutition ; also of a pain in the epigastric region. He attributes these symptoms to the solution of the tartrate of antimony, which he has been taking for two or three days. The throat looks inflamed, the fauces and uvula being covered with a thick viscid exudation. Tongue dry, red round the edges and at the tip. Skin hot Pulse 100. Thirst considerable. Bowels opened twice. Abdomen to be fomented. Antimony to be discontinued. A small dose of castor oil. Blister to the throat. " August 1st.—Passed a bad night; but the restlessness and the troublesome symp- toms described yesterday began to decline towards morning, and he now feels conside- rably better. Tongue moist, but discolored and dry in the centre, and in a small angu- lar space at the tip. Skin hot and dry ; pulse 98 ; three stools ; blister rose well, and relieved the throat. "3d.—Slept well the last two nights; feels better in every respect $ but complains of his tongue, which is fissured; it is cleaner and quite moist; thirst diminished ; skin rather warm ; one stool yesterday, and two to-day ; pulse 80, of good strength; appe- tite improving. 7th.—Convalescent; and able to sit up. He continued afterwards to make a good Recovery. ,, " Case XIV.—John Boyd, aged 23. Was lately quartered at Woolwich, during a period of nine months, when intermittent prevailed, but he escaped the disease. Was seized last night, October 25, 1827, about twelve o'clock; after retiring to bed, with cold shivering, giddiness, and difficulty of breathing, which continued for three hours with great severity, and then became mitigated, but did not entirely cease. In a few hours afterwards, the rigors with the other symptoms recurred with increased violence, and continued so until I visited him at ten o'clock on the morning of the 26th October. He had no sleep during the night. Was still shivering violently, and walked to the hospital with great difficulty from extreme weakness, and his gait was like that of a drunken man. After he was placed in one of the wards, the extremities were found to be cold; heat under the tongue 95°. Respirations 38, and performed with an effort Pulse scarcely to be felt at the wrist, beating 65. He complains of an insupportable sense of coldness ; of excruciating headache between the temples ; difficulty of breath- ing ; oppression at the chest, and debility. A vein was quickly opened ; the blood did not flow readily at first, although the orifice in the vein was well made. When about five ounces of blood were abstracted, the respiration was performed with more ease, INTERMITTENT FEVER. 77 the pain of head was less, and the tremors were slighter. The blood now began to flow in a better stream, and when ten ounces were taken the patient declared he had no complaint, but giddiness and a sense of faintness. Hitherto he had been in the sitting posture, but was now placed in the recumbent, and the arm was tied up. The space of time occupied by the bleeding was two minutes and a half. The pulse was much stronger, beating 96. The thermometer placed under the tongue rose to 99. In the course of five minutes afterwards, a slight rigor supervened, with a return of the head- ache ; and as the pulse was strong and firm, the blood was again allowed to flow from the same orifice to the extent of six ounces, with complete and permanent relief. He now felt " comfortable," to use his own expression. Pulse 80, of good strength. Had a drink of warm gruel, and in a short time a slight moisture appeared on the surface of the body. " Vespere.—The patient was found sitting up dressed. Said he did not feel weak, and that he had been very comfortable all day since the bleeding. Surface moist. Pulse 80, strong. " 27th.—Passed a good night. Had some perspiration. A laxative powder which he took last night operated five times. The report on the 4th November states, that he feels quite well, and as strong as ever he did. Appetite good. Sleeps soundly. Bowels regular without medicine, and he has had no return of the disease since the bleeding, and on that day he was discharged the hospital. "Case XV.—John Rose, aged 22. Has always been healthy till he had the ague at Woolwich, for which he was in hospital twice, three weeks the first time, and a month the second; but says he has since scarcely ever been free from pain of head and loins " October 29th.—After having experienced several attacks since the 16th Octobe*. was seized with a paroxysm between two and three o'clock this morning. At ten he was still in the cold fit; he complained of pain in the head and loins. The tremors were not violent. Tongue rather loaded, but moist Pulse 64, weak and oppressed. Heat under the tongue 92°; in the hands 72°. A vein was now opened, and he was quite relieved before six ounces were abstracted, and the tremors ceased when twelve ounces were taken, which occupied three minutes of time. The thermometer was now again placed under the tongue, and the heat found to be 96° ; in the hand 75°. There had been no application of heat, nor had any warm drink been given. There was a slight moisture over the surface. Upon being asked if he felt weaker since the bleeding, replied, that he is " not aware of feeling weaker." " 30th.—Was quite comfortable after the bleeding yesterday, so much so, that he dressed himself and sat up all the afternoon, and ate a good dinner. Slept well. Bow- els open. Tongue clean. Pulse 64, and of good strength. Thinks that he feels ra- ther weaker than he did yesterday afternoon, but says he has no complaint. " 4th November.—Continues to improve in health. Has had no return of the dis- ease, and was discharged the hospital in the course of a week cured, having used no medicines but laxatives. " Case XVI.—Gunner James Anderson, aged 20. Has been four years a soldW. Served in the Mediterranean for eighteen months. Had several attacks of intermittent, for which he was taken into hospital in one of the Ionian Islands ; and since his return to England had two different returns of the disease. He describes his sufferings to have been always very acute during each paroxysm. Has otherwise enjoyed good health all his life. Appears to have a good constitution, and, with the exception of a yellow tinge, looks healthy. He is stout, well made, and about five feet ten inches high. By trade a weaver. A native of Glasgow. 78 INTERMITTENT FEVER. "3d April 1828—Presented himself this morning at the hospital at Leith Fort, la- boring under all the usual symptoms of inflammatory fever, and complaining much of pain in his head and loins. Thirst is urgent. Skin hot and dry. Pulse 130, full and hard. Hard cough. Stated that he had been attacked about day-light with severe cold shivering, which, after continuing for several hours, terminated in a state of heat and fever. In the course of a few hours after admission, perspiration came on, and the ur« gent symptoms gradually declined as usual. ••4th.—Passed an indifferent night. Complains of cough with which he says he has become affected since his arrival at this station on the 12th March last ; that it becomes much worse as soon as he begins to shiver. After the paroxysm is over, a slight ex- pectoration takes place, which relieves the cough till the next attack. " The paroxysm of yesterday was the fourth, with a day intervening between each. lie is aware of the nature of the complaint, and says it is the same he had in the Ionian Islands and at Woolwich. " Continued in the same state, having a severe paroxysm every third day till the end of the month, when he complained of more than the usual sufferings. His skin became of a bright yellow color, and he was relieved by vomiting a large quantity of bilious matter. '" The attacks still continued ; they have anticipated the usual time by several hours, so that the different gentlemen who went to the hospital to bleed him in the cold stage, were either too soon or too late, and no one was fortunate enougli to drop in at the time, till Mi-. Drever remained in the hospital all night, and he was then bled in the cold stage. The following account was written by that gentlemen. " * I was called at half past one a. m. May 10th, to see Anderson, soon after the com- mencement of the cold sensations. At two o'clock, after the rigors had been violent for about a quarter of an hour, I proceeded to bleed him. The thermometer placed under the tongue stood at 95°. The pulse beat 130 and weak, so as to be counted with difficult}'. A large opening was made in a vein, but the blood only trickled; being afraid that the opening had not been properly made, I tied up the opposite arm and made a good orifice in another vein, but the blood still only trickled; and as the rigors continued very violent, I gave him nearly a wine glassful of spirits ; and in a minute or two, the blood spouted in a large stream, and thirty ounces were quickly evacuated, when vomiting and a tendency to syncope took place. The tremors had entirely ceased, and all the unpleasant sensations. The patient expressed, in strong terms, the ease which had so suddenly been produced. In five or six minutes after the arms were tied up, the tremors returned for a few minutes, and then entirely subsided. Pulse 100. " ' 1 visited him again at the end of six hours, when he told me he had slept very comfortably. Pulse 70. Upon being asked to state the extent of the relief he expe- rienced from the bleeding, he told me that there was a load taken from his breast and head, and no painful feeling was left' " At two regular periods since the bleeding, he was conscious of feeling heavy and uleepy, but had no tendency to rigor, or even to feel cold, although the weather has been exceedingly changeable, and for the most part cold, the wind easterly. He has no kind of medicines but laxatives to keep the bowels comfortable. ^ "Case XVII.—Gunner Robert Young, aged 42. Was in hospital for several months during the winter, complaining of pain in the chest, cough, and copious expectoratioi together with emaciation, prostration of strength, and heavy night sweats. For four ' five weeks, the expectoration was bloody, and amounted on an average to about three gills a day. His pulse was never under 100. The sound of respiration on the right side of the chest was deficient, while it was puerile in many parts of the left lung and INTERMITTENT FEVER. 79 there was no tele to be heard any where. Contrary to expectation, he became much better under the use of considerable doses of the acetate of lead; and counter-irritation produced by tartar emetic ointment to the surface of the chest When his recovery was considerably advanced, and in order to give him the best possible chance, he was sen on furlough to his native place; and when there, was seized with intermittent fever, which induced him to return before his time had expired. " After having experienced many severe paroxysms, he was taken into hospital, at Leith Fort, and on Sunday the 18th May 1828, the following report was made. " Felt the cold fit coming on at half past twelve this forenoon. In a quarter of an hour the tremors were so violent as to shake the bed. From the commencement of the cold fit, he coughed incessantly, without expectoration, and complained of excessive coldness, together with pain in the head, chest belly, and back. Heat of the room 65°. Thermometer placed under the tongue 90°; held in the hand it fell to 76°. Pulse 75, and very weak. After the rigors had continued with violence for ten or twelve minutes, a vein was opened. The first cup, which was filled in five minutes, held twelve ounces; by the time it was half filled, the pain had vanished from the head and chest, the cough had ceased entirely. When the cup was filled, he said the pain had now left the back, and that a very warm, pleasant sensation, was gradually spreading from his back over his bowels and breast. The second cup held between eight and nine ounces; it was filled in two minutes. The blood flowed with more force, but not in so large u stream. The tremors gradually subsided, and all unpleasant sensations disappeared be- fore the arm was tied up. The breathing was easy and natural. Heat under the tongue 93°. Pulse 92, of tolerable strength. There was no sense of sickness, or tendency to syncope. He was again visited in twenty minutes, and found quite comfortable. In the evening he continued quite well, but had a little heat of skin, which was found to be owing to the great number of blankets he still had upon him. Upon their removal the heat disappeared. As he had had free motions from his bowels through the course of the day, no medicine was ordered. '< Had a slight paroxysm on the 20th, and another on the 22d, after which quinine was exhibited, which appeared now to have the effect of preventing a recurrence of the dis- ease, although it had been exhibited in vain, and in much larger doses, before the bleeding. "Case XVIII.—The following is the case of James Bennett, treated by Dr. Alison in the clinical ward of the Royal Infirmary, which was the foundation of his lecture against bleeding in the cold stage, and whose objections and arguments were subsequently re- echoed in the Lancet of Saturday, April 7, 1827, in a communication signed " Scotus." "James Bennet, aged 39, shoemaker, March 27.—Had severe rigors on Saturday 25th instant, accompanied by thirst, anorexia, and pain of head, which continued for more than an hour; were then succeded by heat of skin, vertigo lassitude, increase of thirst, and pain of head. These symptoms continued five or six hours, and then gra- dually subsided during copious sweating. Had a similar paroxysm on tre 26th, and also a less severe one this morning. Complains at present of slight pain below the left false ribs, somewhat increased by pressure or coughing. Pulse 60, full. Respiration natural. Skin cool. Tongue clean and moist. No thirst. Appetite pretty good. Bowels open. Urine said to be high colored. Lips somewhat swollen, with a slight vesicular eruption around the mouth. Has taken purgative medicines, and also a little of the arsenical solution since yesterday. Took an opiate draught this morning when the rigors com menced, after which they continued only a few minutes Has since had no pain of head; little heat of skin; less thirst, and no sweating. Had the intermittent fever more 80 INTERMITTENT FEVER. or less constantly for nine months whilst in Spain, fourteen years ago. Has recently returned from the West Indies, where he resided for the last six years. Lives in a house where several persons have been ill of continued fever.—Fowler's arsenical solution, 3L Water, J vi. Mix. Let him have §ss every sixth hour. "28th.—Shivering commenced this morning at ten, which abated somewhat after taking the draught. At half past ten was still shivering, less violently; with pain of back and head. Pulse 72, rather small. Sixteen ounces of blood were taken, slightiy sizy, crassamentum not contracted. The pains abated and the shiverings immediately ceased. Has headache now, and giddiness. Pulse 72, full, soft, tongue furred, moist. No sweating since the shivering. Pain of left side of abdomen only felt on coughing> No pain of back.—Continue the arsenical solution,—Repeat the anodyne draught " 29th.—Began to sweat at two, which lasted several hours. Had griping and tenes- mus with headache at night, which abated after the operation of a dose of castor oil. No shivering to day. Four doses of the solution taken. Pulse 60. Tongue moist, slightly furred. Complains of weakness.—Continue all the medicines. Let him have lb. i. of beef tea, and one pint of porter. " 30th.—Had a fit of rigors this morning about ten, and took hi9 draught. The shivering was less violent, but lasted an hour. Pulse 80, full, soft. Heat was an hour ago 100°. Tongue slightiy furred, with thirst: Complains of headache, pain of back and left side of abdomen. Bowels confined. Let him have one oz. of castor oil; a saline draught now and then. Continue the others. "31st.—-Much sweating yesterday after having had an enema at night without effect. No rigors to-day. Pulse 68. Tongue whitish.—Let him have S;ij. of infusion, senna, with gij. of sulphate of magnesia.—Repeat the arsenical solution now every fourth hour. "April 1st—Bowels freely opened. Rigors commenced to-day at ten, but slightly. They have become more violent within these few minutes. Pulse 84, pretty full. Skin feels warm. Tongue rather dry. Has pain of left side of abdomen just now. Has just taken the anodyne draught.—Continue the arsenical solution. Give him a powder containing four grains of sulphate of quinine every six hours. " 2d.—Shivering abated quickly after the opiate draught. Sweated much in the evening. Feels easy to-day. Left side of abdomen slightly tender. Bowels open. No nausea.—Repeat the powders of sulphate of quinine every fourth hour. "3d.—Four powders taken. No fit. Very little pain of side.—Continue the medicines. <« 4th.—Five powders taken. No fit. Two stools. Appetite good—To have four ounces of steak to-day, and daily. " 5th.—Had a very slight fit of rigors at four yesterday, succeeded by heat of skin ; full, quick pulse, and sweating in the night; little head-ache, and no pain of side! Pulse and tongue natural. Bowels open—Continue. " 6th.— Shiverings have begun within these few minutes. Pulse 96. Has taken his draught. Hand rather cold. Bowels open.—Continue. « 7th.—Shivering lasted an hour yesterday. Began to sweat soon after, and sweated all night. Complains of pain in the left lumbar region, with some tenderness; no distinct hardness. «8th.-Rigors commenced this morning a little after 9 o'clock, and lasted an hour, though he took an opiate draught containing forty drops of tincture of opium Has sweated some already. Pulse 100, full. Complains of headache and pain of left side of abdomen. Tongue rather dry, with some thirst. No stool.—Let him take a bolus of compound powder of jalap directly. Apply the cupping glasses to the pained part of bis left side, and abstract six ounces of blood. Continue the powders of sulph f quinine. Let him have drink, acidulated with lemon juice, without syrup ad Ib't INTERMITTENT FEVER. 81 « 9th.—Side easier since the cupping. Bolus operated. No headache to-day. Ap- petite good. Much sweating in the night.—Continue. Let him take a mixture con- taining ^i. of sulphuric acid with water.—Additional bread. " 16th.—Had some vomiting this morning, succeeded by rigors about 8 o'clock, which lasted three quarters of an hour, but were not violent Pulse 64. Heat 99°. Sweated a little. No headache or pain of side. Bowels slow. Let him take gij. of infusion of senna, with 3'ii. of sulphate of magnesia, directly. Continue the others. " 17th.—Had a second fit of rigors yesterday at 2 o'clock, which lasted long, although he took forty drops of tincture of opium. Sweated all night. Is free from complaint to-day, but weak. Bowels open.—Continue the powders of sulphate of quinine every third hour. " 18th.—No return of shivering. Has a little pain of left side of abdomen, on mo- tion or coughing. Pulse natural. Appetite good. One scanty stool.—Give him directly a powder containing gr xv. of rubarb, and gr iii. of calomel. " 27th.—Complains of feeling weakness of loins.—Apply a warm plaster to the lum- bar region. " 29th.—Bowels slow, otherwise well.—Let him have immediately a cathartic draught. continue the others. " 30th.—Has complained of nausea and weakness, but without any shivering. Pulse natural. Tongue whitish.—Let him take §i. of a mixture containing 5 ij. of ammoniated tincture of valerian, in § vi. of mint water. Continue the others. " May 1st.—Feeling of nausea and headache abated. Bowels regular.—Let him have one ounce of bark, also a warm plaster for the loins. Dismissed cured. Second attack. "Admitted 25th May.—On the morning of 17th instant, was taken ill with headache, languor, and pain of back, succeeded by slight rigor, which continued for about a quar- ter of an hour, when it was followed by heat and sweating. Has had an interval of seven days without a return of paroxysm, which re-appeared on the 24th with increased severity, the rigor having been much more violent, and of longer duration, accompanied with much nausea, excruciating headache, and those various symptoms which character- ise the invasion of intermittent fever, under an aggravated form. Has had this morning, previous to admission, another paroxysm, which was an hour earlier in the period of its accession, and continued, including its three stages, for about six hours, during the first of which he had much vomiting. Complains most at present of headache, prostration of strength, general lassitude, and soreness of limbs. . Has no pectoral or abdominal symptoms ; thirst is urgent; no anorexia ; pulse 66, full, but soft; respirations 26 in the minute ; tongue furred, but moist; bowels open ; skin warm, rather pungent, and bathed in perspiration ; face swollen ; urine copious. Has been lately a patient in tliis clinical ward, afflicted with his present complaint, of which he was dismissed cured, on the 30th ultimo. The history of the present case derives much additional interest from the circumstance of two of his children having been also recently attacked with ague, for which one of them is now a patient in the infirmary. Let him have griij. of sul- phate of quinine three times a-day, and two colocynth pills to-night. "26th.—Three stools from the pills. No shivering since admission. Headache still severe, Pulse 66, full. Pain of back and limbs preventing sleep. No pain of side or of abdomen.—Apply the cupping instrument to his temples, and abstract eight ounces of blood—Continue the powders. " 27th.—Headache relieved by cupping. Had a severe shivering fit this morning, re- ported to have lasted two hours, and is now sweating profusely. Pulse 66, full. No 11 82 INTERMITTENT FEVER. pain of abdomen or side. Two stools.—Let him have the powders of sulphate of quin- ine every third hour. Also an anodyne draught, with forty drops of tincture of opium, at the commencement of the paroxysm. "28th___Pulse 66. Feels chilly. Bowels open.~Continue powders of sulphate of quinine. " 29th___Had a shivering fit lasting an hour and a half, commencing at nine. Has sweated much. Pulse 66, full. Complains of general soreness. Bowels open. Had nausea, no vomiting.—Let him have an effervescing saline draught every hour. Con- tinue the powders. " 30th.—Pulse natural. No pain to day. Appetite pretty good. Five powders taken. —To have four ounces of steak and a pint of porter. "31st—Took six grains of sulphate of quinine this morning at half past eight. Shivering came on at nine, and lasted about half an hour, but was much slighter. No sweating since. No headache, but complains of nausea and giddiness. Bowels open.— Let him have the effervescing saline draught now and then. Continue the powders. To have ordinary diet to-day, but the steak to be- repeated to-morrow. "June 2d.—Took a double dose of quinine again this morning at half past eight Has had a Httle chilliness; no rigor.—Continue the powders. " 3d.—Began to shiver directly after visit yesterday. Took five grains of sulphate of quinine, after which it went off". Sweated much. Has complained much of tinnitus aurium and giddiness since yesterday afternoon. Two stools from pills taken last night. Pulse 68, full. Tongue whitish.—Repeat the powders every fourth hour; and the laxa- tive pills at bed time. "4th,—No shivering to day. Much less tinnitus. Bowels open.—Continue the powders and pills. " 5th.—Five powders taken. No vertigo or tinnitus. Appetite good.—To have ad- ditional allowance of b^r'ead. " 6th.—Had chilliness; no rigors. Six powders taken. Bowels slow. No pain.— Let him take two colocynth pills immediately. Continue the powders. "7th.—No return of shivering. Complains only of pain of back.—Apply a warm plaster to the lumbar region. Continue the medicines. " 8th.—Bowels slow.—Feels drowsy to day. No shivering.—Let him have the colocynth pills. Continue powders. " 13th.—Bowels slow.—Let him take a cathartic draught. " 15th.—Two laxative pills at bed time. " 17th.—Inflamation of eyes, particularly of right, with adhesion of eye-lids in morn- ing. No headache—Let him have 5 i. of compound powder of jalap immediately. To bathe his eyes frequently with tepid water, and to apply simple ointment to the edges of the eye-lids. «18th. More inflamation of right eye.—Apply the cupping instrument to his temples. Repeat the powder of sulphate of quininine three times a day. "20th.—Eyes still sore.—Apply eight leeches round the eyes. "21st—Two leeches only fixed. Bowels confined. Inflamation of eyes somewhat abated.—Repeat the leeches and purgative draught. " 22d.—Leeches bled well. Eyes less painful. Still inflamed with discharge of tears. Dissolve gr. xv. of the acetate of lead, in g viij. of water, for a collyrium. "24th.—Both eyes somewhat inflamed, with impatience of light and dimness of sight. —Abstract from the arm J x. of blood. Continue medicines. « 25th.—Eyes better. Bowels open.—Continue the lotion for the eyes. INTERMITTENT FEVER,: 83 "26th,—Still some pain of eye-balls; less inflammation, but has some dimness of sight, No pain of head. Iris moves welL—Discontinue the powders of the sulphate of qui- nine. Apply a blister to the nape of neck. " 30th.—Still some dimness of sight.—Let him have ^ i. of simple ointment—Dis* missed cured. "Case XIX.—A. B., a carpenter in Leith, had had many severe attacks of intermit- tent, which weakened him so much that he was almost entirely confined to bed. He had taken a great many remedies, but the disease increased in severity. Several of my pupils watched this patient in order to bleed him in the cold stage ; at length the rigor came on, and blood was drawn to the amount of sixteen or seventeen ounces, stopping the paroxysm. He experienced the same sudden relief that all the others had done from pain in head and loins, great oppression at the praecordia, dreadful sensation of cold- ness. This man, however, had two returns of the disease, which were owing to constant perspirations, which he encouraged, and also from allowing his bowels to get very much out of order. After a few doses of laxative medicine, and insisting on his avoiding the perspirations, he had no return of the disease, and soon recovered his ordinary state of health without any other means. "Case XX.—James Donachie, at. 35, pale and emaciated, applied at the Dispensary on the 10th May, 1828. States that he was at work in Lincolnshire last harvest, where he became affected with a quotidian intermittent, which continued to recur about five, six, or seven o'clock in the evening, till February last, except during his stay in the York Infirmary, and a short time afterwards. He became a patient in the Infirmary of Edin- burgh, in the clinical ward. He further states, that whilst there, the symptoms ran so high that he was bled in the hot stage, but without relief. He remained in the hospital four weeks, was treated with bark, and discharged ; but was affected as severely as ever. Since about March 22, when he came out of the Infirmary, S!he fits have con- tinued to attack him every evening at five, six or seven o'clock, occasionally continuing until the morning. A considerable part of this time he was under the use of Fowler's solution, without the least relief. Mr. Taylor, one of my pupils, bled him during the cold stage. Before the bleeding, his pulse was 63 ;■ the rigor was completely formed. Although the vein was properly opened, no blood came at first; it soon dropped down the side of the arm, and afterward came in a jet, when the rigor instantly ceased, and the bleeding was stopped. One ounce and a half of blood was abstracted. He got a little calomel and rhubarb to keep his bowels open. His strength now increased rapidly, and he had no attack for six days, till the 16th May. During this interval he felt tole- rably well, and only experienced a slight sense of chilliness and disposition to yawn, for a short time, instead of the regular paroxysm, and not every day, as before, but on alternate days, and at 1 p. m. instead of the evening. This last attack came on, as al- ready mentioned, on Friday 16th May, while he was out taking a walk on the Castle Hill, during which he was exposed to a keen north-east wind, which prevailed at the time. He got home with great difficulty. He had another attack on Sunday 18th, which together with the former one, he describes as having been attended with a less severe cold stage, but more intense hot and sweating stages, than he had experienced before. 19th, Complains of thirst, but no loss of appetite; surface pale ; tongue white and moist; pulse 60, soft and compressible ; bowels regular, has no uneasiness/ " Tuesday 20th.—Had no fit but only a disposition to stretch and yawn, with a slight coolness of the surface ; in a few minutes afterwards his skin became hot, attended with moisture on the breast and on the inside of the fore-arms; pulse 80, soft. 84 INTERMITTENT FEVER. " Wednesday 21st—He had sweating yesterday afternoon after the visit; has no complaint to-day. "Thursday 22d.—No paroxysm, but experienced the yawning and stretching, follow- ed by heat and sweating. '* Saturday 24th.—Escaped, and had even no threatenings till « Wednesday 28th, when there was a slight chilliness, succeeded by heat and sweating He had another slight attack on Friday 30th, but both these attacks were again owing to exposing himself out of doors in cold, damp weather. " On June 2d, had a return of the stretching ; yawning; heat; and sweating, which continued profuse all night; indeed every night he perspires profusely, which is not to be wondered at when it is known that he slept with four other people in a low room, eleven feet by twelve. After this he had no paroxysm, and the only remedies which were given were the decoction of quassia, sulphuric acid, and gentle laxatives ; and he went to work on 26th June, as a laborer, with restored health and strength. " Case XXL—Francis Trail, aet 26, presented himself at the Dispensary early in the beginning of May 1828, in a pale and very weak condition, with swollen features, when he gave the following account of himself: He is a native of Ireland, and went to work at the harvest in Lincolnshire in 1827 ; remained there about a fortnight; at that time he was in the enjoyment of good health, and continued so till the beginning of last Ja- nuary, when he began to feel unwell at times, but still was able to continue at his work on the rail-road near Dalkeith. About the end of February he was seized with violent shivering, which was succeeded by great heat and terminated in profuse perspiration; the paroxysms have continued ever since in the tertian form, and he has been unfit to do any thing, his health and strength becoming very much impaired. He was bled early in the disease, in the hot stage, without any remission of his sufferings, and without preventing the accession of the regular paroxysms. The cold stage generally conti- nued from half an nour to three quarters, and he experienced great suffering from pain in the head, and lumbar region, with sickness. On Sunday, 10th May, he was bled to 16 oz. during the cold stage. During the bleeding the rigors ceased, but afterwards a hot stage took place, accompanied with pain in the head and loins. " On Tuesday the 12th, as he felt light and easy, and better than he had done for a long time, he walked a few miles out of town to see some friends, when he had a pa- roxysm, but which was not so severe as on former occasions. On Thursday he had an- other paroxysm, which was slight, unattended by rigors. After this period he had no Cold stage, instead of which, he felt languor, headache, sickness, and pain in the lumbar region, in a slight degree ; he recovered his health and strength rapidly, and in about a fortnight from the time of the bleeding he had no complaint. He stated that his appe- tite was now good, his strength daily improving, and at the end of May he returned to his work cured. "CaseXXn.—Dr. Cambridge, 29th September 1827, had repeated attacks of inter- mittent fever at Ostend some time ago, at which place it was prevalent at the time. Since his arrival in Edinburgh, three weeks ago, he has had a daily paroxysm, and used the sulphate of quinine without effect. His appearance is far from being emaciated, but he looks pale and weakly. " The rigor came on severely at nine this morning, accompanied by insupportable pain of head, shooting from temple to temple, inability to take a full inspiration, with sense of tightness across the chest. The rigors continued for the space of three hours, and then ceased ; but the sense of extreme coldness, and other severe svnptoms con- tinued. I was called to see Dr. Cambridge, and made my first visit at one o'clock INTERMITTENT FEVER. 85 when his sufferings were still unmitigated. He still felt cold. His pulse was weak and oppressed, 130 in the minute ; respiration 50 ; face pale, and features contracted ? tongue loaded, but moist. A vein was opened ; immediately after the blood began to flow, he expressed in strong terms his sense of the sudden relief he experienced ; at the expiration of a minute he could dilate his lungs to the fullest extent. Eighteen ounces of blood were taken, which occupied three minutes of time ; and before the arm was bound up, all his uneasiness had ceased ; the painful sensation of cold changed to that of a pleasant glow of heat, and the surface of the body was covered with a gen- tle moisture. No debility followed, and he was able to walk through the room. A brisk laxative was ordered. "30th.—Had no heat of skin yesterday after the bleeding. His feelings were com- fortable during the remainder of the day ; he passed an excellent night and felt quite well this morning up to the moment of attack. The paroxysm came on at eleven a. m. and although he shivered smardy, yet he distinctly declared that he was quite free from the cerebral symptoms, and all the other very painful feelings which had distressed him on former occasions, excepting the tightness and oppression at the chest. Respirations 36 in the minute. Pulse weak and not to be counted. Mouth slightly ulcerated, and com- plains of a bad taste. Tongue loaded, brown in the centre, and rather dry. Had four large, dark colored, and fetid evacuations since last night, which produced a burning sensation at the extremity of the rectum. A vein was opened, and blood was drawn, to the extent of ten ounces, which occupied four minutes of time , before five ounces were abstracted, he described, in language most poetical, his relief, which was as sud- den as it was perfect. The pulse was reduced in frequency, and became much stronger, and he said he was sensible of an increase of strength ; indeed, he was able to walk through the room immediately without support. In about an hour after I took my leave, the rigors returned with considerable severity, but unattended by headache, and there was little oppression in the chest. He had some fever, and a sweating stage. The sulphate of quinine was again had recourse to, and he had only one other slight paroxysm. His health afterwards improved daily, and was soon perfectly re-established. " Case XXni.—Dr. Cambridge informed me, that after reading my first paper on bleeding in the cold stage of intermittents, which he met with on the Continent, he had an opportunity of saving the life of a clergyman, upon whom he tried the practice, with complete success. This gentleman's health was reduced to the lowest possible ebb, by repeated attacks of intermittent fever. He had tried bark in all,its forms, and quassia and arsenic, without the least mitigation. Dr. Cambridge bled him in the cold stage, and he had no return of the disease, and his health was quickly re-established." I have been favored with the following case of coma, occurring in the cold stage, treated successfully by bleeding, by Dr. Henry Lucas of the Royal Artillery. " Case XXIV.—Gunner William Smith, 9th Battalion. Admitted, August 16, 1827. is perfectly insensible; eyes fixed, pupil partially contractile ; respiration slow and deep; pulse full and slow; skin cool, especially about the lower extremities. Is completely insensible to external stimuli. Was brought from one of the guard rooms, where he had been complaining of feeling ill. Had had attacks of ague. A vein was opened in the arm, and he recovered sense and motion on losing six ounces of blood. He com- plained of cold, though by that time the skin was warmer. Twelve ounces of blood were taken. Warm bottles were applied! to the feet; cold lotion to the head,- and a turpentine enema. In the evening he was found sweating. Bowels not free. Cathartic mixture ordered. 86 INTERMITTENT FEVER. " 17th.—Bowels moved once by the mixture. Pulse soft and full. Skin moist and warm. Tongue rather loaded.—Repeat catharctic mixture. " 18th.—Had distinct rigors last night, succeeded by increased heat of surface and sweating. He was discharged on the 24th, cured. • " Cases XXV. and XXVI.—The following is the extract of a letter from Mr. Brown, now assistant surgeon in the 52d regiment, dated Jersey, 8th August 1827 : " Since 1 had the pleasure of hearing you lecture, I have, in three instances, tried the effect of bleeding in the cold stage of intermittents, and twice with complete success. The pa. tients were invalids, sent from Gibraltar for change of chmate. One bad had ague for eighteen months previous to his coming under my care ; and at the time he left the de- pot for Chatham, seven weeks from his being in hospital, he had no recurrence of fever. In the third case I was not so successful; it was, I think, from the bungling manner in which I opened the vein, I could not get the blood to flow.' Cases XXVII. XXVIII, XXIX. and XXX " Cork, Marlborough Street. «< Sib, Wednesday Nov. 14, 1827. The perusal of your paper upon the utility of blood-letting in the cold stage of in- termittent fevers, induced me to resort to that remedy, in the only four cases of the dis- ease which I have met with since. The disease is of comparatively rare occurrence in this city, and never assumes a very aggravated form. Three of the cases I allude to were stout laboring men ; the fourth was a delicate girl about [twelve years of age, None of them presented very dangerous symptoms. The most distressing symptom wis severe pain in the head, which was generally most intense during the cold fit. The Ion of blood, so far from causing collapse, or adding in any degree to the feeling of debili- ty which existed, seemed to produce quite an opposite effect. The patients expressed themselves immediately relieved, a gentle perspiration ensued, and they appeared as if revived by the influence of a generous cordial. The bleeding, however, did not effect a cure, but the subsequent attacks were infinitely more mild, and yielded in a short time to the exhibition of the arseniate of potass. " The beneficial effects of this practice fully answered the expectations which you announce ; and I have no hesitation in saying, as far as I can judge from limited expe- rience, that we are indebted to your sagacity for a bold and unusually successful innova- in the treatment of a disease, which lias constantly baffled our best directed efforts. You will excuse this brief communication, but I am aware that no reward is more grate- ful to a physician, than the assurance that his suggestions have received and merited the approval of his brethren.------1 am, Sir, With much respect, Your obedient Servant, To Dr. Mackintosh. (Signed) D. B. Bullen, M. D." «' Sib,—In consequence of having read, with great interest, your valuable paper upon the subject of bleeding in the cold stage of intermittent fever, which was publish ed in the Edinburgh Medical and Surgical Journal for April last I resolved to adopt your plan of treatment, in the first case of ague which should occur to me. Ague has not for many years been endemic in this neighborhood, so that the opportunities I may have of further trials of your treatment will probably not be numerous. The results of the two cases, of which I take the liberty of sending you an account, are very favorable. They occurred to me in my practice as physician to the General Infirmary here. Witb a strong conviction that future experience will confirm the correctness of your views INTERMITTENT FEVER. 87 and practice, and with feelings of admiration and esteem for an individual, who has im- proved the practice of medicine, by a^disregard to long established prejudices, and er- roneous doctrines, I remain, Sir, Your obedient Servant, Worcester, July 27, 1827. Jo was Malpen, M. D. To Dr. Mackintosh, Edinburgh." "Case XXXI.—May 5, 1827.—Priscilla Williams, set. 30. Complains of pain in the head. Skin hot. Tongue furred. Pulse 120, small and rather hard. Pain in the epi- gastric region, with loss of appetite. Bowels confined. Has a severe rigor every other morning of half an hour's continuance, which is followed by a hot and sweating stage, Her complaints began with cold shivering, three weeks ago, in the neighborhood of Ox" ford, where ague was prevailing—Applicentur hirudines xii. regioni epigastricae.—R* Extracti colocynth. co. gr. xv.—Hydrarg. submuriatis gr. iii.—Fiant pilulx tres stat su- mendse.—R. Liq. antimon. tart. n\,. xx. Potassx nitratis gr. x. Mist.—Salime % i. M Sumat quartis horis. " 6th.—Pain in the stomach relieved. Headache continues. Bowels freely opened. No rigor yesterday.—Let her be bled during the cold stage to-day. "7th.—Lost ten ounces of blood yesterday during the rigor, when she became rather faint A hot and sweating stage succeeded. Bowels open. Tongue cleaner. " 8th.—Pulse 80, and of moderate strength. Headache and pain in the stomach much better. The rigor came on this morning, during which she was bled to 16 ounces, and a slight hot and sweating stage succeeded. " 9th.—Another very short and slight rigor this morning. " 10th.—Ague returned to-day, but bleeding cut short the cold stage, which was nei- ther followed by heat nor sweating. t "13th.—Puke 72. Tongue clean. Appetite good. Free from pain. Has had no ague since last report. Wishes to leave the hospital. Discharged. "27th___I saw the husband of this woman, who told me his wife was quite well, and had no return of her disorder. " Case XXXII.—May 22, 1827. William Holland, set. 24. Has pain in the head and limbs, with furred and dry tongue. Pulse 96, small. Bowels regular. Has severe rigors of an hour's duration every day, which are followed by the hot and sweating stages. He has great prostration of strength, and a sallow countenance, and is much emaciated. Illness began with a shivering ten weeks ago. He has for some time been wandering about the country, and sleeping in the open air at night.—R. Hydrarg. sub- muriatis gr. iv. Pulveris jalap?e gr. viii.—M. f. bolus stat. sumend. " 23d—Had a rigor yesterday which lasted an hour, and was succeeded by a hot stage and profuse sweating. The pulse in the rigor was 120, and very small. The bowels have been freely opened; stools of a good colour. Headache continues.—Fiat vensesectio dum rigor adsit. " 24th.—Was bled to fourteen ounces during the cold fit yesterday. Whilst the blood was flowing, the shivering diminished. The hot stage followed, but lasted a much shorter time than usual. The pulse was not perceptibly affected by the bleeding.— Sumat mistura cathartica § iss pro re nata. " 25th___Is much improved in appearance. Pulse 80, soft. The rigor came on at the accustomed time yesterday, but the shivering was less violent. Venisection was repeat- ed during the paroxysm. The blood flowed freely, and the rigor ceased immediately upon tying up the arm. The cold fit lasted twenty minutes. The pulse during the rigor v/as 120. No hot fit followed. 88 INTERMITTENT FEVER. " 26th—Had a slight tremor yesterday, which lasted an hour. The hot stage after- wards scarcely perceptible. Bowels open. Tongue much improved. Pulse natural.-. R. Sulphatis quinina: gr. ii. Infusi rosae g i. M.—Sumat secunda quaque hora. "27th.—Had a short and slight shivering yesterday afternoon. No hot stags Another at two o'clock a. m. 29th.—No return of the ague since last report. Pulse 72. Bowels regular. Tongue clean. He makes no complaint. "June 2d.—Continues well. From this time till the 14th he had no return of the complaint. He had regained flesh and a healthy appearance, and was discharged cured.'' The practice of bleeding in the cold stage has also been successfully tried by Dr. Haviland, Professor of the practice of physic in the University of Cambridge, the result of which was communicated to me, with Dr. Havdand's permission, by Dr. W. H. Yate5. The following are extracts from Dr. Yates's letter: " Dr. Haviland tells me, that in con. sequence of your communication to the profession on the propriety of bleeding in the cold stage of fever, he was disposed to make trial of it having, as you would expect, frequent opportunities in these low countries. His principal object was in the first place to ascertain how far it was practicable; for when he read the account, it struck him that it was a practice quite consonant with his own views. He was always assured that in these cases there existed considerable congestion of the larger vessels, and that, could a portion of their contents be safely removed, the general result would be good. He has since tried it in several cases with decidedly beneficial effects.'* The following clinical report on the success of bleeding in the cold stage of intermittents in India, was read by Mr. Twining at a meeting of the Medictl Society at Calcutta, on 5th December, 1S29. This report comprehends ten cases. " Case I.—Was bled to 12 oz. in the cold stage of the 6th paroxysm of tertian inter- mittent He experienced immediate relief, the rigors ceased, and he became hot for about half an hour; he had a slight return of fever daily at noon for six days, not pre- ceded by rigor of cold. This patient had enlarged spleen. "Case II.—Was bled to 14 oz. in the cold stage of tertian ague in the 4th paroxysm. The rigors soon ceased, he had a slight hot stage for about half an hour, and there wu no return of the disease. " Case HI—Was treated with purgatives, quinine and arsenic, afterwards with mercur/ to salivation, without benefit; bled in the cold stage of the 11th paroxysm, he felt imme- diate relief, and had a very short and slight paroxysm without sweating stage. A slight feverish feel remained for eight days after. At the end of 14 days, he says, he haaa return of ague, and on the return of next paroxysm, after one day's interval, he wu bled in the cold stage, and cured. " Case IV.—Quotidian ague of seven days duration, purged and took bark, bled to 18 oz. in cold stage of 7th paroxysm with great relief; was exposed to cold next night, and had continued fever afterwards. "Case V.-—Tertian ague, bled to lb. i. in the cold stage of the 5th paroxysm, with immediate relief; had a short and slight paroxysm, and was cured. "Case VI.—A most distressing tertian, with very severe rigors; bled to lb. i. in the cold stage, and cured. INTERMITTENT FEVER. 89 " Case VII.—Irregular ague, sometimes tertian, sometimes quotidian, bled to 12 oz. in cold stage, with much benefit; he was cured, having in place of ague on the two next days of expected access, a slight feverishness. " Case Vin.—An Asiatic, native of Madras, bled to 6 J oz. in the cold stage of second paroxysm of tertian. The rigors ceased in less than two minutes after the vein was opened, he had no fever, and was cured. "Case IX.—Irregular intermittent, used quinine without benefit, emaciated, bled to oz. vi. in the cold stage, with immediate benefit and no return of the disease. " Case X.—Bled to lb. i. in the cold stage of 6th paroxysm, the cold ceased, and he had a slight paroxysm. The ague returned on its regular day, and he was bled again to oz. x. in the cold stage, which was arrested, and had no ague or fever since." In Mr. Twining's second communication, read at a meeting of the Society at Calcutta, on the 1st of May, 1830, the following additional cases were brought forward. The next six cases !are numbered in continuation from the former paper. " Case XI.—Quotidian ague of five week's duration; the subject a woman ten years in India. Spleen tumid ; had used purgatives and quinine without benefit; V. S. to oz. xiv. in the rigor on 18th December. Rigors ceased in 6§ minutes, and she had no re- turn of the disease after V. S. Purgatives used for several days. " Case XII.—A Mahomedan had eleven paroxysms of tertian; treated with purgatives and quinine ineffectually. V. S. to oz. 3. in rigor on 27th December, 1829. Rigor ceased in eight minutes, and he had no return of the disease. "Case XIII.—Irregular ague in a European, from 16th Oct. to 25th Dec. V. S. in cold stage procured immediate and great relief. Had a paroxysm on 27th Dec. V. S. ad oz. 17. Rigor ceased while blood was flowing. Cured—no return of ague after- wards. " Case XIV.—Intermittent (at first quotidian, afterwards tertian, of twenty days' du- ration. ) V. S. to oz. ix. which shortened the cold fit, and there was no fever or sweating stage. Ague returned on 1st January. V. S. in rigor, to oz. 8. Rigor ceased in 10* minutes. There was no fever, and very little sweating afterwards. Return of ague again on 3d January, but he did not call any one in time to bleed him. He had no re- turn of ague after 3d January. " Case XV.—Tertian ague of three months' duration in an emaciated subject. Cold stage very distressing, with headaches and vomiting. Had tried quinine, purges, and other remedies, with no benefit. V. S. to oz. xii. at beginning of rigor. The cold fit ceased in ten minutes, and all distressing symptoms were quickly relieved. This patient left Calcutta next day, and, as was afterwards understood, had ague on the regular day, but the medical man present refused to bleed in the cold stage. " Case XVI.—An emaciated European, twenty-four years in India, had tertian ague for three weeks, and irregular ague for two weeks before. Rigors usually lasted three hours. V. S. to oz. x. on lOtii January, after rigor had lasted near two hours; the shivering soon ceased. Slight heat, and no sweating stage followed. Paroxysm return- ed on 12th January, at half past 9, and he was bleed immediately to oz. ix. Shivering 12 no INTERMITTENT FEVER. ceased in eleven minutes; little fever, and no sweating followed. The ague did not return. He had a slight feverishness at 10 a. m. on 15th. Purgatives were used. No relapse. " The four next cases were Europeans, treated by Dr. M'Andrew, Surgeon H. M. 14th Foot, who has tried the treatment now described in many other patients, and has not found one in whom V. S. at the beginning of the rigor has failed to effect a cure; he has usually given three or four purges, and says he is so well satisfied with the cures, that in future he will use no other treatment. One of his patients, whose case is detail- ed, was cured by the first V. S. Three others required a second bleeding each. " Six cases were furnished by Dr Berwick, Assistant Surgeon at Beerbhoom:—the patients natives of Bengal. Dr. B. observes, that natives of India may be bleed more freely and with more benefit than most people suppose; he has been somewhat disap- pointed with quinine as a remedy for the intermittents at Beerbhoom. Four of his patients required each only once V. S.; the two others had each a second bleeding; all used purgatives. " Five cases treated by Dr. Makenzie, in Arracan, were Asiatics. One bleeding each was sufficient to cure four of his cases; the fifth experienced great and immediate relief, and felt so well that he walked home a long distance: had a return of the paroxysm at night, and lias been affected with irregular ague since; but living at a distance, has not been seen in time to repeat the bleeding. " Four cases were treated by Mr. Bacon, Assistant Surgeon. The patients were Europeans, and he was well satisfied with the treatment. Two of his patients were cured by the first bleeding, and two others by the second. " Four cases were treated by Mr. Kent, Assistant Surgeon, Bengal Service, who has a very high opinion of the efficacy of V. S. in the cold stage of intermittents. The whole of his patients were cured, each by one bleeding, in the cold stage. One of them was first bled in the hot stage, without much benefit: on the next paroxysm, V. S. during tne rigor was resorted to, and,cured the patient. Mr. K. administered purgatives ac- cording as the condition of each patient required those remedies. " The next four cases were sent by Dr. D. Brown, Bengal Service, who has a favora- ble opinion of the treatment used. Each of his patients only required one bleeding; two of them used also quinine, and all of them purgatives. •' Two other cases were supplied by Dr. French, Surgeon H. M. 49th Regt He like- wise thinks favourably of the practice, and means to try it farther; but declines giving a decided opinion on such limited experience. One of his patients had the rigor cu short and the disease cured by a single bleeding; the other was bled twice, purged freely, and took quinine,- the effect of V. S. on the existing paroxysm being very de- cisive, and affording immediate relief. "Thus, Mr. Twining observes, the practice of eight medical men, at different stations, shews that V. S. in the cold stage of intermittents has been successful with Hindoos and Mahometans, as well as Europeans ; and of the latter several were persons many years resident in India. Some of them were of delicate constitution, and in emaciated condition. In many of the patients, quinine and various other remedies had failed for a long time. The early stage of rigor appears to be the best time to take blood ; but bleeding in an- ticipation of rigor does not seem to be of any benefit Mr. T. concludes by stating, that V. S. at the commencement of rigor appears to be fully as efficacious, and as deserving of confidence, as Dr. Mackintosh has represented ; and his experience up to this time entirely corroborates Dr. M.'s good opinion of the treatment." Several very whimsical objections have been brought forward by Professor Alison, against V. S. in the cold stage of intermittents. These were strongly INTERMITTENT FEVER. 91 and eloquently urged in a clinical lecture by the professor, upon the case of James Bennet, which will be found at page 79 of this work. Statements made in a lecture scarcely demand notice, but as they have been published in one o. the Medical Journals, it has been deemed advisable to enumerate the objections here, in order to expose their weakness and fallacy. 1st, It has been said, that although V. S. in the cold stage does not actually produce death, as was formerly imagined, its immediate or ultimate effect must be debilitating. Even in a continued fever, when the disease is cut short by the bleeding, the effect is debilitating; but as in intermittent we may expect a number of paroxysms, the debility is still more to be dreaded in the progress of the disease. Now this is after all only a truism; but allowing that the effect would be pro- ductive of thrice the degree of debility, yet who would not joyfully compound to cure the fever at the first onset of the disease even at such an additional ex- pense? The cases I have already published, which were narrowly watched by a multitude, I may say, of observers, proves that this kind of debility is purely hypothetical. Not only in fevers produced by sub-acute inflammatory action of some important organ, but also in pure inflammations of the same parts, we bleed in order to produce debility, not as a matter of choice, hut as choosing the least of two evils. But this term debility, is ever haunting the imagination of the Cullenians, according to whose erroneous system, not only are spasm, delirium, and the tremors, but also the oppression of the pulse, the disorder of respiration, the want of appetite, the nausea, and the vomiting, which accom- pany a paroxysm of intermittent, all ascribed to debility. It is no wonder, therefore, that from a priori reasoning, the disciples of this system should object to this practice under such erroneous pathological views. But they should re- collect that I bleed only in certain cases of intermittent, not to produce debility, but to restore the balance of the circulation at as small an expense of blood as possible. 2d, It has also been said, that " bleeding in the cold stage has generally been condemned, and probably from experience." I beg most respectfully to ask the Professor, by whom has it been practised, and for what reasons condemned? 3d, It has been said that it cannot be successful, because " it attacks the ef- fect, and not the cause, of the disease." Let me ask, who knows any thing of the cause of any disease which affects mankind ? There is a great deal of pe- dantry and ambiguity concerning this term cause, as it is generally used in me- dical language. In employing it, some mean to express the agent, whether known or unknown, which actually induces the disease. For example, the ap- plication of boiling water to the surface of the body produces inflammation and its consequences. This is a known cause. An imaginary substance, to which the name of marsh miasm has been applied, is an example of the second. It is this unknown substance to whose agency intermittent fever is ascribed. An- other sense in which the term cause has been applied is the first diseased ac- tion induced by either of the agents. It can easily be shown how very absurd this objection really is, taking it in either sense. In the case of the scald we :<2 INTERMITTENT FEVER. are called upon to treat the effect and not the cause ;—the hot water is remo- ved, but the effect remains. A. B. has intermittent fever; the cold stage is long and severe ; the consti- tution is too much oppressed, and the patient dies ; or rather let me suppose, he would have died but that he is bled. Is it not absurd to object to the prac- tice, merely because the practitioner is not "measuring swords" with the cause, viz. the marsh miasm, but treating the effect ? Or, A. B. has had the cold fit, and is now laboring under high excitement, and the powers of the constitution are unable to produce the sweating stage ; inflammation in the head, chest, or ab- domen, takes place; or it may prove to be a continued, remittent, or billious remittent fever ; are we not to treat the case pathologically, because we should only be attacking the effect, and not the cause of the disease ? In the other sense it will be seen to be an equally erroneous objection, viz. the first diseased action produced by any agent whatever. Let me ask who can point out the first link in the chain of morbid action ? Is it in the ner- vous system, or in the vascular ? Both are seriously involved. If in one, how is it communicated to the other 1 Who knows the structure of a nerve, and who is acquainted with its physiology ? If in the vascular system, whether is the primary diseased action in the arteries or veins, in the capillaries or the trunks, or is the blood itself affected ? It is wholesome to put these questions home to that medical man who is too nice in investigating the occult causes of diseases. If the practice pursued by medical men were to be rejected, and condemned as being " unsatisfactory and unscientific," (as V. S. in the cold stage has been by Dr. Alison,) because they treated the effect and not the cause of the disease, I fear the profession of medicine would soon be at an end, and its professors left in a more miserable plight than Shakespeare's poor apothecary. Upon this principle, it is unsatis- factory and unscientific pathology which leads us to bleed, blister, and give purgatives for the cure of any disorder, because we are treating the effect, and not the cause of the disease. 4th. Another objection has been made, that bleeding in the cold stage is only, to say the very best of it, " a palliative remedy." Does not a similar objection apply to bark and arsenic ? " It may, however, be remarked," (says Sir James Fellowes, at p. 382,) " that, in taking a review of the general practice in intermittent fever, the means usually adopted appear to have had no other view than to lessen the inconvenience of the paroxysms, and that they have not always been sufficiently active to put a stop to the disease in a way that was satisfactory to the patient or to the practitioner." To say the very worst of it, therefore, the practice does not stand on weaker ground than the other re- medies. I have seen much mischief done by the use of bark in aguish dis- tricts ; and I have known one man killed by arsenic. Clark (on Long Voy- ages) mentions a similar accident, but I have as yet known nothing but advan- tage to proceed from bleeding in the cold stage. I wish not to be understood to mean that bark and arsenic will always produce bad consequences, or that INTERMITTENT FEVER. 93 bleeding in the cold stage will invariably prove beneficial. I am convinced that both kinds of remedies require sound judgment in their application ; and that if there is any organic engorgement or alteration of structure, bark must be injurious, if it has any effect at all, and that this is one of the cases likely to be benefited by bleeding in the cold stage. 5th, This practice has also been objected to, forsooth, because it is a " me- ■chanical remedy." It is said " to affect the powers lohich move the blood, but it cannot affect the altered state of the blood itself." That it does affect the pow- ers which move the blood is a fact which cannot be denied, and this is precise- ly one of its great advantages. But to say " that it cannot affect the altered state of the blood," is a mere assertion. I maintain that it does also affect the altered state of the blood. Without entering into the physiological controver- sy about the nature of the changes which the blood undergoes during its circu- lation through the lungs, I may content myself with stating the fact, that some change necessary to life does take place on the blood in the lungs. From the commencement of the cold stage, the condition of the respiration decided- ly proves that the functions of the lungs are much embarrassed. It is not even necessary to inquire into the cause of the pulmonary distress. They cannot perform their functions ;—does it not therefore follow that the blood cannot undergo the usual and necessary changes ? The blood is in a morbid condition, and when taken from a vein in very severe cases, it looks black and does not coagulate. Under such circumstances, when bleeding is had recourse to, it relieves the circulation, unloads the vessels of the lungs, and thereby ena- bles tnem to perform their functions; the blood is acted upon, and the usual changes are effected. Therefore this " mechanical remedy" does also affect the altered state of the blood. But there is another interpretation of the expression, " altered state of the blood." It may relate to a supposed alteration produced on the blood by the morbid agent, the marsh miasm ; and I have no doubt this is the sense intend- ed to be conveyed. In the first place, I may remark we know nothing whatever of this marsh miasm; we assume the existence of such a substance ; and, as has been already stated, some have even ventured to give it sensible qualities, as smell and specific gravity. This is certainly going quite far enough in myste- ry and darkness ; but to say it directly affects the blood is a gratuitous asser- tion well becoming a true Cullenian, whose whole system of physic is founded upon, and carried on from page to page by, the most erroneous and the weak- est assumptions. This has always been my great objection to this system. Its author lost sight of the true Hippocratic maxim in the investigation of diseases. Cullen declared that there " are more false facts in medicine than false theories;" and on one occasion he asserted in his lectures, that what were called "medical facts were nothing more than medical lies." It will be seen, that whenever Cullen came to a difficulty, instead of waiting patiently for an accumulation of facts to enable him to investigate all its bearings, he made a leap over the ob- stacle by assuming a certain thing for a fact. He established a system of 94 INTERMITTENT FEVER. special pleading, and a symptomatical pathology, which have been exceedingly injurious to medical investigations ; and it will soon be generally acknowledged that his labors have retarded, rather than advanced, the science of medicine. In conclusion, I wish to impress upon the minds of my readers, that by V. S. in the cold stage of intermittents, we stand upon vantage ground, by afford- ing our patients the benefit of the following circumstances: 1st, The injury which in many cases results from the continuance of the venous engorgement, which so constantly leads to organic diseases, is avoided. 2d, The danger proceeding either from the want of sufficient re-action, or , from its excess, is also avoided. 3d. The practice prevents debility, in a direct manner, by saving the vital fluid. 4th. The chance of a return of paroxysm is diminished ; or if it should re- cur* the force of the attack will in general be weakened ; and in that case a most important point will be gained, by affording an opportunity for the admi- nistration of other remedies, as bark or arsenic, which might previously have been exhibited in vain. 5th, Experience has also taught me, that bleeding in the cold stage is far more efficacious than bleeding during the hot stage, or in the intervals. Seve- ral cases are quoted, in which bleeding was had resource to in the hot stage to moderate threatening symptoms, but without preventing a return of the disease at the regulur period ; and in these same instances, bleeding in a subsequent cold fit, had the effect, not only of stopping the existing paroxysm, but of pre- venting its return. If any other evidence were wanting to shew the advantage of a radical change in the treatment of intermittent fevers, it will be readily found by contemplating the results which befell one of the finest armies Great Britain ever sent from her shores, and which went to Walcheren on the 5th July, 1809. The pre- vailing disease was intermittent fever, and in the course of six weeks, 8000 sick, were sent to England, and 3000 more soon followed. While seven officers and ninety-nine men were killed in action during the whole campaign, we find that forty officers and 2041 men died from disease. It is further stated in the official returns laid before parliament, that several months after the return of the army, there were on the sick list 217 officers, and 11,296 men! A curious and an interesting fact was communicated to me by Dr. Foot, (who served with the 17th regiment in India,) when he did me the honour to attend my lectures,—that some Persian physicians apply ice to the surface of the body in the cold stage of intermittents, and, it is reported, with good effect. I have also heard that it is a practice with some in India, to use the cold affusion. It is proper, also, to mention the plan of preventing the paroxysm upon the first appearance of its approach, by applying tourniquets to the extremities, which was first noticed by Dr. Kellie, in the 1st and 2d volumes of the Annals of Medicine * The tourniquets appear to act, by confining the blood in the extremities, and preventing so much at least of the congestion in internal organs veSTSS? " menWd ^ ^^ P' 523' " if k Were ^ original in- INTERMITTENT FEVER. 95 Treatment of the hot stage.—The best treatment which can be pursued in the hot stage, is, to remove the bed-clothes as far as the season and the patient's feelings will admit; to sponge the extremities with water; to use cold drinks; and, in fact, to employ every means which can diminish the temperature of the body. If there be symptoms of local inflammation, bleeding is to be had re- course to, either general or topical, which has always been employed, by judi- cious practitioners, under such circumstances. I need not speak of febrifuge and diaphoretic mixtures, which are very good for the druggist, will assist in filling the pockets of the routine practitioner, and suit the notions of a sympto- matical physician. It is more than doubtful, whether such medicines ever di- minished the violence, or shortened the duration, of the hot stage of an inter- mittent. Treatment in the sweating stage.—When the sweating stage commences, it must be encouraged until the uneasy feelings are relieved, or at least mitigated. Great injury is done by allowing patients to perspire longer, by which they are not only unnecessarily weakened, but the subsequent paroxysms of the disease are in general rendered more violent. The best way of arresting this stage, is, to change the linen, after drying the patient carefully with towels, .and to place him on a couch. A second paroxysm has been frequently traced to a chill, occasioned by the coldness of the damp clothes, towards the termination of the sweating stage. Should there be no marks of any local inflammation, the pa- tient may be offered light nourishing food, and even wine if necessary. Treatment during the interval.—The first thing to be done, is, to determine whether or not there exist any local disease, and if so, what is its nature and seat? Medical men have hitherto deceived themselves very much by treating this disease, as well as many others, merely from its name; because it is inter- mittent fever, bark must be prescribed? Another error into which they have fallen, is, that they imagine the only organic lesions which take place exist in the liver and spleen, whereas the brain and the lungs suffer, perhaps, more fre- quently. I have seen fatal affections of the heart also arise in the train of conse- quences from intermittent fever. Bronchitis is also of frequent occurrence. These facts are stated from my own experience; and, except the last respect- ing bronchitis, they are fully proved by the cases and dissections recorded by M. Bailly, as well as by the facts which are to be found in the works of Pringle, Cleghorn, Chisholm, and others. If any organic disease exist, bark will be injurious, until it be either mitigated or entirely removed. Sir James Fellowes (Reports, page 350) states, that the dissections of those who died, discovered to us a series of morbid appearances of which we had no suspicion, and they enabled us to account for many of the phenomena of the complaint, and to form a more rational plan of treatment than that which which we had at first adopted. M. Bailly came to the following practical conclusion, that he bled, to dispose the system to receive the action of the bark, and that he has suddenly, by such means, subdued intermittent fe- vers, which had previously resisted all other means; and he assures us, at page 96 INTERMITTENT FEVER. 366, that although he would not altogether prescribe bark, yet he believes that bleeding alone, in most cases, above all, in our climate, would bring about a more substantial recovery. He also makes a very strong statement at page 375. " In the commencement of an intermittent fever, (says he,) one is al- most always sure to destroy it by a large bleeding;" and he shews that this dis- ease is not so fatal to poor, debilitated subjects, as to those who are better off, and better fed. For example, the mortality at Rome, where great misery pre- vails, is 1 in 26 of the whole population; whereas, in the marshes in the neigh- bourhood of the Sienne, the mortality is in the enormous proportion of 1 to 10 of the whole population. He also assures us, at page 383, that we are not to dread debility; that those patients who were bled by himself abundantly, and at short intervals, not only were not depressed by this debility, but acquired in a few days a state of strength and health which they had not known for a long time. Had this distinguished author been aware of the safety and success of my plan of bleeding in the cold stage, he would not have made the complaint, that in the worst intermittents, that is to say, those in which the patients died in the cold stage, he had " not time to employ bleeding." Speaking of the ad- vantage of bleeding in this disease, he says at page 383:—" Car j'en excepte toujours les fievres intermittentes pernicieuses, dans lesquelles on n'aurait pas le temps d'employer la saignee, si on ne se rendait pas maitre de mouvement nerveux par ce precieux anti-p6riodique." It is in such instances that the great advantage of bleeding in the cold stage is most apparent. In some of M. Bailly's cases, stimulants and bark, in con- siderable quantities, were given without benefit, and in the majority the pulse is described as having been strong. Bark has been long in use, and although I never denied that it had virtues, yet, when given in substance, in the large doses which are admitted to be ne- cessary, I have so frequently seen it do mischief, that the question has often suggested itself to me, whether it was not more injurious than beneficial? It seems to be injurious, in many cases, by overloading the stomach and bowels with indigestible ligneous fibre, and I have seen it cause serious intestinal irritation, as displayed by griping pains in the bowels, diarrhoea, and painful tenesmus. On examining the stools in these cases, they seemed chiefly to consist of bark, with a considerable quantity of mucus, occasionally tinged with a little blood. That preparation of bark, which is known by the name of the sulphate of quinine, is the greatest improvement in modern pharmacy, and the knowledge of its beneficial effects in simple intermittents, affords sufficient proof of the virtues of the substance from which it is extracted ; yet this remedy, all-powerful as it is, is useless in the cold stage, and must also fail in cases complicated with organic disease. Dr. Fordyce, who had great experi- ence in the treatment of this disease, states, that, " in many cases of perfectly regular tertians, the most skilful practitioners have been baffled in the use of Peruvian bark, and every other medicine recommended as useful in this dis- ease." My youthful readers may rest assured, that the same observations are INTERMITTENT FEVER. 97 equally applicable to the sulphate of quinine; yet they will meet very probably with many practitioners, who will assure them that they have never seen a case, in which bark, exhibited in substance, or in any other form, has failed in theii hands. When they hear such statements, they may be satisfied that such practitioners never met with a severe case, or that there is some subterfuge. Some medical men, it is but charitable to suppose, are in the habit of de- ceiving themselves ; for I have heard of many who allege they cure every case of fever, and every case of inflammation, by brandy, port wine and beef-steaks; and that the patients are to be regarded as in no danger, if they can be only got to swallow plenty of these articles. They also state that they carry lancets in their pockets, but they never use them. The sensible part of the profes- sion regards any man as a quack, or an impostor, who asserts such universal suc- cess in the treatment of fevers and inflammations, and particularly by such means. Those who are young in the profession, may rest satisfied that no means hitherto devised can be universally successful; and the cases have been already pointed out, in which the sulphate of quinine may be expected to be beneficial, as well as those in which the same happy result is not to be looked for. It cannot be too strongly impressed upon the mind, that experience has taught me to beware of any preparation of bark, while the patient has fever, or complains of oppression at the praecordia. Sydenham's recommendation of prescribing bark in the intervals, has been supported by subsequent experience. Bark is given in substance, in decoction, infusion, and in extract; but no one who has seen the superior efficacy of the sulphate of quinine, will, I am persuaded, if he can obtain it, ever use bark in any of the other forms. With respect to the doses of quinine, Andral states that Lerminier has prescribed it in a very great number of cases, in two doses of three and four grains each, with an interval of half an hour, four or five hours before the paroxysm. And he assures us, that given in this manner, it has almost always cut the fever short. In some cases, the fever has been equally prevented, by the exhibition of the quinine twelve or fifteen hours be- fore the paroxysm. Once the quinine was given by accident in the middle of the cold stage, and that paroxysm was neither weaker nor more intense than the preceding one. The greater part of those individuals who took the two doses of three grains each, had slighter paroxysms than before ; but the fever was not suddenly cut short, as it was in those who took the two doses of four grains each. He also states that in two cases the sulphate of quinine did not s,ubdue the fever till the dose was increased to twelve grains; and Larminier gave three individuals twenty grains each during the day, stopping the fever without producing any accident. But with several other patients, to all appearance in the same circumstances with the preceding, a few grains of the sulphate of quinine created troublesome nervous symptoms, such as violent palpitation of the heart; oppression ; the globus hystericus ; general uneasiness ; flying pains in different parts of the chest and abdomen.* 13 *Clinique Medicale, p. 488. 98 REMITTENT FEVER. The manner in which I have prescribed quinine, is to give three doses of five grains each, with half an hour of interval immediately before thelexpected par- oxysm; or three grains every half hour, beginning about three hours before the expected paroxysm. I have taken three and five grains, without feeling any thing unusual, and I afterwards ventured upon ten, but a violent headache fol- lowed, which continued for nearly three days ; I have given ten grains, how- ever, to others, on two or three occasions, without producing any such effect Arsenic has been long in use in intermittent fever, and there can be no doubt that it has often proved serviceable. Fowler's solution is the preparation now in general use, under the name of liquor arsenicalis; the dose is from two to twenty drops twice or thrice a day. Other tonics and bitters have been recom- mended; the best of these is the infusion of quassia. Opiates have been ex- hibited, immediately before an expected paroxysm, sometimes with benefit, but they generally produce violent headache. Laxative medicines, to keep the bowels open, form an essential part of the treatment,; and in general, the stools should be examined. I have met with cases which resisted every remedy, till it was ascertained that the patients had given erroneous accounts respecting the number and appearance of the stools ; and upon the bowels being put in pro- per order, the disease has given way without further trouble. From the idea that intermittent fever is a disease of debility, many practitioners give nourish- ing and stimulating diet, with wine, in all cases ; but after the pathological ac- count which I have given, and the appearances found on disection, a word mow need not be said to shew the impropriety of such conduct. In some instances it is beneficial, where there is no local disease, in others it must prove prejudi- cial. The patient should be clothed according to the season of the year, and the temperature of the climate. He should avoid exposure in bad weather, and particularly in our climate during the prevalence of easterly winds, and keep to the house after sunset, till he be sufficiently recovered. REMITTENT OR YELLOW FEVER. This is a fever in which there are remarkable remissions, which are followed in a few hours by exacerbations; so that it bears some resemblance to an in- termittent. This circumstance has led Cullen to identify them; and in his definition of intermittents it will be observed that he has embraced remittents also,—of the last he gives no separate definition. Remittent fever is a disease of warm climates, and when the skin is yellow it has obtained the name of yellow Fever. The milder forms depend upon general functional derange- ment, which runs more quickly into disease of structure than is observed in the fevers of this Country. Remittent fever has a very wide range of character; modifications of the complaint occur without end, according to the organ or organs affected, the character of that affection, the constitution and habits of the patient, and the locality of his place of residence. In its severest form, the REMITTENT FEVER. 99 viscera of the three great cavities are implicated from the first onset of the disease, and there is no complaint in which the appearances on dissection may be so truly predicted. Symptoms.—The disease begins, sometimes with great excitement and with- out rigor ; on other occasions, the rigor is severe. Generally speaking, there is some previous indisposition, such as headache and giddiness; want of appe- tite ; symptoms of indigestion; oppression at the praecordia; constipation of the bowels ; a feeling of debility and fainting; but of all these, oppression at the praecordia, some degree of giddiness, headache, and constipation of the bowels, are the most frequent premonitory symptoms. Sometimes it happens that the patient dies before re-action takes place, but this is comparatively rare ; sometimes cases occur where the seizure is sudden and unexpected,— the patient is struck down, as it were ; he loses his senses ; irritability of the stomach soon appears ; black vomiting ensues, and he is carried off in the course of thirty-six hours. " It often occurred," says Dr. Fergusson, "to a well-seasoned soldier, mounting the night- guard in perfect health, to be seized with furious delirium while standing sentry, and when carried to the barracks to expire in all the horrors of the black vomit, within thirty hours from the first attack." This, it must be confessed, is the most severe form of the disease. There are many varieties, concerning each of which it is impossible to treat in a work like the present. The most frequent form of the disease, is that in which, after the rigor, which may be more or less severe, there quickly succeed violent re-action, heat of skin, and determination to the head, announced by the following well-marked symptoms ; flushed face; conjunctiva injected, the eyes look heavy, and often feel burning ; the expression of the countenance often leads an experienced person to judge correctly of the severity of the attack. The respiration is hurried and frequently laborious, often attended by cough, and the patient occasionally sighs, and seems to gasp for air. The head is thrown about from side to side ; and the patient is excessively restless from anguish. Severe darting pains in the head are sometimes complained of, as also in the small of the back and down the thighs. There is sometimes a burning pain in the pit of the stomach ; exquisite tenderness in the right hypochondrium ; unquenchable thirst, with incessant retching of every thing taken into the stomach. The fluid ejected is mixed sometimes with a great deal of bile, and accompanied with a discharge of flatus, belched up, with great violence. The pulse is various even in people similar in age, constitution, strength, and habits ; but in plethoric subjects who are seized soon after their arrival in warm climates, the pulse is quick, full, and bounding for a few hours at least, after the re-action is fully developed. In some it is quick and not strong, and in others it is not particularly quick, and it is sometimes very irregular. The tongue is furred, perhaps red, but soon becomes parched and dark colored.— These symptoms indicate the first stage of this fever. An anxious and dis- tressed countenance, redness and sense of heat in the eyes, flushed face, intense headache, quick or laborious respiration, burning pain in the region of th 100 REMITTENT FEVER. stomach, with great thirst and excessive vomiting, announce a formidable dis- ease; but, in my opinion, not so formidable and hopeless as another variety, in which there is some insensibility from the first, with coma, weak and oppressed pulse, and cold extremities. The duration of the first stage i3 very uncertain. In severe cases it lasts from twelve to eighteen hours, but in those which are slighter, it may go on for three, four, or five days. In the second stage the skin and eyes acquire a yellow tinge; the heat sub- sides; the head is confused, or delirium appears; the breathing becomes quicker and more anxious ; the eyes begin to look glazed; the pulse sinks ; the retchings are rather more * violent; the matter vomited becomes thicker and begins to look dark ; and if the person be sensible he desponds ; he occasion- ally falls asleep, but instantly awakes in great terror; sometimes he starts out of bed furiously delirious, but instantly falls down in a tremor upon the floor; the tongue is always parched, and in general covered with a dark fur; and the skin becomes clammy. In this stage as well as in the first, there are often cramps in the belly and legs, which distiess the patients much. The duration of this stage is also uncertain. The first stage sometimes terminates by a remission of the more urgent symptoms, when the patient and his friends indulge the fond hope that he may recover; indeed, these remissions often occur, but the deception is soon ma- nifested by the recurrence of all the symptoms in an aggravated degree. In the second stage there are remissions also, particularly towards its termination, when a hope of recovery is again entertained; for although the vomiting be more frequent and more copious, all uneasiness generally subsides, but the pulse sinks, becomes irregular, and intermits; although it sinks in strength, yet it increases in frequency. Nothing is retained in the stomach ; the mat- ter vomited is of a dark color, resembling coffee grounds, and is termed the " black vomit." The breathing becomes more laborious ; the tongue has per- haps lost its fur, it is shrunk, dry, and red ; the eyes are sunk and glazed; the whole features are sharpened. As death approaches, the limbs become as cold as marble ; there is a troublesome hiccup, which perhaps has existed through' out the whole of the second stage. Haemorrhage sometimes takes place from different parts of the body ; the abdomen is frequently as tense as a drum; and death steals on slowly, or takes place suddenly. The symptoms in each of these stages must of course vary much accord- ing as the brain, the lungs, and contents of the abdomen, are more or less af- fected. In some instances the functions of the brain remain undisturbed, even to the very conclusion of the last scene; at other times, when there is extensive disease within the head, the delirium is more or less ferocious, or the patient is comatose ; he exhibits a variety of nervous symptoms, such as con- vulsions, rigidity of the extremities, tremors, suhsultus tendinum, and picking the bed clothes ; or where the head is more slightly affected, the senses are only occasionally obscured ; the patient may be said to be lethargic rather than REMITTENT FEVER. 101 comatose; he is easily roused, and when roused his countenance has a drunk- en or besotted appearance. If the lungs be affected, the breathing will be altered from that of health; mere dyspnoea may, however, exist, without any structural lesion of these or- gans. There may be cough also, attended with pain, followed by expectora- tion. I never saw a case of remittent fever in which the functions of the chy- lo-poietic viscera were not very seriously involved, as indicated by nausea and vomiting, thirst, pain in some region of the abdomen, meteorisin, and altered condition of the stools. It may be mentioned, also, that the functions of the kidneys seem to be al- most, if not altogether suspended, little or no urine being passed during the course of the disease; and upon dissection the bladder is usually found much contracted. Another variety frequently met with in very sickly seasons, is that in which a person, after passing several restless nights, is able to go through some of his duties for the first two or three mornings; but this costs him a very great effort. His weakness increases, the bowels are out of order and consti- pated, or after having been for some time so, he may now complain of diar- rhoea ; he feels alternate chills and heats, but the least exposure makes him complain of cold ; his stomach now begins to get irritable, he takes to bed, his senses become rather obscured, his breathing is affected in no other way than being short, and he cannot, even when he makes an effort, distend his lungs freely; he complains most of oppression at the praecordia: sometimes a remission of most of these symptoms takes place, and his skin, which was never hot, and his pulse, which was never full, quick, and bounding, are now felt to be nearly natural; but in a few hours the symptoms become aggravated. The patient is more inclined to be comatose than restless ; he complains now perhaps of violent pain in some region of the abdomen; the breathing is op- pressed, the extremities cold and damp, while the surface of the abdomen and thorax is hotter than natural; hiccup comes on, the coldness steals onwards to the trunk, the pulse sinks, the countenance looks ghastly, and the patient's fate is quickly sealed. In a work like this, it is impossible to describe all the varieties of remittent fever which occur in warm countries. Sometimes the brain is the organ chiefly affected, when the symptoms are what may be called cerebral and nervous. In another set of cases, the disease is concentrated on the lungs, when the symptoms will vary accordingly. In another set, the different organs within the abdomen may be affected, producing other varieties; and of these there may be various modifications and complications. Appearances on Dissection.—These appearances vary much, according to the duration of the disease, and the organ which has been chiefly affected; some dying in the first stage, when we must not expect to see much, if any, appearance of inflammation. Some patients may have been largely depleted, and we shall therefore see less vascularity in their bodies than in those subjects 102 REMITTENT FEVER. who have lost no blood. Some individuals may have died of remittent fever, with organic leisons produced by previous diseases. All these circumstances must be kept in view when we are employed in the investigation of morbid appearances. Some blood is generally found in the heart and large vessels near it, and also in the lungs, if the individual have not survived long, and not been largely depleted. Pleuritic effusions are sometimes seen, and recent adhesions ; the lungs themselves, in some instances, shew various stages of inflammation, and the bronchial tubes are extensively diseased. In the abdomen as in the tho- rax, various lesions are occasionally observed, viz : the results of peritoneal inflammation ; mortification of the bowels ; the liver pulpy, soft, very yellow, and easily broken down ; sometimes its structure is completely destroyed, and it has been described by some authors to be in a state resembling " rotten cork." The spleen has been found altered in the same manner. The stomach and bowels, when slit open, are found to contain more or less of the dark colored matter which has been vomited during life; and the mucus membrane very vascular, of a deep red color, not in depending portions only, but over a great extent of surface, sometimes throughout the whole. Until lately, it was not much the fashion to examine the mucous membranes minutely; and we still want information on the following points :—Whether the vessels which make such an appearance are in the mucous membrane or not? Whether the whole thickness of the intestine is discolored or not? Whether this color is owing to inflammation or infiltration ? At what particular points ulcerations are most frequently met with, together with a par- ticular description of the appearances of the ulcerated surfaces, and the adja- cent mucous membrane. And it would confer a lasting favour upon me, and a benefit on science, if some enthusiastic pathologist would take the trouble to inject portions with vermillion and size, and send them to this country, together with sketches shewing the recent vascular appearances, if to enrich my rapidly increasing museum, the greater obligation will be laid upon me, and no remu- neration which it is in my power to bestow, will be thought too great a sacrifice for such a boon.* Causes.—It has already been shewn that the extremes of cold and heat are not very productive of disease. Fevers are produced more by sudden changes of temperature, or by heat conjoined with moisture, than by heat itself, how- ever intense. The state of the mind has also a great influence, as well as the habitsof the individual. It has often been remarked, that there is great mortality among troops after their first arrival in a tropical climate. This is sometimes to be attributed to a want of due care on the part of government, in chosing the season at which they ought to arrive. I believe a greater number of men will be lost during the first twelve months, if they are landed at the beginning of the rainy season, than at its termination; perhaps the loss will be double. Great care should be taken * It may be mentioned, that nothing affords me greater pleasure than to spend an hour in my museum, with any pathological enquirer. REMITTENT FEVER. 103 in the selection of the troops; none but well-seasoned soldiers should be sent out. Sir George Ballingall has written very strongly and sensibly upon this subject, in his excellent work on some of the diseases incident to the troops in India. No young recruit should be sent out to be made a soldier ; all his drills and exercises should be completed in this country. When troops arrive in a distant country after a tedious voyage it is natural to ex- pect that they will indulge themselves in many ways beyond due bounds. Cheap new rum, or a rare and an abundant supply of delicious fruits, attract their at- tention, and do incalculable mischief. Some men leave England in the utmost state of despondency, and it will in general be observed that they are the first victims. New comers are also apt to indulge in drinking too largely of cold fluids, and sitting in a thorough draft when the body is over-heated; in fact it requires considerable time before a European obtains knowledge to manage himself properly. Some are fool-hardy, and take no care of themselves what- ever ; and I feel convinced, that an amusement in which young strangers too frequently indulge, known in the West Indies by the name of " Dignity Balls," causes many a death. Many cases have come under my observation, in which fatal attacks of fever appeared to have been produced by inattention to the bowels ; and I am con- vinced that it is a matter of the first importance to every one going to a warm climate, to keep his bowels open by gentle medicine. Repeated observation has induced me to believe, that a person may very often be exposed to any or all the causes of fever, even in the most unhealthy situations, without being affected, provided bis bowels be in a proper state, and his mind free from ap- prehension. These are a few of the many causes of disease in warm countries, entirely independent of the influence of contagion, marsh miasm, and epidemic influence. Pathology.—With respect to this part of the subject, I have little to say, ex- cept to refer to the general account already given of the pathology of fever. Remittent fevers have the same pathology as other fevers, only it will be found in general that the structure of more organs is involved than in the ordinary fevers of this country. But it may be noticed, that there is no species of fever which upholds the doctrines of Broussais more completely than the Remittent. Treatment.—There have been as great revolutions in the treatment of the fevers of warm climates, as in that of any other class of diseases with which I am acquainted. The supporters of the doctrine of putridity have, of course, always avoided bleeding even in the first stage, when they admit the existence of inflamation, for fear of the debility which they expect in the latter stages. They begin by clearing out the primse viae, and then have recourse to bark in very large doses, without regard to the state of the stomach, local inflamma- tions, or any other circumstances. This is the practice recommended by Clark, Lind, and others. They precribed opium, for the purpose of keeping the bark upon the stomach, and gave wine and brandy in considerable quantities, with the view of supporting the strength, keeping off the stage of collapse, and pre- 104 REMITTENT FEVER. venting putridity. But it may be stated without fear of contradiction, that this practice cannot be too severely condemned. It should be recollected, that the stage of collapse must come on sooner or later. No person can pass from a state of fever into that of health and strength ; and the longer it is postponed the worse will it be for the patient, whose situation very much resembles that of an individual in debt, who puts off the evil day from time to time by various means, and when his creditors meet at last, he is found without means to pay, whereas, had he disclosed his real situation sooner, the strength of his credit would have survived the shock without injury. The late Dr. Chisholm, about the year 1793, introduced the plan of affect- ing the system with mercury as speedily as possible, employing bleeding in small quantity, and only occasionally, more with a view of enabling the system to receive the mercury, than as a powerful measure calculated to subdue the diseased action. Now my recommendation would be the reverse, to use bleeding early, as the chief means, in cases which require depletion, and mercury afterwards as an auxiliary. The celebrated Dr. Rush bled and gave calomel to diminish the increased action ; and the reason this practice did not maintain its ground, is, that he trusted a little to the bleeding, and a little to the calomel, on the principal of gradually depleting the system. He rarely took more than ten ounces of blood at a time; and notwithstanding he repeated the bleedings from day to day, yet he never produced decided effects upon the disease, although he sometimes took away from one hundred to one hundred and fifty ounces of, blood. The practice would have been far more successful, had he taken away twenty, thirty, or forty ounces at once. When bleeding is thought necessary in this disease, it is trifling with the pa- tient's life if the blood be not allowed to flow till some impression is made upon the disease, and upon the system ; and it is impossible to determine be- forehand the quantity which will produce one or other of these effects. This is the kind of practice which was pursued by myself and many others who were in the West Indies twenty years ago ; and it appeared to be attended with great success. Some practitioners trust almost exclusively to the action of mercury, and in India more particularly, it is deeply to be regretted that a great waste of hu- man life has consequently taken place. Some years ago, Dr. Halliday, of the Honorable East India Company service, was, by order of the Marquis of Hast- ings, put under arrest, and deprived of rank and pay, for showing, by most in- controvertible evidence, that in the General Hospital of Calcutta, the enor- mous quantity of 26 pounds of calomel were consumed by 886 patients : And that under the digestion of this mineral, the proportion of deaths was 1 in about 6| of the whole sick list,—whilst under a more rational treatment the mortali- ty was reduced about one-half: In fact, that the mortality bore almost an ex- act ratio with the quantity of calomel exhibited. After a delay of several years, Dr. Halliday was restored to his rank by the express order, more than once repeated, of the India Directors. This transaction has never been REMITTENT FEVER. 105 brought before the British public, but having carefully perused all the evidence, I have no hesitation in declaring, that as a piece of persecution, from begin- ning to end, there is no parallel case to be found in the annals of any free country. Wherever the story is known, it must cause a blot, never to be ef- faced, upon the memory of the then Governor-General of India and all his ad- visers, military as well as medical.* The result of the practice of the rising medical officers in India has fully corroborated the statements formerly made by Dr. Halliday; and mercury is not now so much abused as it once was. And as pathological knowledge advances in India, which it is doing rapidly, mercury will be still less trusted to. It must be always kept in remembrance, however, that the liver suffers more frequently in the fevers of warm climates than in this country, and therefore mercury, under judicious management, can- not be altogether dispensed with. In 1796, the deaths in the West Indies under Dr. Chisholm's mercurial plan, were never exceeded, amounting to nearly one half of the whole number of troops. The bold and decisive use of the lancet in this disease has met with an able and influential advocate in Dr. Jackson, who was Inspector of Army Hospitals in St. Domingo, and subsequently in the Windward Islands. This distinguish- ed individual bled to the extent of thirty, forty, fifty, sixty, and even eighty ounces at once in the very beginning; and he repeated the operation within three hours, if the first evacuation had not been productive of permanent be- nefit ; after this he gave calomel in doses of from five to thirty grains, repeated every third or fourth hour. Bleeding has been strongly objected to, on account of the condition of the blood. In some cases it appears of a very dark color, and streaked with red and blueish lines; it coagulates very imperfectly, sometimes not at all, and does not separate any serum. It is in the state commonly called " dissolved blood," and which announces, it is supposed, a putrid state of the whole body, and particularly of the fluids. This appearance does not deter me from re- peating the operation, as I have been long aware, that it exists more or less in all severe cases of congestion; hence I have been frequently able to shew it to my pupils, in cases of intermittent fever, in which I have bled in the cold stage ; and also in cases of congestive fever. It has also been noticed by In- dian writers on cholera ; a similar condition of blood may be seen in patient! affected with cholera in this country, and has been observed in some severe cases of bronchitis. * The author regrets want of sufficient space to speak more fully of the transaction, but he cannot avoid annexing an extract from a letter addressed by the East India Di- rectors to the Governor-General, after full investigation. "Inthe mean time we autho- rise and direct you to remove the restrictions you have placed to the further employ- ment of Dr. Halliday, unless stronger objections shall exist to his restoration, than those which have been reported to us in the proceedings under consideration. It appears to us, that your interference in the professional discussions which were brought under your notice, has been carried further than is desirable, or consistent with the improvement of medical science." Notwithstanding this communication, Dr. Halliday was doomed to undergo still further persecutions. 106 REMITTENT FEVER. Dr. Rush says he paid no attention to the dissolved state of the blood when it appeared on the first or second day of the disorder; but repeated the bleed- ing afterwards in every case where the pulse indicated it. He states a fact which I can verify, that it is common to see sizy blood succeed to that which was dissolved. He states also, that he was never deterred by the presence of petechiae from blood-letting in cases in which the pulse retained its fulness or tension. Although the necessity of keeping the bowels freely open in this class of diseases must be admitted, yet I had not been long in a warm climate before I observed the injurious consequences produced by strong drastic purgatives, and many individuals were lost by the constant irritation kept up by this means. The appearances on dissection, too, warrant me in cautioning practitioners not to persevere too long in using strong purgatives; there can be no advantage from moderating irritation and increased action, if these be immediately re-ex- cited. The common purgative formerly used in the West Indies, was ten grains of calomel and a scruple of jalap. Emetics have been often extolled, but 1 believe every experienced tropical physician will agree with me in cau- tioning young practitioners against their indiscriminate employment; irritability of the stomach is one of the most frequent and troublesome symptoms, and once excited, it is always difficult, in many cases impossible, to restrain it. I have seen emetics exhibited, and the vomiting has continued till death, in spite of every remedy. The same caution is necessary with regard to those reme- dies which are employed for moderating the action of the heart and arteries. When in the West Indies, 1 have often regretted not having a command ol leeches, and I am persuaded, that upon a proper representation, the Govern- ment would take steps, at whatever expense, to secure a proper supply to the medical officers of the army and navy. There is no disease in which dissec- tion reveals so many organic lesions, and the efficacy of abstracting blood in such cases by leeches is generally admitted, particularly after the severity of the disease has been broken by the lancet. After the publication of Dr. Currie's work, Cold Affusion became generally used in remittent fevers, but much mischief followed, and it has fallen into dis- use. Dr. Currie has distinctly stated, that it is not admissible in cases where there is any internal inflammation; therefore, in the majority of cases of the fever now under consideration, the practice will be found to be injurious rather than beneficial. But when the skin is dry and burning, nothing gives the patient more temporary relief, than spunging the body with water, or vinegar and water, which ought to be very frequently repeated. The application of blisters, and other counter-irritants are highly serviceable after bleeding, &c. but should never be had recourse to in this, or any other fever, in the early stage of the disease. I have seen stimulants appear to save life, but in candor it must be men- tioned that I have also seen them very prejudicial; and I believe that nothing 1m the whole practice of physic requires more caution and experience than their REMITTENT FEVER. 107 exhibition; but I shall speak more fully upon this subject when treating of the fevers which prevail in this country. The best stimulants are wine and brandy; in many cases where the stomach is irritable, brandy will be found to be supe- rior to wine. In the last stage great care should be taken to support the heat in the extremities. Partly from the notion of the resemblance between remittent and intermit- tent fevers, and partly from this disease being supposed to be one of putridity, bark has been employed. By some it is recommended throughout the whole course of the disease, by others only during the remissions, and in the last stage ; but I believe it has done more mischief than good. I have often had to blame myself for bringing on an exacerbation, not only by the use of bark, but by nourishment and stimulants, during the first remissions ; and a strong impression is left upon my mind, that it would be better for patients if less were done for them in the state of apyrexia, and also in the commencement of convalescence. No doubt, however, can be entertained, that the sulphate of quinine will be of signal service in many cases. INFANTILE REMITTENT. Many diseases which occur in infancy and childhood have obtained this name, viz. inflammation of the brain and lungs, the irritative fever produced by teething and worms, rheumatic affections, &c; in all of which, and even in cerebral and pulmonary inflammations, there are very remarkable remissions in young subjects. But the disease which is to be considered in this section is a febrile affection, which is in general found to depend on irritation, inflam- mation, or ulceration of the mucous membrane of the stomach and bowels. Symptoms.—The little subject is observed to be listless, fretful, and thirsty, and to pass restless nights, with some heat of skin. In a few days the skin is hot and dry, the thirst and restlessness are increased, the breathing is hurried, and the pulse very quick. The child is more uneasy and restless at night, but towards morning the skin becomes slightly moist, when it has some disturbed sleep 5 the bowels are constipated, or there is diarrhoea, but the former is more frequently met with ; or there is frequent desire to go to stool, but little is pass- ed ; if there be any evacuation, it is discolored and fetid. In color, the evac- uations are not always dark, but sometimes white, shewing a deficiency of bile, and sometimes blueish, but always offensive, often mixed with mucus, and oc- casionally with a little blood. The child cries frequently, and draws its knees up to the breast,—it cries more when the belly is touched, which is hotter than the rest of the body, and tympanetic. It prefers cold water to drink, and fre- quently shews signs of increased abdominal pain after a copious draught; the stomach is occasionally very irritable, and every thing is vomited ; the tongue, being at first moist and loaded, and occasionally very red round the edges, soon becomes dry over a triangular space at the tip. On some occasions it is dif- ficult to keep the hands and feet sufficiently warm, while the face is flushed and the rest of the body parched. 108 REMITTENT FEVER. If proper treatment be not soon pursued, the functions of the brain occasion- ally become disturbed, and it is difficult, in many cases impossible, to deter- mine whether or not disease of structure is going on in the head. On other occasions the respiration, which has been hurried from the first, owing perhaps merely to increased circulation through the lungs, becomes laborious, a troublesome short cough also appears, and, in general, w*«!«l*tion will announce a more or less extensive inflammation of the bronchial memorane; and if the disease be not subdued, wheezing and expectoration will follow. Sometimes the child appears to be recovering for a few weeks, and then re- lapses ; during the remissions he gains flesh and strength, but the abdomen re- mains tumid, and in this condition he may continue getting better and worse till the mesenteric glands become enlarged, or dropsical effusion takes place in the abdomen ; the emaciation • increases ; there is no fever except at night; the appetite is occasionally voracious. In fact, the little sufferer presents all the symptoms of the disease usually known by the name of Tabes Mesenterica. Appearances on Dissection.—The chief traces of disease are found in the abdomen. Sometimes peritoneal inflammation seems to have been the imme- diate cause of death, and I have had many opportunities of ascertaining that in- flammation of this tissue has been excited by the extension of ulceration of the mucous membrane, through the muscular and mucous tissues. The mesente- ric glands are found very generally enlarged, sometimes enormously so, and seem to consist of a cheesy-looking matter, which is usually described as de- pending on scrofulous action, but perhaps without good foundation. On cutting into the stomach and bowels, the mucous membrane will be found in various conditions, occasionally very vascular, thickened, softened, or ulcerated. The ulcerations in the ilium and colon strictly resemble those which I have afterwards to describe in the bowel-complaints of children, except that the whole mucous surface of the colon is occasionally involved in one sheet of ulceration, with a rough and ragged surface and hypertrophy of all the coats, as is observed in many cases of phthisis pulmonalis. When there is no ulceration, we some- times see mere vascularity, with or without softening of the mucous membrane; the quantity of thick mucus adhering firmly to the surface is very great; and it is curious, that after being carefully removed by washing and wiping, I have seen fresh exudations take place during maceration, not only in water, but in spirits ; and I have been surprised, after having laid by preparations for many months, to find them again thickly coated over with mucus. Large abrasions are also sometimes found in the mucous membrane of the stomach, at the sple- nic extremity, which have penetrated through all the tissues at one point; in other places they appeared to be converted into a gelatinous mass. From care- ful examination, it would seem that this kind of disorganization is the effect of previous inflammation. This appearance has excited considerable interest of late years, and has been noticed on the Continent by Cruveilheir and others, and in this country, many years ago, by Underwood. The Profession stands greatly indebted to Dr. John Gairdner of Edinburgh, who has collected a great REMITTENT FEVER. 109 number of interesting cases, some of which occured in his own practice, and which will be found in the first and second volumes of the Medico-Chirurgical Transactions of Edinburgh. It has been stated in the description of the disease, that symptoms of cerebral and pulmonary disease sometimes become lighted up, but on watching the pro- gress of the affection,- these are observed not to form essential parts of it; nevertheless, the appearances sometimes found in the head and thorax, deserve to be mentioned. In the head there is generally effusion in the ventricles, and also between the arachnoid and pia mater, with great vascularity in the latter membrane. In the thorax, the most common morbid appearance is found in the bronchial membrane, which is vascular, and the tubes are more or less filled with mucus, which is to be described more particularly when treating of bronchitis. The substance of the lungs also shews various degrees of inflammation, and occa- sionally there are traces of pleuritis. Causes.—These are indigestible food, such as crude vegetables, sweet-meats, &c; the habit of allowing children to eat too many articles of food at one meal; together with insufficient clothing, and unwholesome food, to which the children of the poor are so frequently exposed. Teething sometimes produces symptoms like those above described. Pathology.—From this view of the phenomena of the disease, together with the appearances on dissection, and the causes, the reader will have anticipated what I have to state respecting the nature and seat of the disease, that it de- pends on irritation and inflammation of the mucous membrane of the stomach and bowels, particularly of the latter. Treatment.—Abstinence from solid food is necessary; even biscuits, crusts of bread, and the pulp of oranges, frequently produce relapses. Leeches should be applied to the abdomen in all cases where there is much vascular action, pain, and much heat of skin, if gentle laxatives, frequently repeated, do not mi- tigate the symptoms. Fomentations should be applied to the abdomen; when the skin is hot and parched, sponging the body frequently with tepid water will often take off the restlessness. The practitioner should be particular in all cases, but more especially in attending children, to examine the stools, and the quantity of clothes with which they are too often covered. A remarkable case occurred to me four or five years ago, which is worthy of being mentioned. A child aged seven was seized with some degree of chilliness, followed by re- action, thirst, want of appetite, nausea; the respiration became hurried, and he complained of considerable headache. He was ill for five or six days before I saw him, and had taken repeated doses of salts and senna. On examination, I found the abdomen distended, tense, tympanitic, and somewhat painful to the touch; his thirst was considerable, the respiration quick, the face flushed, with some headache, and he complained of noise and light; the tongue loaded with a white fur, moist every where but at a small triangular space at the tip, which was red, as were also the edges; he had no vomiting, but a dislike even to the 110 CONTINUED FEVER. smell of solid food; he was very uneasy and restless, passed sleepless nights, and the pulse was quick, but not particularly strong. During the course of eight days, leeches and fomentations were frequently had recourse to, and al- ways with marked relief; but it was always of short duration. Gentle laxa- tives were frequently given, and injections administered, but all to no purpose; the stools were slimy and scanty, and as the child had been so long without even taking gruel, it was imagined that the bowels were empty. The abdomen was blistered. At last something excited my suspicion respecting the state of the bowels, and castor oil was given on the fourteenth day, every second or third hour, after a moderate dose of calomel and jalap. On going to stool, he com- plained very much of pain, he was observed to strain most violently; and after some time, he passed what appeared to be a very large fetid stool, which sur- prised me very much; it was so large that I was induced to examine it minute- ly, when three hard masses were discovered, surrounded with a great quantity of mucus. Upon close examination, they proved to be a dollar biscuit, and two pieces of solid meat; the biscuit was soft, but quite undigested and whole, with the exception of its margin, part of which had been broken off; the depressions generally made on the surface of biscuits were quite distinct, as also several of the letters of the baker's name. This biscuit was seen by a great number of gentlemen who were attending my lectures at the time, and is now in my mu- seum. One piece of meat was large, and must have formed a good mouthful; the other was small, but both were quite unchanged by digestion, and not so putrid as might have been expected; it turned out that the boy was frequently in the habit of bolting whatever he had in his mouth, without mastication. His recovery was progressive after he got rid of these substances. If the disease become chronic, occasional leeching, perseverance in gentle laxatives, a nourishing, but mild and bland diet, a long perseverance in counter- irritation on the surface of the abdomen, by means of the tartar-emetic ointment, and an occasional warm bath, are the best remedies. If there are evidences of effusion into the abdomen, with scanty secretion of urine, a preparation of ca- lomel, squills, and digitalis, in doses proportioned to the age and strength of the patient, will be found serviceable, together with drinks acidulated with cream of tartar. Many of the students attending my dispensary, have seen remarkable recoveries under the plan of treatment above described, even in cases which at first appeared to be hopeless. CONTINUED FEVER. Cullen and others maintain, " that there is no such disease as that which the schools have called a continued fever." There can be no doubt, however, that there is such a class of diseases, if we look at nature; and that Cullen would have seen it if he could have looked through any other medium than that of his own erroneous theories. Cullen's definition—«• Fevers, without inter- CONTINUED FEVER. Ill mission, and without being produced by marsh miasmata, but with remissions and exacerbations, though not always considerable, continuing; two paroxysms in each day." Although all his definitions are bad, this is to be regarded as almost the very worst. Often have I seen slight continued fevers terminate in regular intermittent, and intermittent in continued fever, at least as much as any fever can be said to be continued; continued until death closed the scene, or rather, I should have said, till that stage of collapse took place which precedes death. This definition must be admitted to be too fine-spun; for if there is no continued fever, it may be also said there is no continued inflammation of the brain, or of any other organ. In all fevers, as in all diseases, there are intervals in which the patient is easier, and appears, perhaps, rather better; and there are also nocturnal exacerbations, which may be partly attributed to the sick being worn out and made worse by fatigue, heat, light, and noise during the previous day. All the fevers which are to be described in this class, are called " idiopathic," as well by those writers who have identified in their own minds fever with in- flammation, but who will not allow the existence of " any primary local dis- ease," unless that disease be one of inflammation; as by others, who deny the existence of local inflammation in fever. Cullen belonged to this last class, and he states that he never had seen a case of inflammatory fever but one, therefore he endeavoured to place these fevers altogether beyond the pale of pathology. In this spirit has he framed the definition of fevers: " After lan- guor, lassitude, and other signs of debility, pyrexia; without any primary local disease." The reader will see at once the absurdity of this symptomatical pa- thology, which denies to any fever whatever, except hectic, any primary local disease; for Cullen is subsequently compelled to place inflammatory fever as one of his orders, and although he gives a very common-place reason for calling inflammatory fever " synocha," and an explanation that this term is not to be used in its u vulgar acceptation;" yet we are not to be told in the present day, that the pathology of a disease can be changed by a mere .name, which any one may invent. All Cullen's disciples will be found to fall into the same error, but they become caught in their own net in describing the order synochus, which, according to them, is a compound fever, of an inflammatory nature in the first stage, and typhoid in the second. Cullen, in the 141st paragraph, makes the following statement: " In the case of synocha, (inflammatory fever,) therefore, there is little doubt about the propriety of blood-letting; but there are other species of fever, as the synochus, in which a violent re-action and phlogistic diathesis appear, and prevail during some part of the course of the disease; while, at the same time, these circum- stances do not constitute the princpal part of the disease, nor are to be expected to contmue during the whole course of it; and it is well known, that in many cases the state of violent re-action is to be succeeded, sooner or later, by a state of debility, from the excess of which the danger of the disease is chiefly to arise. It is therefore necessary, that in many cases blood-letting should be 112 CONTINUED FEVER. avoided; and even although, during the inflammatory state of the disease, k may be proper, it will be necessary to take care that the evacuation be not so large as to increase the state of debility which is to folloio." It was Dr. Baillie's opinion, that typhus was as rare as Cullen states inflam- matory fever to be. The truth is, that much depends upon the class of people among whom a physician practises, and the period of the disease at which he generally sees his patients. Our army and navy surgeons have to treat fevers in subjects well fed and clothed, and whose regularity of conduct is enforced by military discipline, which physicians cannot expect among the inhabitants of St. Giles in London, and the Cowgate in Edinburgh. Therefore they seldom see pure typhus in their practice ; and they will have to blame themselves if they often meet with synochus ; for they are too bold and intelligent, and are too well versed in military tactics, not to attack the enemy before he gets possession of their stronghold; and they will be rarely found guilty of declining an engage- ment for fear of another enemy which may appear when they are weakened by the combat. Soldiers and sailors can very rarely conceal a fever; so that tbey are brought at once to the medical officers, who therefore see the disease early, and before it becomes complicated. A great deal also depends upon the treat- ment pursued in the first stage. If a physician were always afraid in the first stage of fevers to apply the proper remedies, when inflammatory symptoms presented themselves, lest a low or putrid tendency should subseqently occur, he will of course frequently see the compound fever " synochus" in its worst form. I have now to treat, first, of fever from functional derangement; secondly, lever from inflammation; thirdly, fever from congestion ; fourthly, a mixed form of fever, consisting of a combination of these three, but in which conges- tion generally predominates at last, commonly called Typhus and Synochus. FEVER FROM FUNCTIONAL DERANGEMENT. All ages and classes of society are liable to this form of fever ; but more particularly children, and those who have the inclination and means to overload the stomach and bowels with too much nourishment. It is not, in general, very formidable ; but cases are occasionally met with which are abundantly alarm- ing, and difficult to treat, from the impossibility of fixing upon any one organ which can be said to be affected severely, and yet all organs are out of order, giving rise to considerable constitutional disturbance. In some cases the symptoms are exceedingly slight for a week or ten days. The patient often feels chilly, which he is apt to attribute to the weather—increasing weakness and languor, which he thinks are owing to impared appetite; he has restless nights, with burning heat in his hands and feet, and some thirst. At last his whole surface is hot; he perhaps goes to stool once a day or even twice, and he passes something, which satisfies him that his bowels are right, when all the time they are constipated; and when a medical man is called, he will find him much in the following state :—skin parched; thirst considerable ; tongue load CONTINUED FEVER. 113 ed with a yellow fur; without appetite ; and the pulse perhaps about 95 or up- wards ; the urine scanty and high coloured. He complains of restlessness, particularly at night; and general uneasiness, with oppression at the praecor- dia ; he has slight headache ; but complains most of pain in the lumbar region. The stools, when examined, will be found fetid, scanty, and adhesive; or watery and dark coloured, containing small hardened portions of feces, often mixed with a good deal of mucus. He loathes the articles of food which in a state of health he most relished, even tea and coffee, milk, beer, &c. During the night, his mind wavers; if he fall asleep, he appears restless and disturbed, and awa- kens with a start, the effect perhaps of a terrific dream; occasionally there is delirium. In some cases these symptoms continue even in a slighter degree for fourteen or fifteen days, and at last terminate in local congestion, or in inflam- mation of some organ, and in the end assume the type which is termed typhoid; in fact, these are the cases, particularly where there is delirium, which many people call " typhus mitior." This is the kind of fever which is in general cured by confinement to bed; a steady perseverance in gentle laxatives, repeat- ed two, three, and even four times a day ; quietness, and abstinence from solid food. These are the cases in which wine is often prescribed by Brunonians, with far less detriment than solid food or beef tea. These are the cases in which the cold affusion has been so serviceable when used in the early stage, because there is as yet no local inflammation. Sometimes the fever is very sharp, and there is considerable excitement, with in reased heat, general uneasiness, and delirium ; the pulse above 100, full and strong; much oppression at the praecordia ; the respiration hurried; the tongue loaded, perhaps dry and parched; and the bowels very much disordered. Treatment.—I have a great dislike to treat this form of fever, and for the fol- lowing reasons : first, the patient has been long ill before he confined himself and sought for medical advice. Secondly, the symptoms even then are appa- rently mdd, while internal organs are seriously impeded in their functions. Third- ly, if inflammation have taken place in any internal organ, it is more difficult to treat than in pure inflammatory fever, in consequence of the exhaustion occa- sioned by the previous indisposition. Fourthly, nothing can be beneficial if the greatest attention be not paid to the moral management of the patient, giving him laxative medicines at regular periods, and rigidly withholding improper articles of food. Bleeding is certainly not necessary in all cases, but it is ser- viceable in many. I have had several cases of this description on my hands at one time during the autumnal months ; and I have chosen patients resembling each other as closely as possible in habits, temperament, &c. I have drawn blood from some of these and not from others, and I never had reason to regret bleeding, but I often had to lament not doing it. It may be here mentioned, that bleeding is often employed from other motives than to cure inflammation. It is sometimes employed to moderate excitement, to diminish plethora, to alter irregular determinations of blood, and also to remove venous engorgements; but the only period for the lancet is the first days of the disease. 114 , CONTINUED FEVER. In such cases bleeding may be objected to, as it has been even in inflamma- tory fevers, but I am sure it is safe in a majority of cases ; and this conclusion has been strongly impressed upon me by observing the manner in which this kind of fever, in particular, frequently terminates. First, it sometimes termi- nates upon the appearance of an eruption, which eruption is generally urticaria, sometimes erysipelas, which acts beneficially by counter-irritation. Secondly, it often terminates by epistaxis. Thirdly, by diarrhoea; or by profuse night- sweats. And fifthly, by abscess. Taking a common sense view, in reflecting upon these matters, I cannot help coming to the conclusion, that it is best for the practitioner to take the law into his own hand, and to deplete in cases which require it, before the strength of the body is reduced by the natural effects of diseased action. If in doubt about the propriety of general bleeding, the prac- titioner can have recourse to leeching; and in the class of cases now under consideration, the best place to apply the leeches is upon the abdomen or loins. Experience has led me to this practice, even in cases, in which, although the symptoms ran high, no local inflammation could be detected, and I can speak strongly of its success ;—the number of leeches to be proportioned to the age and constitution of the patient, as well as the severity and duration of the disease. Emetics are very serviceable in the first stage of this fever, in order to unload the stomach of any crudities it may contain. It has been already stated, that laxatives frequently repeated are highly necessary: to an adult I give powders consisting of two grains *)f calomel, and six or eight of jalap or rhubarb, or a pill with the same quantity of calomel and four grains of the compound extract of colocynth. A child of six years old will require the same quantity of calomel, and four of jalap or rhubarb,—the dose to be repeated every second, third, or fourth hour, according to circumstances, till evacuations are produced, or till a fourth dose has been given, when the medicine is to be assisted by the admi- nistration of mild injections. Fomentations may also be applied to the abdomen. If the body be hot, it should be spunged with cold or tepid water, as may be most agreeable to the patient's feelings. Opiates are rarely admissable in this form of fever. In neglected, or ill-treated cases of this class of fevers, affections of the brain, or bronchial membrane, are greatly to be dreaded. FEVER FROM INFLAMMATION. It will be recollected that, in a former part of the work, the arbitrary doc- trines of fever promulgated by different individuals, viz., that fever depended upon inflammation of one particular viscus or set of viscera, were rejected; and my own opinion was distinctly stated, that inflammation of every tissue of the body, occasionally gave rise to febrile disease. Symptoms of Inflammatory Fever.—In this disease the combination of symp- toms denominated fever is present, and depends upon inflammation of an acute or sub-acute nature, of some organ or tissue of the body. Cullen's definition: CONTINUED FEVER. 115 " Heat much increased; pulse frequent, strong, and hard; urine red; the animal functions but little disturbed." Although this fever sometimes takes place without any cold stage, yet it is generally ushered in with a rigor. During the early stage, the patient feels drowsy, yet cannot sleep ; he is reluctant to move from one room to another, from a feeling of languor and debility; there are loss of appetite, vitiated taste, thirst, loaded but moist tongue, which soon becomes dry ; general soreness is complained of, and there are nausea and vomiting ; headache, and pain in the back ; occasionally a combination of all these symptoms is present. Some- times after the first rigor, heat of skin, and all the other symptoms of fever, im- mediately set in; on other occasions, there are alternate chills and flushes of heat for several days, till at last the heat predominates, and is permanent; the face is flushed, the skin intensely hot, with thirst, restlessness, general uneasi- ness ; in most cases there is more or less delirium at night. It is necessary to observe, that the symptoms vary according to the organ principally affected; but in all cases where there is great excitement, the breath- ing is quick and anxious, the belly costive ; the tongue becomes parched, but it may be loaded, or very red, with its papillae much raised,—or intensely red only at the tip and round the edges; the pulse is generally full, strong, and bounding, beating above 100, perhaps even 130 in the minute; there is also oppression at the praecordia. In very acute cases, I have observed the skin not only parched and burning, but red, making a considerable approach towards an exanthematous affection. Inflammatory fevers occasionally terminate by hemorrhages from different parts of the body, particularly from the vessels of the nose and bowels; by diarrhoea,—collections of matter in various parts of the sub-cutaneous cellular membrane, and by profuse sweats. But these natural terminations are not to be depended upon. If the fever go on without proper treatment, disease of structure ultimately takes place, in severe cases as early as the seventh or eighth day; in slighter, not before the twelfth or fifteenth; and in still slighter, not till between the twentieth and thirtieth. Whenever this event happens, all the symptoms of typhus gravior, with petechiae, &c. &c. take place, and then the case is called synochus. It has been stated that the symptoms vary not only according to the nature, but more particularly the seat of the disease ; and it is necessary in this place to give a description of these, which may be made applicable to the other kinds of fever. There are several general symptoms which are common to a vast number and variety of diseases ; as headache, heat and dryness of skin, thirst nausea, restlessness, anxiety, oppression at the praecordia, dyspnoea, scanty urine, small fetid stools, &c.; but there are some symptoms which particularly announce disease of particular parts. If the head be affected with inflammation, the symptoms will vary according as the inflammation affects the membranes, or the substance of the brain itself.— 116 CONTINUED FEVER. If the membranes, there will in general be delirium, increase of strength, such that it will require some care to keep the patient from starting out of bed; the eyes vascular, with the pupils contracted or dilated, and the countenance may present a ferocious expression; the patient will perhaps complain of pain of head, by gesture if he cannot by words ; the carotids will throb, there will be great restlessness. The face is not always flushed, it is sometimes pale; the pulse will be various, the tongne dry, and perhaps in constant motion. Subse- quently starting of the tendons, picking- of the bed-clothes, and sometimes con- vulsions, take place, particularly m young subjects ; the patient shews a dispo- sition to sleep, and then becomes comatose, which state gradually increases; the pupds are dilated, and squinting often occurs. The respiration becomes more and more rapid and irregular, with an occasional interruption, immediately fol- lowed by a sigh; the pulse, which had been quick at first, and had afterwards become slower, is now again rising in frequency; it is irregular, and intermits. The coma becomes more profound, and death takes place with or without convulsions. If the substance of the brain be inflamed, the heat of skin may not be in- creased, the pulse may fall under the natural standard; perhaps it will beat 60 or 50, and I have seen it even slower. The extremities may be in constant motion or not; they may be rigidly contracted, particularly the forearms, or it not so, they become contracted the moment the arm is touched even to feel the pulse. The rigidity may be confined to one arm with or without paralysis ; the pupils are generally dilated, and the eye-lids half or fully open, sometimes one is shut and the other open; the tongue is not dry till towards the last stage of the disease. In both varieties the respiration is much in the same state. The bowels are generally bound, and when stools are procured, they are passed involuntarily in bed, as is the urine ; sometimes the bladder loses its power completely, and be- comes greatly distended. If the lungs be affected, the respiration will become more laborious; there may be cough, with more or less expectoration ; the patient may complain of a sensation of rawness under the sternum and in the windpipe, or perhaps a stitch in the side may be felt; but here, as in all affections of the chest, we must make use of our ears in addition to the other symptoms, in order to discover whether any inflammatory affection is going on in the respiratory organs. Tho advantages of the grand discovery of ausculation will be stated more at large when treating of the diseases of the chest; but it may be mentioned, that even before I had been much used to the stethescope, I was able to point out "pri- mary local affection" to exist in the lungs, in cases which were supposed to present the pure idiopathic fever. If the seat of the inflammation be within the abdomen, it will in general be an- nounced by one or more of the following symptoms,—pain, increased on pres- sure, but it must be remarked, that when the mucous membrane of the intes- tines is the seat of the phlogosis, frequently little or no pain is experienced even CONTINUED FEVER. 117 upon pressure. The patient will prefer that position in which the abdominal parietes are most relaxed; there is more or less tympanitis; and the heat is greater over that part of the body than any other. Nausea and vomiting are more or less severe; the patient drinks large quantities of cold fluid, although he knows it will produce an increase of pain, and perhaps will be immediately vomited. The condition of the tongue, has, I fear, been too much disregarded. The most extensive inflammation, and disorganizations of various kinds, may be going on in the mucous membrane of the stomach, and bowels, without pro- ducing redness of the tongue or elevation of the papillae. Nevertheless, when the tongue is in that condition, or when it is covered with small ulcers, or when it looks red and glazed, or as if skinned, with or without patches of white fur, we are enabled to determine that the fining membrane of the alimentary canal is in a diseased condition. Appearances on Dissection.—It may safely be said that there is not an organ or tissue of the body which has not been seen disorganized in fevers, and parti- cularly in inflammatory fevers; and after what has been stated, and from cir- cumstances which are still to be stated, it is thought unnecessary to dwell at present on this subject. Treatment of Inflammatory Fever.—Sydenham, whose works are among the greatest ornaments which medical literature possesses, recommended, above a hundred and sixty years ago, the same or nearly the same practice, which stands good in the present day. He was led by his great wisdom and expe- rience into a proper line of treatment, although he had not the advantage which we enjoy, of examining morbid appearances after death, to confirm his views. He had erroneous notions, it is true, in consequence of his imperfect acquaint- ance with morbid anatomy, but he was the first who pointed out the impropriety of treating all fevers alike, by shewing that different organs are affected in dif- ferent cases. He pointed out also very precisely, that a fever requires different treatment in every stage as it advances. He likewise made pointed observa- tions against the farrago of medicines which were generally prescribed, and his own plans were exceeeingly simple. It was he who first introduced the plan of purging in fevers. His chief hope seems to have been on the lancet, laxa- tives, and opiates, the strict antiphlogistic diet, and allowing no solid food. If he could have proved his opinions by an appeal to dissections, it is probable there would not have since been so many changes in practice. An emetic, followed by gentle laxatives ; a bland liquid diet; small doses of the solution of the tartrate of antimony; and perfect quietness, will produce a cure in very slight cases. But in severe cases it is necessary to open a vein, and take away as much blood as will make an impression upon the disease, without reference to quantity. Young practitioners are often prevented from using the lancet, because there is no decided fixed pain ; but they may rest as- sured, that in fevers, and more particularly in inflammatory fevers, some internal part in particular is suffering, although it does not exactly appear to their inex- perienced eyes. Local inflammation is often concealed by the general irrita- 118 CONTINUED FEVER. tion and uneasiness which prevails ; and it does not shew itself to a superficial observer till it has become very severe. We must not bleed in the manner re- commended by the French, at least in inflammatory fevers. Boisseau, urging the necessity of general bleeding, says, p. 99. of his work entitled Pyretotogie Physiologique, Ed. 1824, " Less than S ounces should not be taken at each operation; but this quantity will rarely suffice, it is necessary in general to draw 12 ounces ; one may carry it even to 16 ounces, in subjects of whom I shall speak, but one never ought to exceed this quantity. It is belter to repeat the bleeding." I would also beg to refer to the cases and dissections published by M. Andral, in the 1st vol. of his Clinique, in which the deplorable effects of similar undecided practice are too evident to require being pointed out. The causes of the failure of bleeding in this, and other diseases, arc; jmt, most physicians order the precise quantity of twelve or sixteen ounces of blood to be taken from all adults, without reference to sex, age, peculiarities of con- stitution, or the actual pathology of the disease. Secondly, By the long pe- riod which is allowed to elapse between the bleedings, the strength is diminish- ed, while little progress is made in eradicating the disease. Thirdly, No dif- ference is in general made between bleeding a plethoric individual, and one who is in the opposite condition of system. Fourthly, The period of the dis- ease influences a pathological physician, while it does not one who never looks at the inside of a dead body. Fifthly, The good effects of a general bleed- ing are very frequently lost, by not following it up, in proper time, by a secon evacuation ; or by local bleedings, which are often found to be most efficacious. Sixthly, The good effects of bleeding are often marred by neglecting to era- ploy counter-stimulation, and counter-irritation, as well as by loading the pa- tient with too many bed-clothes, and by errors of diet. The patient should be seen within a few hours after the first bleeding, and the operation should be repeated at a short interval, if necessary. If this be done, particularly if followed by laxatives, blisters, and the use of the tartar emetic, it will rarely be necessary in an inflammatory fever, however acute, to bleed a third time. But if, at the second or third visit, we find the pa- tient so well as not to require further loss of blood, we are not to conclude that he is out of danger; and it is necessary to impress upon the minds of stu- dents and young practitioners, that if they are to do good in such a case, the greatest attention must be paid at the very commencement of the disease: vi- gilance at this period will save much subsequent trouble and anxiety. When leeches are necessary, they should be applied as near the affected organ as pos- sible. With regard to antimony, objections are very justly entertained against its use, when the stomach and bowels are either irritated or inflamed. Some practitioners do not allow their patients to use fluids freely, particular- ly cold drinks ; but I believe this is a most injudicious prohibition, and that they may, in general, be allowed to gratify themselves in this respect. The practitioner should be regular in his visits in all acute case's, as sick people watch the hours, and become impatient and dissatisfied till he makes CONTINUED FEVER. 119 his appearance ; and he should be careful how be ex-presses himself, for one word, or even a slight alteration of countenance, may rob the patient of all hope. When the state of collapse comes on in fever, the patient should be careful- ly watched, that he may have his nourishment and medicines at proper inter- vals, and that the heat of the body may be properly supported. Stimulants are frequently necessary at the termination of this class of fevers; but nothing in the practice of medicine is more difficult than to determine, whether a stimulant given in such a case is to do harm or good. When it is given, let it be in small quantity, closely watching the effect. If I were com- pelled to state, whether more mischief would follow the exhibition of stimulants in every case, or withholding them, I could safely say, that giving them in eve- ry case would be highly prejudicial. For although I have seen marked bene- fit produced by stimulants, yet I have more frequently observed mischief; they are most beneficial when exhibited to patients with either a compressible, or a very irritable pulse, and to those who experience profuse perspirations. CONGESTIVE FEVER. This is a fever, in the most severe form of which the pulse and the heat of the skin are generally below the natural standard. In slighter cases, the ex- tremities are cold, or have a tendency to be cold, while the heat of the trunk of the body is increased. The purest example of congestive disease, to which I can allude, is the epidemic cholera as it prevailed in India, and which has lately appeared in the east of Europe ; the next example is to be found in those individuals who die in the cold stage of the yellow, or any other fever. The existence of congestion is also well displayed in the first stage of intermittent fever ; and I have seen many cases of pure congestive fever succeed the cold stage of an intermittent, when full re-action could not develope itself as usual. Congestive fever is a very common complaint in this climate, and one which is usually treated as a typhus. It is a disease which Sydenham knew well, and treated in the most judicious manner, as will be seen by consulting Swan's edition, p. 567. After stating that the invention of the term malgnity, has been far more destructive to mankind than that of gunpowder, he describes a3 decided a case of congestive fever, as is to be found in any modern work. " But if it be inferred (says Sydenham) that there is some malignity in the case, not only from the purple spots, but also from finding the symptoms of fever milder sometimes than should seem agreeable to its nature, whilst, notwithstand- ing, the patient is more debilitated than could be expected for the time, I an- swer that ail those symptoms only proceed from Nature's being, in a manner^ oppressed and overcome by the first attack of the disease, so as not to be able to raise regular symptoms adequate to the violence of the fever; all appearance* being quite irregular. From the animal economy being disordered, and in a manner destroyed, the fever is thereby depressed, which in the true natural order generally rises high. I remember to have met with an instance of this 120 CONTINUED FEVER. kind, several years ago, tn a young man I then attended; for though he seemed in a manner expiring, the outward parts felt so cool, that I could not persuade the attendants he had a fever which cotdd not disengage and shew itself clearly, because the vessels were so full as to obstruct the motion of the blood. Hmc- ever, I said that they would soon see the fever rise high enough upon bleeding him. Accordingly, after taking away a large quantity of blood, as violent a fever appeared as I ever met with, and did not go off till bleeding had been used three or four times." This case proves, beyond all doubt, that Sydenham must have had very good notions of the pathological condition of the body, from the expressions he uses, as well as from the practice he employed. This disease has been described by several tropical physicians, but partial- larly by Dr. Jackson; and it was in warm climates that I first obtained cor- rect notions upon the subject. But the profession is much indebted to the late Dr. Armstrong, for the very excellent manner in which he has illustrated its nature and treatment. Symptoms of Congestive Fever.—We shall find, upon inquiry, that the patient has had a threatening of indisposition for perhaps ten days, a fortnight, or even three weeks, previously to confining himself,—that his appetite has been gradu- ally impaired, with irregular action of the bowels; and that he has occasionally complained of alternate chills and flushes of heat, till at length the chillinett- prevailed. This is the history which we in general receive of the progress # the severe cases. Even in mild cases, the heat of the skin is diminished; thfl pulse is weakened, or it is oppressed, and beats perhaps not more than 50 or 60; the prostration of strength is very considerable; the tongue is in general moist, and more or less loaded ; the patient is lethargic, rather than comatose, though coma may subsequently take place; he can be roused, but the sensi- bility is evidently diminished; he complains of giddiness, confusion of intel- lect, heaviness, pain or sense of weight, either at the crown of the head or forehead. The general functions of the body will be found to be more or less impeded ; but disturbance of some particular organ, in general, manifests itself, and the symptoms must of course be thereby considerably modified, as in other febrile diseases. In congestive fever, as well as in others, the brain may be the seat of disease in one person ; the lungs in a second; the liver and me- senteric vessels in a third ; and so on, the disease being essentially the same, but modified according to the principal seat of the congestion. i In congestive fevers there is generally a peculiar expression of countenance, it looks besotted ; the manner of the patient is undecided, with an appearance of carelessness, and his words seem, as it were, to hang in his mouth • the cornea looks dim; the pupil, in the first stage, is rather dilated, and is Set much affected by light. If the patient attempt to walk, he staggers like a drunken man. There is always more or less prostration of strength, and in severe cases, he is unable to stand upon his legs, or to move his hand to his head, even from the first. The respiration is short, quick and weak. He fte CONTINUED FEVER. 121 signifies that he has a great load in the praecordial region. As the disease ad- vances, he becomes more and more comatose: picks the bed clothes; and is always found lying upon his back, slipping down by imperceptible degrees to the foot of the bed ; the surface becomes more cold; the breathing more diffi- cult ; the face assumes a leaden hue; and occasionally, though rarely, con- vulsions take place; sometimes there is nausea and vomiting, and sometimes diarrhoea; most frequently, however, the patient is constipated. It maybe shortly mentioned, that the appearances on dissection are much the same as those described in intermittent fever. With respect to the causes, they are the same as in other fevers; but I have seen several very severe cases produced by bathing in the sea, and remaing too long in the water; by taking a drink of cold water; and by a weakly person exposing himself to a damp, cold wind, when his body had been previously heated. Pathology of Congestive Fever.—No one can tell which is the first link in the chain of diseased action. Congestion may take place upon hearing disas- trous news, which, some say, proves that a peculiar action in the brain is the first phenomenon; but, then, exactly the same circumstance may happen from taking a cold drink, or remaing too long in the water when bathing, Sgp. &c; therefore, it must be confessed there is a great deal of ambiguity about this part of the pathology. But it is unnecessary to go over the same observations which were made when treating of intermittent and other fevers, further than to state shortly, that when the head is the chief seat of congestion, thero are early symptoms of lethargy, coma, and * diminution of sensibility, frequent chills, followed by other well known nervous symptoms, and occasionally by convul- sions. When the heart and lungs are loaded, there is an oppressed, irregular, or intermitting pulse; weak and hurried respiration; cough; marks of impeded circulation in the face, and a difficulty in supporting the heat of the body; and in some rare cases, violent pain in the region of the heart, and along the arms, is complained of. It may be remarked, that whenever the pulse feels weaker than natural in a severe disease, it is an excellent plan to place the ear to the region of the heart, for [we shall often find it acting most powerfully when the pulse is weak in the extremeties. When the congestion affects the vicera within the abdomen, there is generally a sense of fulness and distension about the stomach; the bowels are irregular, being either too loose or bound ; and in either case, when stools are procured, they are found to be clay-coloured and very fetid, with very little bile, or very dark. This opportunity may be seized for the purpose of noticing the most probable means which the animal system possesses, to prevent the balance of the circu- lation from being lost. First, there is a power possessed by all animals of preserving to a certain extent a proper degree of heat under every condition of atmospheric vicissitude,—thus the heat of the body is not a degree higher under a burning tropical sun than in this country, which so far prevents cold from producing, a lost balance of the circulation. 16 122 CONTINUED FEVER. Secondly, The elasticity of the coats of both «*^ .^T^^Z prevent the state of congestion, because they are capable ol c ^^ tension, and are still contractile. These are assisted by the ire which subsists between the vessels of a part. This is well f^*™^ ™ experiments which have been performed on the frog's foot, to nature of inflammation. When a part is first irritated, the *°mentum of the blood is greatly increased ; at last a vessel becomes obstructed, a^otal of blood cannot pass through it, but is seen to make a retrograde movement, and find its way by another branch. The pathology of this fever is happily illustrated by comparing the symptoms with the phenomena which occasionally take place in eruptive levers, and to which I shall now make only a short allusion. In some cases when the erup- tion is tardy in making its appearance, alarming symptoms, and even convul- sions, take place. After the eruption has made its appearance, it sometimes suddenly and prematurely disappears, when congestive symptoms occur. Let the inquirer ask himself, where has the blood receded to, which a moment be- fore rendered the skin as red as the shell of a boiled lobster? Treatment of Congestive Fever.—In considering this part of the subject, it is very useful to remember the efforts which are made by the powers inherent m the constitution to remove internal accumulations of blood, if they be in anj way short of that degree which kills the patient instantly. The first of these, and the most common, is the state which in medical language is called re* tion, which in its turn may create inflammation of the organ most affected »» the congestion. We have next increased secretion, as a natural means of re- moving the congestion; as is well exemplified in the cholera morbus of India, in which, for the most part, an immense discharge takes place from the intes- tines and stomach. In the treatment of all diseases, the physician has to determine wheftw ii will be most advisable to leave the case to the natural efforts of the constto- tion, assisting them a little in their operations, or whether he is by a bold decisive measure to step in to relieve the system at once. In this case, he is apprehensive that the heart and other vital organs may be too much overloaded and oppressed to create full re-action, or that the system will sink under the task. He has also to fear the effects of the re-action, which may terminate in ex- tensive local inflammation. Anxious to escape these evils, he will follow the plan pursued by Sydenham in the case quoted at page 119, and he will open a vein with a view of at once restoring the lost balance of the circulation. The quantity of blood necessary for this purpose, in any given case, cannot be pre- viously estimated. A stimulant may be at the same time necessary, to rouse the action of the heart a little, and make the blood flow from the orifice. 1 have frequently proved, before a number of witnesses, that it is not inconsist- ent with good pathology to bleed and stimulate at the same time. When a vein is opened, the blood will perhaps only trickle down the arm at first; on other occasions it will spring from the orifice in a large strea nd CONTINUED FEVER. 123 suddenly stop before a table spoonful is evacuated. Some think this owing to an alteration in the position of the arm,—others, to the tightness or slackness of the bandage. Physicians frequently attribute this phenomenon to debility, and they take it as the most certain sign that the patient will die in their hands, were they to carry the operation farther. But it must be recollected that the blood is moving very slowly in the arteries, while the veins are gorged. When an'opening is made in the vein, it suddenly empties itself, and as a supply is not quickly at hand, it is sometime before the blood begins again to flow. Let the finger be placed on the orifice, the vein will be filled, and the blood will spring again. Heat is also to be applied, and if possible, the patient should be placed in a warm bath; if that cannot be obtained, the feet and legs should be plung- ed into very warm water, and hot bottles placed round the body. The patient is to be rubbed with stimulating fluids, such as heated spirits of turpentine, and aqua ammoniae; drachm doses of ether may be given, or a solution of the carbonate of ammonia, in the proportion of eight or ten grains to an ounce of water. He should be encouraged to drink warm fluids. The caution and dis- crimination which ought to be pursued in drawing blood under such critical cir- cumstances, need not be insisted on; suffice it to say, that a stimulant ought to be at hand, and a finger should be on the pulse of the opposite arm, to watch the effects of our practice. If every thing go on well after the bleeding, the bowels being in a proper state, two grains of calomel and one of opium may be given in a pill, and re peated every three or four hours. ■ General bleeding is only admissible in the earliest stage of congestive fever, unless in cases in which the pulse is still strong and full. Should.the proper time for V. S. have passed, stimulants are sometimes found serviceable, but must be administered with caution, and relinquished for perhaps debilitating re- medies, upon the first appearance of re-action. If, at any time in the subse- quent progress of the case, there should appear signs of local disease, the ap- plication of leeches and blisters should be had recourse to, and the patient is to be treated during convalescence in the same manner as in any other fever. MIXED FORM OF FEVER BETWEEN THE LAST-MENTIONED THREE, BUT IN WHICH CONGESTION PREDOMINATES. THIS IS USUALLY DENOMINATED TYPHUS AND SYNOCHUS. In the disease which is now to be sketched, there is a combination of the last three described fevers, appearing under two forms : 1. The functional fever, subsequently united with congestion, and this forms, t apprehend, the Typhus of authors. 2. The inflammatory fever, subsequently united with congestion, and this is the Synochus of authors. The first variety begins in the manner which has been already described in fevers from functional derangement, but subsequently, an accumulation of blood takes place in the centre of the system. When the circulation becomes so 124 CONTINUED FEVER. much embarrassed, all the symptoms of congestive fever take place, the pa- tient having been debilitated by the previous diseased action. The second variety commences in the manner which has also been already described in inflammatory fevers, but subsequently the balance of the circula- tion becomes more and more lost, and congestion follows ; in which state of the system, the inflammatory action is suppressed, but not extinguished. This takes place when debility and exhaustion have been already produced by the previous disease. The brain, lungs and organs in the abdomen, are liable to be implicated, and in the worst cases which occur, they generally are all affected, either simul- taneously or in succession. Hence there is a complication of symptoms, and as the disease principally affects the poor, who are ill clothed and badly fed* and as medical advice is not in general sought during the first stage of the disease, we usually find it very difficult to manage. In the early stage of the first variety, and when alone any thing like aetive practice should be had recourse to, the symptoms certainly denote debility, which are as yet occasioned by oppression and obstructed action only; and often have I seen cases immediately and permanently benefited by drawing blood, in which, had the operation been postponed for twenty-four hours, it would have been quite inadmissible. It may likewise be remarked, that much of the oppression and debility also depends on the condition of the lungs, which, besides being congested and therefore unable to perform their functions properly, are subsequently still further embarrassed by an inflammatory affec- tion of the bronchial tubes. Both these conditions tend to prevent the changes in the blood, which are well known to be elaborated in the lungs; therefore, all organs must suffer additionally, and the brain of course among others. The bronchitic affection in fever has attracted my attention for many years, and I am led to believe, that few instances of febrile affections take place, without bronchitis appearing in some stage of the disease, and very often it is the pri- mary affection. In all the fevers which are called putrid, and which are ac- companied by dark-colored spots on the surface of the body termed petechia;, it will be found, I am almost inclined to say invariably, that bronchitis prevails to a great extent. The somewhat livid and circumscribed redness which is seen so often in the fevers called typhoid, is principally owing to the embar- rassed state of the lungs ; and exactly the same circumstances take place in the second variety, the synochus. In the second variety, bleeding may be had recourse to with benefit, later in the disease than in the first, and often have I seen it decidedly beneficial when cases were going wrong under the injudicious use of stimulants and tonics. In proof of these statements, the reader is referred with confidence to Dr. Mason Good's account of typhus, in his second volume, (from page 230 to 258.) According to his views, this being " a disease of sensorial debility, leading on to putrescency," is to be treated by tonics ; bleeding and purging are among the foremost objects of prohibition." Nevertheless, in the next page, the fol- CONTINUED FEVER. 125 lowing 'contradictory statement is advanced, " hence the fever will be aggra- vated from local irritation, and the affected organ will be in danger of inflam- mation, if not of gangrene." There is no class of diseases, in which the stethescope is of more practical advantage than in fever, for, as has been already mentioned, the heart may be found beating violently, whilst the pulse at the wrist is so weak as scarcely to be felt, and when symptoms of general debility appear to be very great, and the extremities' cold. To a patient in such a state, most medical men would na- turally be led to give wine, beef tea, and animal jellies, which they would not do if they were aware that the action of the heart was strong. During the last eight years, I have seen many severe cases of fever, in which marked benefit was produced by withdrawing stimulants, and the patients have ulti- mately recovered after being leeched and blistered. It has also occurred to me to be called in consultation to cases of " idiopathic" fever, in which I have not only detected active disease, but have convinced the practitioners that it was going on. I shall never forget two cases of " idiopathic typhus," in which unfortunately my diagnosis was verified by dissection, in one of which the patient died of pleuritis and bronchitis conjoined ; in the other, of perito- nitis. Let it not, however, be supposed that I am an enemy to stimulants in all cases of fever; on the contrary, I have seen patients occasionally snatched from the grave by their judicious employment. What is wished to be im- pressed upon my readers, is, that in all fevers we have to dread local conges- tions and inflammations, more than debility and putridity. That I am in the habit of using stimulants in fever, I can appeal to the gentlemen who have been my pupils, and who have witnessed my practice ; and I can also appeal to them for the truth of the following statement:—that much mischief has occasionally followed, and that therefore I feel fully as anxious about the result of a stimulant as a bleeding. When a stimulant is necessary, wine is the best; and experience has taught me that wine, or any other stimulant, is far less likely to do harm than beef tea and animal jellies. Cases can no doubt be quoted, where stimulants, in large quantities, have been administered from the beginning of the disease, and the patients have re- covered. But the best way for any one to come to right conclusions regard- ing this question, is, to judge from the general result of what he has himself seen. I have had many opportunities) of observing that recoveries were slow- er, and relapses more frequent, in oases treated upon the* stimulating plan, than the antiphlogistic. Emetics cannot be too highly extolled in the last stage of some cases of fever, particularly the varieties called typhus and synochus, but only in those in which the bronchial tubes become filled with muco-purulent matter. This happens in consequence of the patient being too long asleep, or not coughing up the matter before too much has been secreted. Many of my friends have seen the happy results of administering emetics in such cases, and more parti. 126 CONTINUED FEVER. cularly, my dispensary pupils will not forget many instances of this among our poor patients during the late epidemic fever in Edinburgh. Clenliness, free ventilation, and quietness, are three great and essential cir- cumstances to be attended to in the treatment of fever. The alvine evacua- tions should be removed instantly out of the room ; and it is of great conse- quence to attend that the quantity of bed-clothes be not too great in the first and second stages of fever when the skin is parched, or too small when the patient is approaching to the state of collapse. The extremities should be examined at every visit by the physician, as sometimes the symptoms are aggravated in consequence of cold limbs, which will perhaps require no other remedy than the application of heat. The state of the bladder should be attended to, for although the urine is generally suppressed, yet occasionally it is not so. The temperature of the room can scarcely be too cold in the first stages, but I have often seen much injury produced by keeping it too low in the stage of collapse* Many patients have been strikingly benefited in less than half an hour after their bodies were made warm, and perhaps their lives ultimately saved, without Ilia assistance of any other means. Some owe their death to being removed from a warm and ill-ventilated room into the cold ward of an hospital; so frequently has this happened, that I am obliged to run all hazards from bad air, bad nursing, and filth, rather than send my patients to the Infirmary of Edin- burgh, which is ill constructed for any class of patients whatever. The sick are also badly classified, which is perhaps no fault on the part of the medical at- tendants, who ought to be well aware that the temperature of a ward, calculated for fever cases in the first stage, is too cold for those in the last. Every fever ward of great extent should be warmed by means of heated air, and provided with water-closets for the use of convalescents. For a considerable time it baffled me to account for the discrepant histories of fever which have been handed down to us, and for the confidence with which opposite practices have been recommended to our notice; but further experience has convinced me that this discordance of opinion may be account- ed for by one or other of the following circumstances : 1st, A difference in the character of the prevailing epidemics, and the con- stitutions of the persons affected; fot example, a functional fever will bear stimulating remedies which would kill a person laboring under an inflammato- ry fever, particularly if the inflammation affected a vital organ. A stimulant given in congestive fever may operate beneficially; whereas in functional fe- ver, or in inflammatory fever, it would be very injurious. A well fed, and pre- viously healthy soldier, who has no cares, will in general have a high-toned fe- ver ; whereas a poor, ill-fed, and badly clothed laboring man, worn out by cares and anxieties, and living in an ill-ventilated and filthy apartment, will be affected with one of an opposite character. 2d, An arbitrary and too often empirical practice, which has hitherto been too frequently followed. One physician always bleeds in every case of fever, another stimulates ; and when the results are analysed, perhaps it will be found CONTINUED FEVER. 127 that the proportion of deaths is the same, and even these results will vary to support the one practice or the other, according to the habits and constitutions of the patients ; for instance, if our army and navy surgeons were to stimulate thrUughout the course of the fevers they have to deal with, they would scarcely save a patient; and if practitioners entrusted with the care of the sick poor were to bleed all their cases of fever, they would be quite as unsuccessful. 3d. Writers are too often guilty of an error which all medical men are liable to commit, viz, of mixing up opinions with matters of fact in their statements. 4n, and the child soon became quite sensible. So far from debility fol- lowing it was necessary to apply leeches next day to the head; the child made a rapidrecovery, and was running about in the course of a week. In evjry respect, the treatment must be conducted in the manner detailed in congestie fever, as well as in the congestive form of scarlatina. The Lflammatory disease is the form most generally met with; we have the usual erotive fever,'preceded by rigors, depression, and debility; along with the fever,the patient has a dry cough, with hoarseness ; frequent fits of sneez- ing and cqyza. He also complains of giddiness and pain in his forehead, as well as in he back; bis pulse is various, sometimes frequent and small, or fre- quent and strong, often it is irregular and oppressed ; the bowels are generally confined, tod the evacuations fetid. In the course of the second, third or fourth day )f the fever, the symptoms run higher ; the eyes are tender, red, watery, anc inflamed; the dyspnoea, which was slight at first, is now more severe; thepatient complains of tightness of the chest, pain, and oppression at the praecordk. The eruption appears first on the face and neck, in twenty-four hours it is foind on the breast, and afterwards gradually spreads over the rest of the body; it onsists of small red papulae, slightly elevated, resembling recent flea-bites; thse soon form themselves into extensive patches, irregular in shape, their mrgins having somewhat of a crescentic appearance. The erup- tion is sometines very extensive, at others slight. The throat, when examined, will be observed to be covered with small red patches, occasioning difficult deglutition. Sometimei irrmediately before the eruption comes out, the patient is seized with violent sickness and vomiting; sometimes with convulsions; but if the eruption subsequently comes out freely, these symptoms abate. In a greatmajority of cases, the disease is rather slight, and the internal dis- turbance, whch is discovered by the symptoms already described, is generally very much appeased soon after the appearance of the eruption, particularly if it come ou freely and plentifully. Occasionally, however, the symptoms are very seere from the beginning; the cough is frequent and harsh; there is considerable dyspnoea, with hot skin, thirst, and a quick pulse ; and the child is occasionaly so comatose, that this symptom early attracts our attention. As the eibarrassment of the lungs Increases, which may happen in any stage, the fee becomes discolored, and sometimes presents a purple appear- ance, and occasionally the eruption over the whole body assumes a dark color; 144 MEASLES. this is the state which is called rubeola nigra, and is probably that form of he complaint described by Dr. Watson and others, under the term Putrid Measks. After the natural disappearance of the eruption, the fever, dyspnoea, ind cough, in some cases increase, attended or not with considerable gastro-ute*- tinal irritation and diarrhoea ; occasionally inflammation of the eyes, an< en- largement of the glands of the neck, succeed. Blistered surfaces freqiently slough ; and it has been remarked by Dr. Watson, Dr. Ferriar, of Marches- ter, and others, that an ulceration of a particular character attacks the »uden- dum of girls, from which few recover; three cases have fallen within ny ob- servation, two of which proved fatal; and it is my opinion that dea* is not owing to this ulceration, but to internal disease. Dissection, in two f advance- ment ; sometimes even excavations of the lungs. It ought to be noticed, that the inflammatory appearances in tty brain and bowels, together with the disease of the substance of the lungs, an< the pleuri- * This is the disease which has been described in the 7th vol. of the Med. Chir- Trans. of London, by Dr. Kinder Wood, who saw twelve cases, of which mly two re- covered. The case of recovery which I have noticed, was under the care f Dr Moffit of the 7th Hussars ; the patient was a soldier's child. The disease follwed a very- slight attack of measles. For an account of this singular disease, vide Vo ii. p. 303. MEASLES. 145 tic effusion, are to be regarded as accidental circumstances; whereas the inflam- mation of the bronchial membrane is an essential part of the disease, and may be traced from the beginning of the complaint. Treatment.—In the slighter forms of this disease, as in scarlatina, very little treatment is necessary, further than confinement to one room, the free exhibi- tion of gentle laxatives, and low diet. The medical attendant should be still more watchful in this disease than in scarlet fever, at the period when the erup- tion naturally recedes, for reasons already mentioned. In the severer forms of measles, bleeding is often necessary during the eruptive fever, when the pec- toral symptoms run high, and appear threatening; and also when coma and con- vulsions take place, both of which are more likely to happen, but particularly the latter, if the child be suffering from difficult dentition. I was called once to see a fine boy of two years of age, who, during the eruptive fever, was seized with convulsions in the night, at the period when the eruption ought to have made its appearance, and from whom nine ounces of blood were taken. Next day he had nine or ten leeches applied to his head: the symptoms were after- wards exceedingly slight, and he made a rapid recovery. He bore the bleed- ing without any tendency to syncope, while his brother, a boy of twelve years old, labouring also under the same disease, and who required blobd-letting for pectoral symptoms, fainted upon the loss of two ounces. When bleeding is neeessary, it ought to be performed in the manner already described when treating of inflammatory fever; a sufficient quantity should be taken as early as possible in the disease, and the operation ought to be repeated at short intervals; but when the bronchitic symptoms have been allowed to go on neglected till the air passages are gorged with mucus, bleeding is a very questionable remedy, and no doubt often does irreparable mischief, for reasons which will be fully noticed when treating of bronchitis. Leeches are to be em- ployed as directed in scarlatina, and also blisters.* Antimony is also highly' serviceable; and opiates m the last stage, when there is restlessness and irrita- bility, if the air passages are not filled with mucus. The warm bath affords much comfort to the patient in all the exanthemata, every night, or every other night, after the eruption has declined, and when the cuticle is exfoliating. Du- ring recovery, great attention should be paid to the diet, clothing, and state of the bowels, so as to avoid the disagreeable circumstances which so often follow the exanthemata, viz., the formation of tubercles in the lungs; inflammation and ulceration of the mucous membrane of the bowels, producing the disease which is called tabes mesenterica, and also glandular affections of the neck, inflamma- tion of the eyes, and chronic eruptions of the skin. This is a very different line of treatment from that which is still recommended by Dr. James Hamilton, jun., and which is founded upon the most curious no- tion that can well be conceived, viz., that the bad symptoms in measles are not * When a blister is applied to a child, under any circumstances, the part should be carefully examined daily by the medical attendant, but more particularly in the eruptive fever*. 19 146 SMALL-POX. occasioned by inflammation, but by " torpor of the lymphatics." But as thia statement may not be credited, Dr. James Hamilton, jun. shall be allowed to speak for himself. At page 377 of the work already quoted, last edition, the following passage will be found: "As the debility which always attends and follows measles is the most prominent feature in the progress of the disease, it is not easy to understand the reasons why practitioners have been led to over- look so obvious a circumstance. The objections to wine and nourishing diet, which it is so often necessary to combat, probably arise from the supposition, that the frequency of the pulse and cough are the effects of inflammation, when in fact they are occasioned by the torpor of the lymphatics!!!" SMALL-POX. This disease commences with rigors, followed by febrile symptoms, which continue from forty-eight to sixty hours, and even longer, before the eruption appears; and it is no uncommon thing for children to be seized with convul- sions during this period. The attack is frequently very sudden : vomiting ge- nerally occurs; there is pain in the head and back ; and the patient com- plains very much of oppression at the praecordia, and a pungent pain in the pit of the stomach, much increased on pressure; there are also decided marks of general disease of the mucous membranes, and more particularly that of the bronchi, announced by dyspnoea, cough, and wheezing. Physicians have divided this disease into two kinds, from the form which the eruption assumes. When the pustules do not run into each other, the dis- ease is termed distinct; when they are very numerous, and run into each other, it is termed confluent; all the symptoms being more severe, and attended with more danger than in the former. The eruption first appears on the face, in the form of small red papula. About the third day, a vesicular appearance is observed on the top of each spot, which is soon depressed in the centre, and is found to contain a transparent fluids with an inflamed circular margin. About the sixth day the eruption loses the depression in the centre, and instead of serum, will now be found filled with a puriform matter. When the pustules are numerous, the parts swell much, and the neighboring skin is of a red color, from the extension of the inflamma- tion. About the seventh day, some of the pustules on the face burst, and upon the eighth or ninth they begin to dry and scab over the rest of the body. The swelling which affects the face, hands, and feet, more severely than other parts of the body, gradually declines ; the skin remains of a dark brown color after the scabs fall off, and it is many weeks before the surface recovers its natural appearance. This is the course which the distinct small-pox generally runs, and when treated properly it is rarely fatal, every thing depending upon the state of the lungs and brain. SMALL-POX. 147 In the confluent small-pox, all the precursory symptoms are more severe ; the eruptive fever runs higher ; the pain in the epigastrium and dyspnoea are more complained of; convulsions and delirium also more frequently take place ; and the patient runs more risk of secondary fever, and danger from extensive inflammation, ulceration and sloughing of the skin. In both varieties, but particularly in the confluent, copious salivation some- times takes place, and soreness of the throat is a marked symptom ; upon ex- amining the mouth and fauces, vesicles or pustules may be observed as far down the pharynx as the eye can reach. I have seen the same appearance on the mucous membrane of the rectum, in a case of small-pox in which there was prolapsus ani: and in the year 1823, a great number of my pupils had an opportunity of seeing a similar case. I am not aware whether this appearance in the fauces and rectum follows an increase and decline simultaneously with the eruption on the skin. In some severe cases, petechiae are seen, when the eruption has begun to decline ; bloody vomiting and diarrhoea with tenesmus, take place ; and the dyspnoea frequently increases as the disease advances. The inflammation in the skin is frequently so deep and severe, that the death of a portion takes place, perhaps of the cellular substance, as in carbuncle, and this is one cause of what are called pock-mocks. In Small-pox, as well as in other acute diseases, there is a congestive form, in which the system is unable to raise sufficient re-action ; there is conse- quently more oppression; the surface is pale ; the eruption flat, and never ma- tures properly ; the dyspnoea is very considerable ; and I verily believe this is the form which is called the most malignant. In severe cases, death takes place before the eighth day, but, generally speaking, the fatal event happens sometime between the tenth and seventeenth days. The proportion of deaths is said by Dr. G. Gregory, who must be a very good authority upon this subject, to be about one in every six persons who re- ceive the Small-pox in the natural way. But during the prevalence of an epi- demic, the mortality is sometimes one half. Indeed, it appears that during a severe epidemic at Ceylon in 1819, the number of native inhabitants taken into the hospital at Kandy, amounted to 931 ; of these 525 died. Since the publi- cation of the first edition of this work, I had occasion to attend 50 cases of Small-pox, all of which were distinctly traced to the imprudence of a woman who exposed her unvaccinated child to the contagion, when visiting a sick friend. Of these 50 patients, 35 had gone through the process of vaccination ; 15 had never been vaceinated, (they were infants under one year of age.) All the protected cases recovered. Of the 15 unprotected cases, 10 died. Three only of these had the disease slightly. Of the 5 children who survived the attack, one did not recover perfectly, and died of chronic bronchitis some months afterwards. Appearances on Dissection.—Head.—I have seen marks of inflammation of the membranes, evinced by a considerable arborescent vascularity on the sur- face of the brain, the vessels of the pia mater being greatly loaded with blood; 148 SMALL-POX. together with effusion under the arachnoid, and into the ventricles. But it be- comes me to speak with diffidence with respect to this part of the subject. Dr. George Gregory says, at page 105, that he has " never been able to trace any morbid appearance in the head," which is rather at variance with the results of my limited experience, and with a statement which he subsequently makes at page 108. In directing the mode of treatment, he says, "It is to be remem- bered also, that in Small-pox, fully as much as in any other form of fever, there is a tendency to congestions and inflammations in the head and thorax." " A patient," (says Batting, p. 76,) " during the cure of a very extensive fracture of the skull, was seized with Small-pox, &c. &c. It was curious to observe in this patient, the appearance of variolous pustules upon the granulations of the dura mater." Although I have been prevented, by the impatience of surviving friends, from opening the head as often as I could have wished, yet many opportunities have been afforded me of examining the contents of the thorax and abdomen. I have seen pustules in the pharynx, larynx, trachea, and oesophagus, in those who died on or before the twelfth or thirteenth day, on some occasions closing up the larynx. The mucous membrane of the bronchi very vascular, and the air tubes completely gorged with matter, most frequently of a reddish color { but in no instance have I been able to discover a pustular appearance below the bifurcation. The substance of the lungs congested with blood, and in the first and second stages of inflammation ; and in one instance there was pleu- ritic effusion. On examining the body of a deformed girl, who died under an attack of Confluent Small-pox, the peritoneum and pleura were studded over with small circular spots, which looked like a faded eruption, but perhaps they might have been produced in the manner which we sometimes see in cases of purpura. I have observed nothing in the stomach to account for the severe burning pain complained of in the epigastric region; the mucous membrane has certainly shewn vascularity, and has been covered with a viscid exudation, the follicles being much increased in size, which appearance often extends throughout the whole intestinal tube; and in three or four instances, I have seen ulcers having a pustular appearance, with a depression in the centre, in the jejunum, ileum, and also in the large intestines, of which the preparations and drawings are in my museum ; and some of them were surrounded by an inflammatory areola. Treatment.—Small-pox under every form is a serious disease, for however mild it may appear in its attack, its consequences are always to be dreaded. The confluent, however, is a very dangerous disease; and we are to be guided in the treatment by observing the state of the brain, and the organs contained within the thorax, as well as the condition of the surface of the body It was formerly the custom to keep patients very hot, and to employ stimu- lants ; and the consequence was, that the mortality was immense ; but for ma- ny years past, patients have been kept cool, and the antiphlogistic re«imen re- commended, but, I fear, too little practised, from the dread of putridity. Bleed MODIFIED SMALL-POX. 149 mg has been often employed, and strongly recommended, in this disease, par- ticulary during the eruptive fever; but it has as often been condemned, because it destroyed that strength, which, it is alleged, is so much required in the latter stages of the disease. But the same language is used in the purest inflamma- tory fevers. In all the successful cases of confluent small-pox occurring in adults, which I have treated, except one, amounting in all to about eighteen, bleeding was employed, and largely employed, in the eruptive fever, to mo- derate what was thought to be local inflammation, without suspecting that they were cases of small-pox; several of the sufferers were my pupils, who had had themselves bled before I was called in. In a number of instances blood has been drawn even after the appearance of eruption, and with decided be- nefit ; but upon the whole, I am then disposed to trust more to leeches for re- lieving local inflammations. The state of the throat and air passages requires daily and minute examination, and after the eruption comes out, the application of leeches is often necessary to the neck, and also to the chest, to reduce inflam- mation. Bleeding before the appearance of the eruption may be expected to moderate that symptom, which is of the greatest consequence, as many die from the severity and extent of the external inflammation. The appearance of petechia? does not prevent me from ordering the application of leeches, in cases which require this practice. With respect to other points of treatment, they are similar to those which have been recommended in scarlatina, measles, and other febrile diseases. I may be allowed, however, on this occasion, to in- sist on the propriety of trusting to nature a little more than is generally done, when the patient begins to convalesce, avoiding attempts to hurry it on, and re- store the strength, which, in a great proportion of cases, is the cause of se- condary fever. A number of disagreeable circumstances often take place as sequels of small-pox, and the most painful one is the formation of boils on va- rious parts of the body, and sometimes even carbuncles, of which there are suc- cesive crops tormenting the patient for weeks. Glandular affections also fre- quently follow, as well as4 ophthalmia tarsi, and ophthalmia purulenta. I can state from experience, that it is a good plan to open the pustules on the face early, in order to prevent marks. MODIFIED SMALL-POX. There are several circumstances, which are said in medical language to modify this horrible disease. The mysterious power of vaccination in pre- venting small-pox is now admitted ; experience, however, has taught us, that this antidote does not always succeed; but the generality of cases of small- pox which follow vaccination are very mild. Individuals are sometimes attacked also a second time with small-pox, and in my comparatively limited expe- rience, I have known upwards of twelve well authenticated instances. The 150 CHICKEN POX. first attack is generally supposed to modify the second, and to render it milder; but it is curious, that all my cases of secondary small-pox, with the exception of two, were remarkably severe ; whereas I have never seen a severe case of smallrpox after vaccination. Previously to the great discovery of Dr. Jenner, respecting the power ot vaccination in preventing small-pox, the disease was modified, and rendered less severe and fatal, by inoculation. This practice had been long followed in the East, and was introduced into this country from Turkey, by Lady Mary Montague. An interesting question arises, to determine why the inoculated small-pox should be so much milder than the natural ? This is, perhaps, easily answered. A proper season of the year is chosen for the operation ; the patient undergoes a certain preparation, and his bowels are particularly attended to. In the modified disease, the stages are all shorter, and the eruptive fever is slighter; the convalescence is less tedious, and the sequelae are not so trouble- some. This disease must be treated according to the general principles hitherto laid down. CHICKEN POX. This disease, known also by the name of varicella, has been often confound- ed with small-pox. Those who maintain the identity of the two diseases, and who have figured in the controversy that has been so long earned on, have ne- vertheless completely failed in proving their position with respect to one point, while they have succeeded in another, apparently without being aware of it, Looking at the diseases symptomatically, there is no doubt a striking difference. The symptoms are all much slighter in chicken pox; the eruption is vesicular, and there are repeated crops; and further, this disease is rarely attended with danger; but a pathological eye cannot fail to discover a marked resemblance. The only questions to be determined are the following: Does an attack of the one disease prevent the other? Will matter taken from small-pox produce va- ricella, or from varicella small-pox? Extensive experience enables us to an- swer both in the negative, and therefore they cannot be identified any more than measles or small-pox.* With respect to the treatment of varicella, it is only necessary to mention, that it must be conducted in the same manner with other slight eruptive fevers; and it should be remembered, that some local inflammation may arise even in the very slightest of them. I have known two fatal cases of varicella, one from inflammation of the substance of the lungs in an adult, the other from in* * Vide Dr. Hennan's papers and experiments, in Ed. M. and S. Journal, Vol. xiv. p. 409. MILIARY FEVER. 151 flammation of the membranes of the brain in a child eighteen months old.* Since the publication of the first edition, I have been reminded of a third fatal case which occurred in 1825, in a child five months old. Traces of inflammation were found in the chest and abdomen. The head was not ex- amined. MILIARY FEVER. This disease is characterized by an irregular eruption, of exceedingly small round vesicles of the size of millet seeds, and which feels, when the hand is passed over it, as if there were small grains of sand beneath the cuticle. Each vesicle is surrounded by a slight inflammatory blush. This disease is said to be idiopathic, as well as symptomatic. There can be no doubt whatever, that an eruption of this character occasionally appears in the course of all fevers and inflammations; and in such cases, attention ought to be directed to the original disease. It is also considered one of the diseases of child-bed. Since women in that state have been treated in a pro- per manner, by avoiding hot stimulating drinks, and by admitting cool air, it is not very frequently met with. It is described by authors to commence with rigors, sickness, and languor, approaching to syncope, quick pulse, heat of skin, and thirst. The eruption does not usually appear till four, five, or six days af- ter the commencement of the febrile attack. Previously to its appearance, there is a sense of pricking, tingling or itching of the skin, sometimes attended with a benumbed state of the extremities. The patient is greatly oppressed and complains of a sense of weight about the chest; the spirits are low, and a profuse perspiration takes place, which is frequently remarked to have a sour smell. At length the vesicles form into small scales, and fall off in a few days. The eruption is generally distinct, but sometimes confluent; it is said rarely to affect the face, and different crops may appear in the same fever ; it attacks those most frequently, who have been previously weakened by disease, fatigue, or long continued sweating, or who have had a hot regimen. The miliary vesicles often occur during the course of many of the puerperal diseases, such as milk fever, inflammation of the brain and peritoneum. Mr. Burns, in his Principles of Midwifery, p. 420, says, " Whether the mi- liary fever be idiopathic or symptomatic, the treatment is the same." If he mean to state, that slight miliary eruption is to be treated in the same manner as miliary eruption " depending (to use his own expressions,) on fevers con- nected with a morbid state of the peritoneum or brain, which generally prove fatal," I cannot concur with him, as the eruption is to be regarded only as an accidental symptom of another disease * It has been thought proper to pass over vaccination, as it forms a part of surgery-, rather than of physic; and it has been determined not to dwell upon surgical subjects in this work. 152 ROSEOLA.—URTICARIA. Treatment.—If this disease occur in the course of inflammation of the peri- toneum, brain, &c. the particular disease ought to be treated in the proper manner, without reference to the eruption. If not, the bowels are to be regu- larly attended to, sweating is to be avoided, as well as every thing which heats the patient; and indigestible food must be prohibited. Whenever the patient is found perspiring, the linen should be changed in a careful manner, and the body properly dried and rubbed with a soft towel; in this case sulphuric acid will be found very useful, and there can be no objection to the moderate use of wine and bitters. ROSEOLA. Is a fever attended by a rose colored efflorescence, without wheals or papu- lae, and apparently not contagious. It has often been confounded with measles and scarlet fever, and I have seen the wisest heads baffled in determining the' point; in one case in which such a division of opinion took place between two physicians, a third declared that the patient labored under small pox, and the result of the case proved that his opinion was correct. This is a disease which may frequently be traced to indigestible matter, and particularly fruit, in the stomach and bowels; therefore the treatment is very simple, so simple, that even in the higher ranks, medical men are seldom con- sulted; and they would probably be still less frequently called, only that pa- rents are afraid that it is scarlet fever. Confinement, attention to the bowels, and avoiding solid animal food for a few days, are the best means which can be adopted. Willan and Bateman have given an account of seven varieties of this disease, but no practical benefit can be derived from such minute hair-breadth distinc- tions as these and other skin nosologists have drawn.* URTICARIA. This disease is known to the vulgar by the name of nettle rash, and is dia-, tinguished from other febrile eruptions, by circular elevations of the cuticle, oi a red color, with a white spot in the centre, and is usually termed a wheal; and here again Willan and Bateman have unnecessarily described six varieties. The eruption is generally preceded by marks, the most distinct, of gastroin- testinal irritation and fever ; and the patient is affected with restlessness, op- pression, languor, and want of appetite ; his tongue, however foul, will in ge- neral be found red at the tip, and round the edges. If the eruption be very ge- * It affords me great pleasure to refer to Mr. Plumbe's Practical Treatise on Diseases of the Skin. That gentleman has taken up correct views of the subject, and treats of all the affections pathologically, therefore he has few sub-divisions. It is- the best work we possess on the subject. THE PLAGUE. 153 neral, the patient suffers much distress from the heat and itching of the parts, but the internal disorder will be found to be relieved. Sometimes the rash ap- pears only when the individual is heated by exercise, or by wine, or when he is undressing himself; and it is also frequently excited in a fresh part, by friction or scratching. This is an affection which is often produced by eating particu- lar articles of food. It appears to me, that individuals who are frequently subject to this affection, and others of a similar nature, during youth, are those who in after-life are af- fected with gout. It is sometimes difficult to distinguish urticaria from another very painful and troublesome affection, which is known by the name of erythema fugax; but this is a matter of no practical importance, as both eruptions are produced by the same causes, and cured by similar remedies. Urticaria may continue for an indefinite period, and may be reproduced in particular constitutions every time the stomach is disordered. Treatment.—Nothing is more simple than the management of a case of urticaria; but much more depends upon the patient himself, than upon the re- medies which a physician may prescribe. The patient must find out, by ex- perience, the articles of food which disagree with him, and he must have sufficient resolution to avoid them for a time. It should be impressed upon young practitioners, that danger sometimes proceeds from the repulsion of the eruption by cosmetics. A very beautiful young lady was frequently troubled with febrile symptoms and this rash. She was attended by an eminent physician, who gave her a large bottle of a strong solution of sugar of lead, with directions to sponge her body with the wash when her skin was very itchy. Upon' the first occasion, she stripped herself, and applied it as extensively as she could, and it surprised her that the itching suddenly ceased; upon examination, the eruption, which was very vivid before, had now almost entirely disappeared. She instantly felt sick, oppressed, and fainted ; and continued for such a considerable time in a state of insensibility, that her attendants were doubtful of her recovery. She survived, but has not since known what it is to enjoy a day's good health. Besides avoiding every thing that disagrees with a patient, it may be men- tioned .that gentle laxatives are essential remedies; and that an emetic is highly useful, if any indigestible matter be still in the stomach. THE PLAGUE. The disease which is now to be shortly described, appears to be an endemic fever, attended during its course by buboes, carbuncles, or some eruption on the surface of the body. It is, under certain circumstances and seasons, highly contagious; and it would seem also to be occasionally epidemic. 20 154 THE PLAGUE. The accounts we have of the phenomena of this disease are so contradic- tory, and the history of morbid appearances are so few and meagre, that I have not sufficient data before me wherewith to form pathological descriptions. The plague, it would appear, is sometimes very mild, at others very severe; and if it be a fever, of which I have now no doubt * the symptoms must not only vary in intensity, but they must also have a very wide range of character. It must have varieties and shades arising out of one organ being more severely affected than another, as well as from local congestions and inflammations. The plague appears to be modified also by season, situation, and habits of in- dividuals. It is not to be wondered at, therefore, that different writers should have given different histories of the symptoms and progress of this disease, but as yet, we have no pathological description that can be depended on* therefore, my observations must be brief. It seems to be the general opinion, that the plague is nothing more than a malignant typhus, and the only peculiar symptom that has been described is the bubo, carbuncle, or the appearance of some eruption on the surface of the body; and all writers agree in opinion, that the safety of the patient very much depends upon the suppuration going on speedily and kindly. The plague, therefore, seems to be closely allied to the exanthemata, and more particularly to small-pox. The disease appears to be ushered in by rigors and oppression, followed by heat of skin, great prostration of strength, giddiness, and headache; the ex- pression of the countenance is besotted, and the eyes have a muddy, glistening appearance. It is stated, however, that in some cases there is a ferocious as- pect; in others, the patient's look is subdued. The pulse varies much; it is sometimes quick and full, at others, quick and small; sometimes described as being hard, at others, soft. The intellect is sometimes clouded; at others, there is insensibility and fierce delirium ; occasionally stupor takes place, ana* and in some cases the functions of the brain remain distinct and clear. The patient, in general, seems indifferent respecting his fate ; the tongue is at first moist, although it may be more or less loaded ; there is sometimes constipa- tion, at others diarrhoea; the stools are always highly offensive; the stomach is in general very irritable, every thing taken being almost instantly rejected. In a few days from the first attack, generally the third, pains, often acute, are complained of in the groins and arm-pits ; and unless the swelling and suppura tion of the glands go on quickly, death soon takes place. Sometimes carbun- cles appear with or without the buboes ; but petechiae more frequently than car- buncles. Discharges of blood from the stomach and intestines often take place in the last stage. Sometimes the disease is very rapid in its progress; fre- quently it runs its course in thirty hours. It is said that if the patient survives the fifth day, the bubo being completely formed, he may be pronounced to be *I have had the pleasure of enjoying several communications with Dr. M'Guffuc, who resided many years in Turkey, and who has seen the disease. It is his decided opinion, that the plague is a fever attended by buboes, &c. THE PLAGUE. 155 doing well, if not actually out of danger. As in the acute eruptive diseases, there are two periods fraught with greater danger than others, viz., thai at which the bubo makes, or ought to make, its appearance, and that at which it ought to be matured. The convalescence, as in all severe fevers, is very slow, which is attri- buted to the extremely debilitated state in which the patient is left; but there can be little doubt that a great deal is generally owing to bad nursing, and want, perhaps, of sufficient comforts. It is a curious and interesting fact, that Sir James M'Grigor and Sir John Webb, the former the director-general of the medical department of the army, the latter director of the medical department of the ordnance, should have dis tinguished themselves in the same field of investigation, having been both em ployed with our Egyptian army thirty years ago, when they displayed that talent, zeal and humanity in the performance of their duties, which endeared them to all who were placed under their care. It was there these distinguished persons gave evidence of the great powers of mind and regular habits of busi- ness, which marked them out, as men admirably qualified for the high situations m which they have been subsequently placed, and which they have filled with so much honor to themselves, and benefit to the service. Their statements respecting the plague, will be read with much interest and advantage.* Treatment.—Sydenham recommended free and repeated venoesection in this disease, during what may be called the eruptive fever, and it has occasionally been practised since his time ; but even Sydenham himself seemed latterly to prefer sweating the patient, under the idea of withdrawing the pestilence in that way from the body, which weakened him less than blood-letting. Some indi- viduals condemn bleeding entirely. The same difference exists with regard to purging. Cullen condemns both, but recommends the violence of re-action to be moderated, as far as it can be done, " by taking off the spasm of the extreme vessels." The application of oil to the surface of the body is believed to be a preservative, and it has also been employed to cure the disease; but even upon these points, such opposite statements have been promnlgated, that we have no means of forming correct opinions. A great number of other remedies have been strongly recommended, as mercury, wine and bark, camphor, opium and aether, emetics, diaphoretics, and the cold affusion; and if my notions of the disease be at all correct, there are cases and stages in which several of these remedies, if not all of them, may prove highly beneficial; but there are others in which they must have the very opposite effect For example, if there be violent inflammation and congestion of the brain, no one will say that wine, aether, bark, or camphor, are the proper remedies; but in which cold applica- tions to the head, and the action of mercury, might be beneficial. In the last stage of the disease, the lancet would be most improper, when wine, aether, opium, and even brandy itself, may snatch the person from the grave. If the * Sir James M'Grigor's Medical Sketches of the Expedition from India to Egypt Sir John Webb's Narrative, 6th vol. Medical Transactions. 156 THE PLAGUE. stomach be irritable, which it almost always is in this disease, no one, I hope, would think of making it more so by exhibiting emetics and large doses of of bark. It is to be feared that the recommendation and condemnation of various important remedies have taken place, without reference to the stage of the disease, the particular organ or organs affected, the peculiarities of the pre- vailing distemper, as well as the idiosyncracy of the patient; but it becomes me to speak with diffidence upon a subject, with which I must acknowledge my- self to be very imperfectly acquainted. The reader who wishes for more minute information, must peruse the various works published upon this subject; or a most excellent abstract of them, in the 3d volume of Dr. Mason Good's Study of Medicine. The chapter on the plague appears to me to be the most meritorious part of his work. PART II. DISEASES OF THE ORGANS CONNECTED WITH THE DIGESTIVE SYSTEM. CHAP. I. DIFFICULT DENTITION. Few children go through the process of detention without some suffering ■ and when teething is difficult, a variety of complaints arise which come undei the denomination of infantile diseases. These are fever, determination to the head, convulsions, cough, bowel complaints, cutaneous and glandular affections, inflammation of the eyes, and soreness behind the ears. Authors have long remarked, that children who teethe at an early period, have least suffering ; and the same observation has been made with respect to those who have a considerable flow of saliva. There have been instances of children born with teeth, which happened, it is said, to Richard III. and Lewis XIV., and Haller has cited a considerable number of similar cases. Some infants cut the first pair of teeth by the end of the third month; in other instances, not until they are sixteen or eighteen months old. In general, however, they are cut between the sixth and eighth month. The two centre incisors of the lower jaw commonly appear first; in the course of a month, their opponents in the upper jaw protrude; after this, the two lateral incisors of the lower, and then those of the upper jaw, appear. Between the twelfth and sixteenth month, the anterior grinders of the lower, and then those of the upper jaw are cut; subsequently the cuspidati or eye-teeth protrude, and after these the posterior grinders ; so that children usually have the first set of teeth (twenty in number) complete by the time they have attained the age of two years, or two and a half. There are generally intervals of several weeks be- tween the cutting of each pair. The formation of each tooth goes on in a membranous and vascular sac, which is firmly united to the gum ; and if we attempt to tear the gum from the jaw, the sac is brought along with it. This sac, it would appear, subsequently becomes absorbed; but when it is thicker than usual, more vascular, and long of being absorbed, it is one of the alleged causes of difficult detention. The irritation produced by the pressure of each tooth against the gum in its ad- vancement to the surface, particularly when the child teethes late, and the gums are hard and cartilaginous, also occasions the different phenomena which are ranked under the name of difficult detention. 160 DIFFICULT DENTITION. A child under such circumstances is observed to be restless, fretful, and fe- verish ; to sleep little, and is often seized with sudden fits of screaming. The bowels are out of order, and the evacuations fetid. On some occasions, marks of determination of blood towards the head take place, viz. great restlessness, flushed face, sudden fits of crying, apparent suffering when brought into the erect posture, startings, slight spasmodic movements of the muscles of the face, and even general convulsions. Many children, whenever they cut a tooth, are teazed with a cough, depend- ing on bronchitic irritation or inflammation. This is announced by wheezing. Others suffer from constipation, while many are afflicted with troublesome diar- rhoea. Cutaneous and glandular affections are often observed during difficult denti- tion. The glands of the neck, and the sub-maxillary, are those generally af- fected, and they sometimes suppurate. Of the eiuptions, the herpes larvalis and lichen are those most commonly seen. Occasionally there is inflammation of the eyes, particularly that form which is termed ophthalmia purulenta ; and sores take place behind the ears, which seem to operate beneficially. This statement will shew the propriety of exa- mining the mouth, when we are called to a child labouring under these, or any other affections, during the period of dentition; and it may be well to mention here, the appearances the gums will present under such circumstances. The mouth may be very hot, and on examining the gum over the tooth which we sus- pect, it will be found to be elevated, very red, sometimes white and shining: the ridge or seam, which runs along the jaw in the direction of the teeth, will in ge- neral be found to have disappeared. Under such circumstances, the tooth may >e pronounced to be far advanced; at all events, it is well to be able to say whether it be near at hand or not, as mothers are often disappointed if the tooth over which the gum is cut, does not shew itself in a day or two; whereas, if they are told beforehand that it is not so near, they will in general be satisfied. The best remedy is to divide the gum, down to the very tooth, by crucial incisions. Many people entertain a dislike to this operation, from the idea that the gum is hardened by the cicatrix; but they may be safely assured that this is not the case, and that the tooth will be advanced, certainly not retarded, by the scarifi- cation. If the operation be effectually performed, it constitutes the principal part of the treatment; should the gum even heal immediately, the bleeding will remove the local inflammation, upon which the febrile symptoms frequently sub- side. The bowels must be kept freely open, and the tepid bath is often of great service. If the face be flushed with other marks of determination to the head, the application of cold may be tried, the child should at least sleep without its cap, and use a hard pillow; frequently have I seen it advantageous to change a iown pillow for one filled with fine shavings. It is probable that some of the serious affections of the brain to which children are liable may be attributed to warm caps and soft pillows. The bowels must be more freely acted upon; and if these means do not succeed, it will be well to apply leeches to the feet, which DIFFICULT DENTITION. 161 may be subsequently placed in warm water, for the purpose of encouraging the bleeding; besides which, the haemorrhage is better under command upon the ap- plication of a bandage. Many practitioners are heard to complain of the great difficulty in stopping the bleeding in young children, but I never experienced any myself. In the first place, we ought always to point out the situation where the leeches are to be applied, which I take care shall be, if possible, over a bone, against which pressure can be applied. Secondly, not to apply too many at a time: it is rare to find more than one orifice troublesome, from which the bleed- ing will be easily suppressed, by gently pinching the skin between the finger and thumb for a few minutes. I have never been obliged to use the actual cautery, or even caustic. We are often not called, however, till convulsions have actually taken place, which are to be treated in the manner to be subsequently described in the 2d volume. I may however, mention here, that the child should be put into a warm bath as soon as possible; the face sprinkled with cold water; and if a fit should continue long, and threaten danger, a vein should be opened on the instant. Should the external jugular be readily observed, blood may be drawn from it; but if a vein cannot be found, the hot bath and stimulating frictions must be trusted to till leeches are obtained. Great attention should be paid to keep up a brisk action in the bowels, by means of suitable doses of calomel and jalap, or calomel combined with rhubarb or scammony, together with castor oil and injec- tions ; but all these means will be of no avail unless the gums be freely scarified. Cough is occasionally a troublesome attendant on teething, and practitioners will be found, in general, to act empirically, unless they are able to ascertain whether it depend upon any diseased action in the lungs, or merely upon irrita- tion about the epiglottis and pharynx. If the latter, a common cough mixture may do good; but it will be inefficacious, perhaps injurious, if the cough pro- ceed from bronchitis, which may sometimes require the application of leeches or of a blister, or counter-irritation produced by a mustard plaster, or the oint ment of tartar emetic. If the lungs be very much loaded with mucus, which is easily ascertained, an emetic will be very serviceable; but the treatment of bronchitis need not be dwelt upon in this place. It is only necessary to state the general principles, with reference to the affection now under consideration. When a child, who is suffering from difficult dentition, has diarrhoea, we should not be in a hurry to check it, particularly if there be marks of determination to the head. The bowel complaints of children are of so much importance, that it is necessary to treat of them in a separate article, with a view to point out their pathology; but it must be mentioned in this place, that the best practice is to exhibit a little castor oil in the first instance; and if there be any pain in the abdomen, warm fomentations are to be used; should there still be signs of suf- fering, a leech or two may be applied, followed by very small doses of Dover's powder, or a drop or two of Battley's sedative solution of opium. It is very fortunate that children, upon the occurrence of the most trifling fe- brile symptoms,,or disorder of the bowels, are liable to eruptions on the surface, 21 162 DIFFICULT DENTITION. because they act beneficially by removing irritation and increased action, on many occasions inflammation itself, from internal organs. When these erup- tions take place during the course of dentition, it will almost always be found best not to meddle farther with them than to enjoin cleanliness; indeed, on many occasions, do what we will, the eruption continues, the child becoming better between the periods of cutting teeth. I have frequently seen great mischiei done when external applications had the effect of repelling the eruption, and on more than one occasion death itself. In "porrigo larvalis," when there is great heat, itching, and inflammation of the part, I have found it answer well to apply leeches to the inflamed surface. The child's hands should be muffled, to pre- vent the face from being scratched. Glandular affections may be safely let alone, unless they become inflamed and painful, when the practitioner will do well to apply either leeches or a soft warm poultice. If matter forms, the sooner it is let out the better, in whatever consti- tution it may occur, there being far more danger of leaving a disagreeable mark, by allowing the pus to discharge itself spontaneously, than by using the lancet. We are often consulted respecting inflammation of the eyes at this period of life. Generally speaking, the disease will be found to be confined to the con- junctiva; sometimes to the tarsi; there is rarely deep-seated inflammation of the eye itself. A leech or two applied to the temple, is always safe practice, as well as a blister behind the ear: indeed nature points this out, by the relief which supervenes, upon a natural sore appearing in that situation. Let me add, that whenever we have occasion to blister a child, we should be careful that none of the powder of cantharides is sprinkled upon the surface of the plaster, which fre- quently creates unnecessary irritation; and above all, the blistered surface should be carefully examined every day by the medical attendant, till it shews a healing tendency, as it is apt to slough, which the timely application of a linseed poul- tice will very frequently check. With respect to the natural ulcerations that take place behind the ears, it is only necessary to use frequent ablution with warm milk and water, and to take care that they are not unrtecessarily irritated. Great uneasiness is often produced by carelessly removing the dressings; this might always be avoided by previously applying tepid fomentations. Under all the circumstances which have been mentioned, an occasional opiate is very beneficial; but no medicine of this kind should be left in the way of au ordinary nurse, who will often administer it to secure to herself a quiet night, to the great injury of the child: even Dalby's carminative, or syrup of poppies, should never be left in the nursery. I have known many children destroyed by their constant exhibition. The American soothing syrup is another remedy that is perhaps too frequently ordered by medical men: it is supposed to soften the gums, and to render the process of teething easier; which it does, not by mol- lifying the gums, but by virtue of a narcotic principle which it contains. A child, when teething, carries every thing to its mouth, bites it, and thereby seems to experience relief, and nothing will be found to please it more than the nurse rubbing the gums with her finger. A gum-stick promotes the flow of sa- liva, and amuses the infant. CHAP. II. DIFFICULT DEGLUTITION FROM INFLAMMATION, ULCERATION, OR ENLARGEMENT OF THE TONGUE; CYNANCHE TONSILLARIS; CYNANCHE PHARYNGEA; INFLAMMATION OR ULCERATION OF THE CSSOPHAGUS. Difficult deglutition may be produced by inflammation, ulceration, or en- largement of the tongue; which are often caused by the action of mercury and other metallic poisons. If the affection be produced by mercury, leeches applied to the cheeks are said to be very useful, as also a wash composed of a solution of the chlorate of soda, or that of lime. Several serious cases of inflammation of the tongue have lately been published. Two will be found in the 92d and 93d Nos. of the Edinburgh Journal, and a fatal one in the 214th No. of the Lancet. If I can frust my own observations, I am inclined to be- lieve that inflammation and enlargement of the tongue are generally owing to some temporary diseased action in the chylo-poietic viscera. I may appeal to the experience of any professional man, who is liable to derangements of the stomach and bowels, whether he has not, on such occasions, felt his tongue sometimes swollen and painful, and even slightly ulcerated in different parts of the tip and edges; and whether he has not been led to attribute such a condition to the state of his digestive organs. Whether this view be correct to the full extent or not, the stomach and bowels must be attended to in the treatment. Children in particular are very liable to white specks, vesicles, or ulcerations , on the tongue, and over all the mucous membrane of the mouth and fauces. These specks are called aphthae; we meet with this affection in two forms, one of which is mild, the other very severe. In the first, the treatment consists in keeping the bowels gently open, avoiding solid food, and using the warm bath. In the last, I feel persuaded, from the vomiting and purging, and the intensity of the other symptoms, that the disease affects considerable portions of the intes- tinal tube, and requires a different plan. Before the appearance of the ulcera- tions in the mouth, the constitutional symptoms occasionally run high, which are sometimes relieved upon the mouth becoming sore; so that this affection has some resemblance to the exanthemata. Mr. Burns, in describing this disease, states, that " the child is sometimes drowsy, and oppressed for some hours, or even a day or two, before the spots appear, and occasionally is affected with spasms. The fever and oppression are often mitigated on the appearance of the aphthae." Children affected in this manner, suffer great pain, and are con- sequently exceedingly peevish. The stools are generally acrid, sour, and dis- 164 CYNANCHE TONSILLARIS. coloured; there are often tenesmus, and prolapsus ani, and the surface around the anus is excoriated. Successive crops of aphthae appear, which resemble small portions of curdled milk adhering to different parts of the tongue and mouth; after a time they become yellow, and seem to slough off, but may be renewed many times. When they drop off, the parts below frequently look raw, particularly in severe cases, in which the crust sometimes becomes dry and hard; occasionally the parts look very foul, dark-coloured, and have a fetid smell. A case of an adult lately fell under my observation, in which great suf- fering was produced; the sloughs were most extensive, and portions even of the palate itself were thrown off. The diseased action frequently extends into the air passages, announced by dyspnoea and cough. Children brought up by the spoon, are more liable to aphthus affections than others, as well as those whose bowels are neglected, or are insufficiently clothed. Treatment.—This pathological description of the disease, leads at once to the proper mode of practice. In the two cases of inflammation of the tongue re- corded in the Edinburgh Medical and Surgical Journal, V. S. and the applies* cation of leeches, produced temporary benefit only, while deep scarifications were had recourse to with permanent advantage. It is probable, however, that suffi- cient attention has not been always paid to the condition of the stomach and bowels. With respect to the severe cases of aphthous affections of the tongueand mouth, I can speak strongly of the advantages derived from the frequent appli- cation of leeches to the abdomen, if the strength be good; the warm bath, and counter-irritation on the abdomen by means of a stimulating embrocation, or the tartar-emetic ointment. The contents of the bowels should be discharged by an occasional dose of castor oil. An injection, composed of a few drops of lauda- num, and a table spoonful of starch or gruel, may be thrown into the rectum, by means of a small penis syringe, but it is difficult at all times to make a child retain it. Dover's powder, united with aromatic powder, is also a good remedy. If a child upon the breast be affected in this manner, no other food should be allowed; if it be already weaned, ass' milk ought to be provided; but if it can not be procured, whey mixed with a little cream, and occasionally a little thin gruel, may be substituted; beef tea, and soups of all kinds, are, according to my own experience, bad, until the disease be far upon the decline; if the child's strength be sinking, wine, properly diluted, is far less exceptionable than soups or animal jellies. A weak solution of the chlorate of soda, combined with an opiate, will be found serviceable, a tea spoonful for a dose. Considerable mi* chief is sometimes done, and children are very much and unnecessarily fretted, by the application of borax and sugar introduced into the mouth upon a cloth, or a finger, and rubbed so as to remove the crusts. CYNANCHE TONSILLARIS. There are two varieties of this affection, the acute and chronic. In the acute, the swallowing is difficult and painful; the voice is altered, and in verv severe CYNANCHE TONSILLARIS. 165 cases the respiration is impeded; the pain, generally speaking, is severe. On looking into the throat, the tonsils, uvula, and even part of the palate, are seen much swollen, and very vascular, and sometimes the throat is swollen external- ly. Loss of appetite, thirst, head-ache, and general fever, for the most part, ac- company this disease; occasionally these symptoms run high, and there is deli- rium. In some cases only one tonsil is inflamed; in others, the uvula only; sometimes white specks are seen upon the inflamed part, surrounded by a vis- cid exudation, which present the appearance of ulcerations. The white specks alluded to, are sometimes produced by exudations of lymph, at others, by seba- ceous matter making its escape from the mucous follicles. It has often been in my power to prove, that the sebaceous matter is one cause of a " bad breath." This form of sore throat bears a considerable resemblance to the cutaneous af- fection termed acne. Occasionally, however, ulcerations are observed in the throat. Cynanche tonsillaris terminates in resolution; sometimes in suppuration, ul- ceration, and sloughing. When matter forms, the patient's sufferings are gene- rally increased, the dyspnoea is considerable, and he is said in common language to have a quinsy. The most frequent cause of this complaint is supposed to be cold, produced by sudden vicissitudes of weather; but I imagine there is a combination of causes in the production of inflammation of the throat, and that the principal are a disordered state of the stomach and bowels, and the formation of the sebaceous matter above alluded to. Many individuals are known to me, who never have a sore throat, unless the stomach and bowels have been for some time out of order; as well as others, who for a series of years have escaped an attack, by regulating themselves properly in this respect. Treatment.—This complaint is sometimes very little under the power of the usual remedies, unless it be attacked at the very beginning; and it is only in such cases, or to check the inflammation from running into extensive ulceration or sloughing, that Y. S. ought to be had recourse to. Leeches may be applied externally, under similar restrictions. It has been recommended, that they should be applied internally to the part immediately affected; in which last case, each leech is introduced by means of a tube, with a thread through the tail; but when it is thought necessary to draw blood from the part more immediately af- fected, it is much more easily and speedily done by scarifications, and much less painful to the patient. Blisters are very frequently useful. Females have a great objection both to leeches and blisters; but particularly to the former, from the marks they produce. Laxative medicines are highly necessary, and must be frequently repeated. Emetics are much extolled. The best gargle, if it be necessary to wash the throat, is a little warm water, or acidulated infusion of rosea. Inhaling the vapour of hot water is productive of great benefit, whether suppuration is to take place or not. When matter forms, dyspnoea frequently becomes a marked symptom, therefore the sooner it is discharged the better for the patient; and it is by no means a painful operation, the relief being often in- 166 INFLAMMATION OF THE PHARYNX. stantaneous. Several fatal cases have come to my knowledge, although I have not seen one myself; it is strongly suspected, however, that the immediate cause of death has been inflammation extending into the larynx and bronchial tubes. Chronic cynanche tonsillaris may be either the consequence of acute inflam- mation terminating in the chronic state, or may take place as the effect of sub- acute inflammatory action; the uvula is found enlarged and hard, as are the ton- sils. If the case be recent, stimulating applications are found useful, and a suc- cession of blisters to the throat; if these means do not succeed, and the enlarge- ment is permanent, particularly if the voice be affected, the patient becomes an object of surgical treatment. Sometimes extensive and troublesome ulcerations are produced, as the effects of chronic, as well as of acute inflammation in the throat; and in treating these, it is necessary in the first place to attend to the general health, by regulating the state ©f the stomach and bowels, and also the diet, which ought to consist of mild and digestible substances. Leeches and blisters are often serviceable; but the most efficacious application, is a solution of the nitrate of silver in dis- tilled water, in the proportion of four, six, and even ten grains to the ounce. The ulcerated surface is to be carefully washed, before the solution is applied. This operation, however insignificant it may appear, must be done with proper care, as bad consequences have been known to follow. There is a preparation in my museum, in which the epiglottis is completely destroyed by common caus- tic, rudely used. INFLAMMATION OF THE PHARYNX. In this affection the tonsils and uvula are not invariably inflamed, but upon looking, the parts being exposed to a bright light, we can often see the throat and pharynx very vascular, and loaded with viscid lymph, which the patient to constantly making efforts to dislodge by hawking and spitting. The pain on swallowing is fully greater than in the last described affection, I have seen patients suffering severely, some apparently in great danger. When it is severe, the lancet must be used, followed or not by the application of leeches and blisters, according to circumstances. The inhalation of the vapour of hot water affords remarkable mitigation of the symptoms, and in slight cases, nothing further is required but to keep the bowels open, and allowing moderate nourish- ment. INFLAMMATION AND ULCERATION OF THE CESOPHAGUS. Of all the structures in the human body, the oesophagus is perhaps the least liable to disease. In general it is difficult to detect inflammation of the oesopha- gus till ulceration and constriction take place. I have seen only one case of universal inflammation of this tube not caused by poison, in which the lining membrane was in a sloughing state. There is a preparation in my museum that displays similar appearances; in this case, however, there were no symptoms AFFECTIONS OF THE OESOPHAGUS. 167 indicative of disease in the tube. In the former case which I attended, there was pain and difficulty in swallowing. Both patients were also affected with phthisis. Inflammation may be partial, affecting only a part of the calibre of the oesophagus; and if ulceration follow, there will be no contraction, but the patient will feel slight pain and a momentary stoppage when the bolus of food arrives at the spot. If the whole calibre of the oesophagus be involved in the inflamma- tion, the pain will be more considerable, not so much from constriction as from the effort to vomit, which is produced by irritation. If it terminates in ulcera- tion, occupying the whole tube, constriction will take place with increased dif- ficulty in swallowing. Patients have been known to be three and four days, and even a week, without food. Treahnent.—Attention to the bowels, topical bleeding, and extensive counter- irritation, are the best means which can be employed. Nourishing injections thrown into the rectum, are to be assiduously administered when the patient is unable to swallow a sufficient quantity of food. It is the practice in such cases to introduce instruments into the oesophagus, to produce dilatation; but I have seen it very injurious in several instances, when the operation was performed during the inflammatory stage. Affecting the system with mercury has been highly extolled, but perhaps without sufficient consideration. If the constriction be permanent, after the inflammation and irritation are subdued, a surgeon may be called to make cautious trials with a bougie; perhaps an oesophagus tube wfll be found the best instrument for this purpose. CHRONIC AFFECTIONS OF THE (ESOPHAGUS. Sometimes the gullet is diminished in diameter by flesby excrescences, tu- mours, or occasionally scirrhous contractions are observed; and more rarely ossification. Some individuals have survived contractions of the oesophagus for a great many years, being obliged to have food introduced into the stomach through a tube. Chronic diseases of the oesophagus are frequently found to have made considerable progress before their existence is even suspected. The smoke of tobacco and stramonium, the abuse of mercury, and drinking fluids either excessively hot or cold, have been assigned by writers as the gene- ral causes, but perhaps too hastily. Of all the remedies which have been recommended to us in such cases, the bougie is undoubtedly the best; and if at any time there should be much pain, leeching, counter-irritation, and narcotics, are to be had recourse to. ; Many other circumstances produce difficulty in swallowing, as for instance, want of the uvula, tumour in the pharynx, ulcerations in the larynx, or upon the epiglottis. The first two belong more to the surgical department than the me- dical, and therefore cannot be treated of in this work; the last two shall be no- ticed among the diseases of respiratory organs. CHAP. III. INDIGESTION. Under this head I shall treat of the affection which is commonly called dys- pepsia, with its usual attendants, flatulency, tympanitis, heartburn, and pyrosis; and also of the painful affection termed gastrodynia. Dyspepsia is a most troublesome disease to treat; and I believe the physician, to be able to do so effectually, should have suffered from it himself, as one who has had the good fortune never to feel as if he had a stomach, can scarcely be- lieve, or almost listen to, the complaints of those who have experienced that sen- sation. One symptom is more prominent and urgent in one case than another; a little flatus in the stomach occasionally produces violent nervous symptoms, sometimes as if the brain were seriously affected; and the whole will vanish after one or two sour eructations. Some patients appear as if they could not survive the difficulty of breathing under which they labour; and it will be found to depend, perhaps, on flatus rising in the oesophagus, producing the affection called globus hystericus. Remedies have not the same effect in any two cases; all plans of treatment will most generally fail, unless the patient himself can discover what articles of food agree with him better than others, and has reso- lution enough to adhere to a proper regimen. Dyspepsia may arise from va- rious causes: first, from simple functional derangement of the stomach, duode- num, liver, spleen, or pancreas; secondly, from indigestible and acrid substances taken into the stomach; thirdly, from structural derangements in the digestive apparatus; fourthly, from long continued constipation; fifthly, from derange- ments in other important organs. Dr. Wilson Philip, who has written an excellent work upon this subject, has divided the disease into three stages. This plan would do admirably well, if dyspepsia were as regular in its march as intermittent fever; but in practice, such an arbitrary arrangement will not be found useful, because the second, or even the third stage, may be produced at once, without advancing regularly through the others. First stage of indigestion.—The first symptoms of indigestion are a sense of fulness and uneasiness in the region of the stomach, arising either from too great a load of food, from some indigestible article, or from flatulent distension of the •tomach; frequent acid eructations, constipation, loaded tongue, and some thirst, INDIGESTION. 169 follow. Sometimes sore throat is complained of; it is difficult to keep the hands and feet in a sufficient degree of heat; and occasionally there is severe headache. These symptoms may steal on slowly, and from being felt only occasionally, are neglected ; or they may be produced suddenly, by indulgence in a copious draught of very cold water, or from anxiety, grief, fright, or other severe mental affections, or by too violent exercise after a full meal. Physicians are rarely consulted in the first stage of the complaint; for the patient either drives on through it, or relieves himself by a day or two's absti- nence, and by taking a laxative. If a person, however, take little heed of him- self, he is soon heard to complain of restless nights, oppression at the praecor- dia, and becomes sensible of diminution of strength, and heat of skin; his ap- petite becomes fastidious; he is either very costive, or is affected with diarrhoea. The alvine discharge is sometimes very bilious; at others white, shewing a want of bile; it is sticky, drops with difficulty from the body, and is very fetid. After the patient obtains passage from the bowels, he still feels much loaded, and very often considerable quantities of half-digested food will be observed in the stools. Persons labouring under such symptoms, will very generally be heard to at- tribute their complaint to a "fit of the bile; and many medical men, I fear, con- found stomach disorders with those of the liver, and too frequently exhibit pow- erful mercurial preparations, to the great injury of the patient. Treatment of the first stage.—The cure of this form of the complaint is not difficult. The patient is to be directed to abstain from the use of soups, and whatever else distends the stomach; to eat little, and to leave off while he has still an appetite; to keep his bowels open with a little rhubarb, Henry's calcined magnesia, or a compound colocynth pill; and to take regular exercise. He should, as much as possible, avoid any cause which has a tendency to produce mental excitement or depression. The second stage of dyspepsia is marked, according to Dr. Wilson Philip, by the supervention of tenderness in the epigastric region, and a hard pulse; and he very justly considers these two symptoms of much practical importance. The patient now feels very sensible to the impression of cold; he is often chilly, and afterwards complains of flushes of heat; his hands and feet have sometimes a dry, burning sensation, particularly during the first part of the night, extremely cold at other periods, painfully so when he first goes to bed; his skin becomes hot in bad cases, towards morning a perspiration breaks out, and the patient en- joys some quiet sleep. When he awakes, although he may complain of not feeling refreshed, yet the symptoms are greatly relieved. His debility is now greater, with some emaciation; he complains of languor, and always desponds. There is considerable uneasiness and fulness in the epigastric region, and an occasional darting pain towards the spine, together with a burning sensation in the stomach. Palpitations are now, perhaps, very troublesome; they are not constant, however, but become worse after dinner; the least thing agitates the mind, and produces them. The patient sometimes coughs and expectorates in the morning, and supposes he is consumptive; or there is vertigo and headache, 22 170 INDIGESTION. with imperfect vision, as, for instance, seeing two objects instead of one, or only barf an object, and it is impossible to persuade him that he is not threatened with apoplexy. In cases of dyspepsia, some individuals, particularly those with light hair, are very liable to inflammation of the tarsi, with purulent exudation; and sometimes little abscesses form, which are called in common language " styes." The kid- neys frequently suffer, the flow of urine being either too sparing or too copious, attended with complaints which are called " gravelish." It is my belief that dyspeptics are more liable than others to inveterate skin diseases, and to stone in the bladder. It will be found also that most of the individuals who labour under hoemorrhoidal affections are dyspeptics; and it may be mentioned, that ( have rarely seen a person afflicted with fistula in ano, excepting when it pro- ceeded from external injury, who has not been a martyr for a long period to this class of complaints. Pure surgeons should make themselves acquainted with these facts, and a great many other points of medical pathology. It is rare to see all these complications, but they are occasionally met with in the same patient. I have seen many patients consider their lives as burdens to themselves, and there is often a strong tendency to commit suicide. Should the symptoms continue severe for a considerable time, some serious organic lesion may be dreaded; but the lungs, liver, and brain, are the organs which most frequently suffer, and form what may be termed the third stage of dyspepsia. Treatment of the second stage.—Whenever the patient complains of tender- ness in the epigastric region, with a hard pulse and bad nights, local bleeding by cupping or leeching frequently produces the best effects. My own plan, in severe cases, is to apply leeches, to the number of twelve or eighteen, two or three times if necessary, before counter-irritation is had recourse to; and the best method of producing irritation, is by frictions with the tartrate of antimony ointment, which must be persevered in, first on one part, then on another, so as to produce a succession of pustules. I have been led to place much depend- ence on this practice, by observing that dyspeptics have sometimes been re- lieved, at others cured, upon the appearance of a spontaneous eruption. In se- vere cases, the diet should consist of gruel, arrow root, milk, calf-foot jelly, light pudding, and good bread ; and these should be allowed in limited quantity; more than a breakfast tea-cupful at a time will overload the stomach. Soups and vegetables should be avoided, at least for some time. Gentle laxatives, so as to open the bowels twice a-day, are to be used. The tepid bath will be found very useful; but perspiration must not be encouraged after coming out of the bath. The patient should be clad according to the season of the year; and it is of great consequence to keep the feet comfortably warm and dry ; in order to ensure this, worsted stockings are too frequently directed to be worn, which, in many individuals, will produce the very circumstance it is wished to avoid- It was a long time before I could discover the cause of this ; and I believe I may now state confidently, that worsted stockings, worn by people whose feet INDIGESTION. 171 perspire, will tend to produce coldness of the extremities; under such circum- stances, I find the object is attained, if the patient wear an under stocking either of silk or thin cotton. Exercise in the open air is highly necessary as soon as the patient's strength will permit; if he ride on horseback, the feet should be additionally protected in cold weather by mud or cloth boots, and he should never make use of horse exercise for two or three hours after a meal. By de- grees, he may be allowed a small tea-cup full of chicken or beef tea; subse- quently, he may eat part of the breast of a chicken or game to dinner, till he is able to return to ordinary fare. The physician, in severe cases, ought to insist on his patient keeping notes of his diet, particularly during his recovery, which will enable him to compare his present state of health with the articles he had eaten the day before. The best diluents he can use are, an infusion of camo- mile flowers and lemon-peel, and wine and water; stimulants are to be com- menced with great caution, and not until the pain in the epigastric region and heat of skin are subdued ; perhaps the best stimulant is cayenne pepper with food, which affects the whole bowels as well as the stomach, and tends to ob- viate constipation. Ginger tea will be found serviceable, together with a glass or two of good sound wine once or twice a-day. Wine sometimes, however, produces acidity, in which case a small quantity of brandy in water is found an agreeable substitute. Dyspepsia is one of those diseases too generally treated by the routine prac- titioner, from its name, without reference to the pathological condition of the body on which the numerous symptoms depend. If such a person were asked, what he would prescribe for a person who had dyspepsia? he would quickly reply, tonics! I have no objection to the medicines which are usually admi- nistered under the denomination of tonics, provided they are not given for the purpose of running up a bill, or prescribed at times when something better might he done for the patient. But I have some doubts respecting the truth of the received notion of their action, I do not think it is by giving tone to the stomach. These remedies are bitter, and, I imagine, produce increased secretion of the fluids connected with the digestive process. On putting a little quassia or gen- tian into the mouth, immediately a flow of saliva takes place, which continues as long as the taste is perceptible, and even afterwards, when the person thinks of the bitter taste. May not a similar action in other organs, follow the appli- cation of the same substance? If the liver be not doing its duty properly, calomel or the blue pill may be ex- hibited at bed-time, followed by a very small dose of salts in the morning; but it is a despicable practice to give blue pill in every disease connected with the digestive function. And it is much to be regretted, that the great name of Abernethy should ever have been associated with such insufferable quackery. The above treatment is to be persevered in for a long time, changing the diet and the laxatives now and then, but continuing the counter-irritation and appli- cation of leeches alternately. After a time, cold bathing in the open sea may be cautiously tried; the shower bath, or sponging the body with vinegar and water, often produces the best effects. 172 INDIGESTION. It would be needless to dwell here upon the treatment necessary in the third stage of indigestion, when some organic lesion is supposed to exist. This must vary according to the organ diseased, as well as the nature and extent of the affection. The disease termed dyspeptic phthisis by Dr. Wilson Philip, is only met with, generally speaking, in cases of long standing. My experience, however, leads me to state that bronchitis is the primary affection in such cases, the tubercles form subsequently. Flatulency and tympanitis.—These are symptoms of dyspepsia, but require a few separate remarks along with heartburn and water-brash. Some people suffer extremely from flatulency and acid eructations. Five or six instances have fallen within my observation, of individuals who frequently passed enormous quantities of flatus upwards; and it is presumed these are cases to which Dr. Mason Good would apply the term cholera flatulenia. In all such instances, the patient had previously eaten some crude vegetable sub- stance: generally, the ordinary salad mixture, or radishes. The remedies which seemed to afford the greatest relief were aether, aromatic spirit of hartshorn, warm brandy and water, or brandy by itself, and essence of peppermint. Tympanitis may be detected by percussing the abdomen; it is often a trou- blesome symptom, not only in this affection, but in fever; and the best remedy which can be used is turpentine. It is better to try it, in the first place, by in- jection, in the proportion of a table spoonful to eight or ten ounces of thin gruel, which the patient is to retain as long as possible. If this plan do not succeed, half an ounce is to be given by the mouth, with the same quantity of castor oil. Infants, during the first months, frequently suffer very much from flatus in the stomach and bowels, which will in general be found to depend, either on the pernicious and unnecessary custom of giving them castor oil and other medi- cines to open their bowels, or food they are unable to digest. In truth, the moment an infant is born, and often before it is dressed, castor oil is exhibited, which frequently produces griping; this is attributed to wind, and want of some- thing to eat, therefore a quantity of gruel is given, which often increases the child's sufferings; Dalby's carminative is then given, which affords temporary relief. Few infants can be expected to thrive well under such management. The usual remedies for flatulence in infancy are, dill water and oil of aniseed. Pyrosis, or loater-brash.—In some long standing cases of indigestion, parti- cularly in old people, in women more than men, and those who live principally upon farinaceous food, a considerable quantity of limpid fluid is discharged from the stomach by eructation. . This is the affection which is called water-brash. It is a symptom of scirrhus of the stomach also. It attacks the patient generally in the morning and forenoon: at first consi- siderable complaint is made of pain in the pit of the stomach, famtness, a sense of tightness, as if the stomach were closely drawn up to the back bone, and the uneasiness is increased upon moving into the erect posture; at last the limpid fluid is discharged in considerable quantity at different times, when the pain sub- GASTRODYNIA. 173 sides; sometimes the fluid has an acid taste, but in general it is stated to be in- sipid. Occasionally the discharge takes place without being preceded by any severe symptom. Heartburn is, next to flatulency, one of the most frequent symptoms in indi- gestion, and it is also one of the common attendants on pregnancy. When heartburn exists, the patient complains of a burning pain in the pit of the sto- mach ; every kind of food creates acidity; and hot, acrid eructations take place, which seem to irritate the oesophagus. Some women suffer very much from this symptom during the whole course of pregnancy, but the moment delivery takes place, it generally vanishes like magic. Henry's calcined magnesia, and careful attention to the diet, often mitigate this symptom. The super-carbonate of soda and potass are frequently used, and sometimes with benefit; as also, charcoal and chalk mixture. The remedy which I have found most successful in producing temporary relief, is the com- mon extract of liquorice. Cases are now and then met with, which resist all these remedies, together with leeches and opiates. The oxide of bismuth, sul- phate of iron, and sulphate of zinc, have been highly extolled. I have exhibited them often in such instances, but without benefit. The points to be chiefly at- tended to, are the regimen and laxatives. GASTRODYNIA. The stomach is liable to a neuralgic affection, which is known by this name, as well as by the term cardialgia. Gastrodynia is closely connected with dys pepsia, often occurring as a symptom ; but it may exist as the primary disease ; sooner or later, however, the digestive powers suffer. Symptoms.—Sometimes the appetite remains good ; but in general it is im paired. There is a gnawing pain in the stomach, extending very deep to the back, accompanied by anxiety, sense of constriction, tendency to eructate or to vomit, with occasional faintness, sometimes headache and constipation, and the patient is occasionally relieved by eructation; a considerable quantity of limpid fluid is sometimes discharged; in fact, this affection is often complicated with pyrosis. After a severe attack, a patient sometimes escapes without another, for a week, month, or even a longer period. All the symptoms enumerated do not take place in every case; sometimes there being only pain and anxiety, with some nausea, which are increased after taking food. This affection is almost unknown before the age of puberty. Besides, depending on a diseased condition of the nerves of the stomach, it is probably occasioned by a diseased state of the pancreas, spleen, and liver. Sometimes it is produced by scirrhosities of the stomach and duodenum, and it is also a very troublesome attendant on gout. This disease has of late years excited a great deal of interest in France, as well as in this country; and although no additional light has been thrown upon the nature and seat of the disease, still very considerable practical advantages cannot fail to be derived from pe- rusing the writings of M. Barras, and Dr. James Johnson. 174 GASTRODYNIA. The chief causes of gastrodynia, generally speaking, are supposed to be, long-continued use of indigestible food, very hot or very cold drinks, dram- drinking, long fasting, worms. The chief articles which produce a paroxysm in an individual liable to the affection, are salads, and all other crude, uncooked vegetable substances, sweet-meats, new bread, cherries, nuts, olives, and above all perhaps, roasted chesnuts. The cure depends, therefore, upon avoiding such articles in future, together with fat, oils, and butter. During an attack, a vomit will often suddenly check it, if exhibited within two or three hours after the offending matter has been eaten; hot flannels are to be applied to the epigastric region; gentle laxatives, and the warm bath, are to be employed, together with bitters, alkalies, magnesia; and in bad cases counter-irritation is to be persevered in for a considerable time. I have known one or two patients, who for many months at a time could not put any kind of food into the stomach, without previously taking a small dose of the sedative solution of opium; and we are told by Roche and Sanson, that in the worst form of this disease, which had resisted bleeding, bitters, and antispasmodics, Dr. Francois found lactucarium successful. It is a curious fact, that although sweet things generally aggravate the complaint, the extract of liquorice frequently al- leviates the pain considerably. M. Barras insists much upon the necessity of making the patient take animal food, although it may for the time increase his sufferings. CHAP. IV. DISCHARGE OF BLOOD FROM THE STOMACH AND BOWELS. I. Haemorrhage from the Stomach.—This form, which is termed Haemate- mesis, is sometimes occasioned by diseases of the liver and spleen, and takes place also occasionally in fevers; but these are not under consideration at present. Haematemesis most frequently attacks women, particularly those who are unmarried, of a plethoric habit, and at times when there is an obstruction, or some other irregularity of the menstrual discharge, and who are constipated. Each attack is generally preceded by a rigor. Pure blood is seldom vomitted, unless from external violence, or the erosion of the coats of a blood vessel. This discharge rarely coagulates, and seems rather to be the product of pas- sive haemorrhage, or exudation from the minute vessels of the mucous mem- brane. It is supposed to be a very easy matter to distinguish this affection from those haemorrhages which take place from the lungs. In haematemesis it is said the discharge is preceded by a sense of weight, pain in the region of the stomach, and that it is unaccompanied by cough, &c. But these distinc- tions will not answer in practice, and it may be of great consequence to a medical man, that he should not give an assurance of safety, in a case which may prove fatal in a few minutes, as the following instances will shew.—A child was attended by Dr. Yates, when that excellent gentleman was a pupil at my Dispensary. It had been for some time complaining of cough and ano- malous symptoms, which were relieved from time to time, and it was able at last to go to school as usual. Still it occasionally discharged a little blood, and died suddenly, after vomiting a considerable quantity. On dissection, the stomach was found filled with a coagulum, and there was also a considerable portion in the small intestines in a fluid state. It was evident that there had been active haemorrhage, but after the most minute investigation, no blood-vessel could be found from which it had issued. The relations began to complain of the time we had been over the body, and at length became very impatient, so much so, that we were obliged to give up further examination; but the whole of the contents of the thorax, including the oesophagus and great vessels, having 176 DISCHARGES OF BLOOD. been carefully dissected out, were surreptitiously conveyed to my museum for minute inspection ; and it was discovered that the blood found in the stomach and bowels, had proceeded from a ruptured artery in a cavern in the superior lobe of the left lung. A fistulous opening was found running upwards from this cavern, and communicated high up with the oesophagus ; so that when ulceration produced a rupture of the vessel, the blood passed in this direction, and found its way into the stomach. The preparation is in the museum, to- gether with an accurate and beautiful drawing by my friend Dr. Alexander Thomson, an enthusiastic pathologist. Another remarkable case occurred in the dispensary practice, in an old man. He had enjoyed remarkably good health until lately, when his appetite became impaired, and he complained of dyspeptic symptoms, which gradually increased in severity, and he was at last reluctantly obliged to seek for medical advice, at the age of 72, for the first time, I believe, in his life. He complained of so much uneasiness in the region of the stomach, that he was cupped several times, and counter-irritation was produced over the part affected, with consider- able relief. One morning he discharged a little blood, between the act of coughing and vomiting, and he soon died after passing a considerable quantity. Upon dissection, it was a subject of general remark, that the external appear- ance of his body, as to shape and plumpness, was more like that of a man half his age. Every internal organ appeared sound; but on cutting through the stomach into the duodenum, the pylorus was found thickened and indurated, and an ulcer about the size of a horse-bean was discovered in the duodenum. on the surface of which the gaping mouth of a large artery was discovered, from which the haemorrhage had taken place. Treatment.—As the disease generally attacks plethoric individuals, and is seldom accompanied by debility or oppression, practitioners have no scruple in employing blood-letting during an attack, and it is frequently successful, by im- mediately checking the discharge. Quietness, cold acid drinks, and a course of laxative medicines, are also essentially necessary. If the haemorrhage re- cur after bleeding, or should it take place in a constitution already debilitated, the acetate of lead, either in solution or in the form of pill, in doses of two grains every second or third hour, will be found serviceable. II. Haimorrliage from the bowels.—This was formerly known by the term Haemorrhoidal Flux, and it was believed by the ancients to be salutary i but now such a discharge is always regarded with anxiety, as it frequently tends to undermine the constitution, and like other long continued haemorrhages, leads to affections of the brain,—a remarkable and fatal instance of which lately fell under my observation. When blood is discharged by stool, it will sometimes be found to proceed from an injury done to the verge of the anus by a hard and constipated stool, from a ruptured blood-vessel in the bowels, or from the diseased excrescences which are found at the termination of the rectum, known by the name ot haemorrhoids, vulgarly called piles. These have been divided into two kinds, DISCHARGES OF BLOOD. 177 external and internal, which last are also called blind piles. They may be said to be painful excrescences on the verge of the anus, or in the rectum, usually attended with a discharge of mucus or of blood. The profession is not agreed as to their pathology; but after a careful ex- amination of the opinions which have prevailed, and of the diseased parts them- selves, I feel disposed to believe there are at least four distinct kinds of haemor- rhoids. 1st, They are sometimes nothing more than a varicose state of the hemorrhoidal veins, with, perhaps, a slight thickening of the mucous membrane of the rectum itself. 2dly, They are formed by an effusion of blood in the sub-rnucous tissue, with a slight thickening of the membrane. 3dly, They are mere fugosities from the surface of the mucous membrane; and accordingly are found to vary very much in seize, shape, and appearance. 4thly, A pro- lapsed state of the mucous membrane of the rectum, which subsequently be- comes indurated, and in a manner strangulated, by the contraction of the sphincter. Symptoms.—Individuals who are thus afflicted, suffer only occasionally, and then it is said, in common language, they have " a fit of the piles." A sense of fulness is felt in the rectum, attended with an occasional stinging pain, which is sometimes very severe and darting, increased when passing a stool, during which a quantity of blood is discharged. A strong desire is experienced to sit and strain, which is termed tenesmus. After this has subsided, a sense of heat fs felt for a few minutes. But when the piles are external, they often swell enormously; are very tender, however small they may be, and sometimes ulce- rated. In this case the discharge may be constant, taking place, however, in small quantity at a time ; on other occasious there is copious haemorrhage, fol- lowed by relief from pain. When the inflammation runs high, induration of greater or less extent is left, in consequence most probably, of effusion of lymph into the cellular membrane, to which may frequently be traced strictures in the rectum, and tubercular formations close to the verge of the anus. Causes.—The injury done to the parts by the frequent passage of indurated feces; use of aloetic purges ; long continued exercise in the erect posture; sit- ting on a cold or damp seat; and every circumstance which impedes the flow of blood through the veins of the abdomen,—are causes of this complaint. The pressure of the gravid uterus, therefore, is sometimes a cause, as well as tumors affecting different parts of the uterine system, and diseases of the liver, &c. But it will be almost always observed, that individuals, affected with piles, have been long and seriously afflicted with gastro-intestinal irritation.* Treatment.—The bowels must be kept constantly well regulated by the gen- tlest laxatives, carefully abstaining from the use of aloes in any shape. A large mucilaginous injection, exhibited immediately before going to stool, will be found highly serviceable, and the best way of preparing it is by making a decoc- tion of linseed. Sulphur has been erroneously supposed to be a specific. * The pernicious habit of taking a book or newspaper to read in the water-clo9et, when at stool, is very frequently a cause of this unpleasant complaint. 23 178 DISCHARGES OF BLOOD. Balsam of capaiva was recommended and used by Dr. Cullen, by introducing it into the rectum; but in the ordinary cases of blind piles, gentle laxatives, occasional injections of decoction of linseed, together with rest in the horizontal posture, and a moderately antiphlogistic regimen, will suffice. When the piles are external, tender, and inflamed, the application of leeches, or punctures made with a lancet, are also productive of great benefit, by diminishing the ten- sion and pain. In severe cases the recumbent posture is actually necessary, and I have seen the inflammation run so high, and attended with so much suf- fering, as to require general bleeding. Poultices and warm fomentations are very serviceable in alleviating the pain, and sometimes anodyne injections must be had recourse to; considerable relief is obtained, if the excrescence can be pushed within the sphincter. An ointment, made by mixing equal parts of powder of galls and opium in hog's lard, and a weak solution of nitrate of silver, are frequently used with benefit. If a great deal of blood be lost, whether at once or at different periods, a careful examination should be made with the eye, as well as the finger, in order to ascertain the exact point from which the bleeding proceeds, and it is neces- sary sometimes to apply caustic, the ligature, and even the knife; but these are matters of surgery. I would only further beg to insist upon the necessity ol attending more than is generally done in these cases to the constitution, and particularly to the general condition of the mucous membranes; and young practitioners should bear in mind, that neglected cases of piles often terminal* in fistula. CHAP. V. COMMON COLIC; PAINTER'S COLIC; ILEUS, INTUSSUSCEPTION; INTESTINAL CONCRE- TIONS; PROLAPSUS ANI; AND CONSTRICTION OF THE RECTUM 1,—Common ;colic may be produced by indigestible food, constipation, and a diseased condition of the Miliary secretion. Symptoms.—Griping pains and flatulent distention of the bowels, with a sense of twisting in the region of the navel, are felt, sometimes with contraction of the abdominal muscles; and occasionally, though rarely, with some degree of nausea and vomiting, which takes place more frequently when the affection is produced by the biliary secretion, and in which case there is generally loose- ness of the bowels. Flatus is sometimes heard rumbling backwards and for- wards in the bowels, which is more classically termed borborygmus. The pain comes on in paroxysms, during which the patient thinks he experiences rehef by pressure applied to the abdomen, which in general distinguishes the affec- tion from others of an inflammatory nature. But it must be recollected that cases of colic, when neglected, often terminate in inflammation of the bowels. Treatment.—It is a most essential point to obtain free evacuations from the bowels speedily, particularly by means of an injection ; certainly the best is composed of tobacco, in the proportion of half a drachm infused for ten or fif- teen minutes in eight or ten ounces of boiling water; to be strained, and exhibit- ed when sufficiently cool. If the attack succeed immediately after a meal, an emetic may be given to dislodge the offending matter. A considerable quantity of oil of cloves should be administered along with castor oil, or any other pur- gative ; or oil of turpentine may be used by injection. Warm fomentations to the abdomen, or the general warm bath, may be employed. Some cases of abdominal inflammation are attended by symptoms so slight as to resemble colic very closely, so much so, that in many instances it is diffi- cult, and in some impossible, to determine this point of diagnosis. In such circumstances, it will be well for our patients if we do not attempt to refine too nicely; if in doubt whether the case be one of inflammation or of colic, it is our duty to give the benefit of that doubt by using the lancet, particu- larly if the bowels are obstinate. The advantage of opium is very doubtful till the bowels have been properly moved and the evacuation examined. In a case of colic from vitiated bile, diluents, such as barley water, are to be employed, together with a weak solution of salts, and afterwards opiates. If the ISO PAINTER'S COLIC. bowels be open, and we are perfectly satisfied that there is no danger of inflam- mation, a stimulant such as brandy, is often beneficial. Some women, at the menstrual period, have griping pains in the bowels, more particularly in the course of the colon, accompanied by considerable dis- tension of the abdomen, attended or not by constipation; frequently the pain extends from the caput caecum to the arch of the colon. The best remedy in such cases, is a turpentine or assafcetida injection, combined with warm fomentations, proper regulation of the bowels and diet, and sometimes the warm hip-bath. PAINTER'S COLIC. This is also known by the names, collica pictonum, Devonshire colic; and in the West Indies it is commonly called dry belly-ache. This is the form of colic produced by the introduction of lead into the system, whether in food, by respiration, or cuticular absorption. It is a disease which was long known and described before its cause was discovered. The discovery was made in Germany about one hundred and thirty years ago, by detecting publicans putting a preparation of lead into their wines. It is said that the disease used to prevail in Devonshire, and other places where cider is manu- factured, in consequence of putting lead into the casks, to render the cider sweeter. The disease also prevails in the neighborhood of smelting furnaces and lead mines ; indeed it is even said, in such situations, to affect the lower animals, such as poultry, pigs, &c. House painters, plumbers, potters, gla- ziers, and all who are compelled by their occupation to handle lead much, are subject to this disease, particularly if they are not well guarded by personal cleanliness. Sir George Baker* was the first who drew the attention of the profession in this country to this interesting subject. It must be mentioned, however, that cases do occur displaying the same phenomena, course, and ter- mination, which have been produced by exposure to cold and damp, when there could not be the most remote suspicion of the action of lead upon the system. Symptoms.—The pain never leaves its principal seat about the umbUicus and pit of the stomach ; at first it is dull and remitting, but gradually increases to be very severe and constant. The pain, in some severe cases, strikes through the back, and patients have told me that it resembled a stab through the body, others have felt as if they were cut in two at the umbilicus. In other cases the pain extends to the arms and hands, down the back and pelvis often affecting the lower extremities. The integuments of the abdomen feel retracted and hard, and I have seen the strongest men rolling and weeping like children. The whole surface sometimes suffers from pains, which the patients ascribe to rheumatism ; there is also constipation, sometimes tenesmus, and occasionally sickness and vomiting. The sickness and vomiting are most severe at the height of the paroxysm; acrid mucus is sometimes vomited, or bile mixed with mucus, affording temporary relief. Hiccup sometimes supervenes, together with retraction of the testicles. ♦Vide Papers in the 1st and 2d Vol. of the Lond. Coll. of Physic. PAINTER'S COLIC. i8l It is a matter which strikes every one with astonishment, that notwithstand- ing the violence of the symptoms, and the excruciating sufferings of the pa- tient, the pulse is rarely much affected till the disease goes on for some time ; in the end, however, it becomes quick and small. It has been remarked by some, that the feet and toes are occasionally affected, as in gout. Spontaneous relief is said to follow a copious discharge of scybalous matter, like sheep's droppings mixed with mucus and considerable quantities of blood. Occasionally, it is said, sweating produces a crisis. Sometimes the disease produces palsy of the superior extremities, and occasionally it terminates in death, which is preceded by a loss of sight and hearing, delirium, and convul- sions. One attack leads to another; that is to say, a predisposition is left. Colica Pictonum is a most afflicting disease to treat; for, do what we wiH, the patient is seldom relieved under a week, even when well managed, and re- lapses often take place at times when he is apparently doing well. He may be pronounced to be in great danger, however, when there is delirium, violent spasms, and convulsions. Appearances on dissection.—The following is an abstract of the appear- ances found on dissection, in the bodies of a number of individuals who died of this affection in the hospital of Beaujon, under the care of M. Renauldin. Redness, thickness, and ulceration of the mucous membrane of the alimen- tary canal, and often enlargement of the mesenteric glands, corresponding to the inflamed or ulcerated portions of this membrane. The redness varied from that of bright rose even to violet and brown; it was disposed in points, in streaks, and in patches, and sometimes occupied an extent of several feet. The thickness was variable. The ulcerations were found almost always toward the termination of the small intestines, near the valve of the colon, which was sometimes destroyed; and in cases where diarrhoea prevailed, ulcerations were found in the colon; and sometimes they were observed in the stomach. They were occasionally deep, and numerous; sometimes the sto- mach and intestines were perforated.* Treatment.—The nature and seat of this disease are imperfectly known; but there can be no doubt, from the symptoms during life, and the appearances found on dissection, that it is probably seated, in the first instance, in the nervous system, and that we have to dread inflammation of the mucous mem- brane of the stomach and bowels. I have often tried local bleeding by re- peated cuppings and leechings on the abdomen and flanks; and I can speak confidently, from experience, of the good effect of this plan. I have always had an unaccountable dread of opening a vein in these cases, perhaps from prejudices of education; but since I have seen the above account of the ap- pearances on dissection, my objections to it are so far removed, that I shall hereafter try it, on proper occasions, cautiously. • Vide Roche and Sanson, vol. i. p. 528. These authors inform us that M. Renauldui had two hundred and seventy-five cases during the years 1821-22-23. 182 ILEUS. The remedies of the first importance, are calomel and opium, given in pills containing four or five grains of each, repeated at short intervals, so as to affect the system as speedily as possible. This remedial means has been strongly recommended by my friend Dr. Musgrave, of the island of Antigua. One of the most severe cases of colica pictonum that ever fell under my care, occurred since the publication of the first edition. The patient was an apothecary's shop-man, aged 32, previous health good, and habits regular. The attack appeared to be owing to bathing the feet several times in a solution of acetate of lead, to suppress a fetid perspiration. In this case the parox- isms of pain were very distressing; the abdomen hard and distended; the features sharp and anxious, with hiccup and vomiting. The pulse did not ex- ceed 80 till after V. S. had been twice repeated, and large doses of calomet and opium administered, when it rose to 110. V. S. produced no relief; to- bacco injections, fomentations, &c. were used in vain. The symptoms, how- ever, became much mitigated after the third large dose of calomel and opium, conjoined with croton oil. He relapsed certainly, but was convalescent on the third day, and recovered progressively. The bowels are extremely torpid in this disease, therefore common remedies must not be depended on; croton oil in doses of two, four, and six drops, must be given repeatedly at proper intervals, still continuing the calomel and opium. Turpentine is to be exhibited, both by the mouth and by injections. Large injections are to be administered; sometimes stimulating, at others unstimu- lating. Hot fomentations are to be applied; counter-irritation, when the disease is on the decline, which is to be for some time persevered in during the convalescence. The nitrate of silver has been strongly recommended in three, five, and six grain doses, in pill three times a-day.* Dr. Percival gave fifteen grains of the sulphate of alum every fourth, fifth, or sixth hour; and he assures us the third dose seldom failed to alleviate the pain.f It is proper to mention, that Dr. Reynolds has the credit of being the first who proved the powerful influence of opium over the morbid action produced in the system by lead. ILEUS. The attack comes on exactly like a common colic; afterwards vomiting takes place, which subsequently becomes incessant; sometimes even feculent matter is discharged by the mouth, and the abdomen is much distended. The symptoms vary much in intensity. Sometimes the pain is severe, amounting to tormina, at others it is slight. In some cases the febrile symptoms run high, in others there is no fever. In this, and even in common colic, the abdomen should be minutely examined with the hand, to ascertain whether or not a hernia exists; for I have seen two or three instances where much valuable time was lost, in consequence of mistaking a case of hernia for colic. * By Dr. Robert, 5th vol. Med. Trans. fVide 2d vol. Ed. Med. Essays. ILEUS. 183 Appearances on dissection, and pathological remarks.—Considerable dilatation of one part of the intestine is generally seen, while the continuous part is con- tracted; the parts above the contracted portion, are frequently distended with fluid and flatus. Sometimes" the intestine is of a livid color, inflamed and even mortified. At other times there are marks of peritoneal inflammation; and on some occasions, gangrene, without peritonitis. In treating of the nature and seat of this disease in the first edition, opinions similar to those of Dr. Abercrombie were advanced, viz. that the disease pro- bably consists of " a paralysis of the muscular coat of a part of the intestinal tube, which leads to great dilatation; while the continuous portion of the bowel is contracted, which produces a temporary obstruction." " But, (it was added,) there is much ambiguity on this subject." Since that period I have thought frequently on the subject, and from an interesting conversation with Dr. Wil- liam Stokes of Dublin, one of the most ardent and accurate pathologists in this country, I have become convinced that Dr. Abercrombie's views are erroneous. In fatal cases of ileus, the bowel has been generally found in two opposite conditions,—one part contracted like a cord, and another part above much di- lated. The point to be determined is, which of these is the primary seat of affection. Dr. Abercrombie thinks it is the dilated portion, and that " the doc- trine of spasm, as applied to this subject, must be admitted to be entirely gratui- tous ; and we must proceed upon facts, not upon hypothesis, if we would endea- vor to throio any light upon this important pathological question."* In the last sentiment I most cordially agree; and as I think the author has substituted hy- pothesis for facts, I shall shortly state several reasons for dissent. 1st, Dr. A. avers, that " the collapsed state of the intestine, in ivhich it as- sumes the form of a cord, appears to be the natural state of healthy intestine." ■*' That in a case of ileus, the distended part is the real seat of the disease; and that the contracted part is not contracted by spasm, but is merely collapsed be- cause it is empty, its muscular action being unimpaired," p. 136. We submit, that the cord-like contraction is not the natural state of intes- tine. If it were the natural condition of parts, it would be always seen on dis- section, when the bowels are unaffected by disease, whereas it is avowedly rare and according to our observations, is only seen when the intestinal tube is in a morbid state. This appears to be satisfactorily proved by Andral, Billard, and others. We have examined the bowels of animals, opened during life, and on no occasion found the tube in the state which is asserted by Dr. Abercrombie to be natural. 2dly, It appears to us that Dr. Abercrombie does not connect ileus with any known pathological state. He considers ileus to be a great and uniform dis- tention of a part of the intestine, with loss of power of its muscular fibres. In short, he supposes the distended intestine to be in the state of paralysis, and that this is the primary disease. He states, also, that the " usual progress of the disease is into inflammation and its consequences," p. 138. * Researches on the bowels, p. 134. 184 ILEUS. Dr. Abercrombie cautiously avoids the term " paralysis;" but it must be ad- mitted, that loss of muscular power proceeds either from paralysis, or inflamma- tion in the part. If paralysis, it is the opposite of the state of irritation, for innervation is abstracted, not added. If inflammation, then Dr. Abercrombie is wrong; but in neither case can he be correct. It will be observed, also, that he does not denominate the cord-like state of the intestine, " contracted," which he ought, but " collapsed," which term he ought not to have employed, because it conveys any thing but a correct notion of the actual state of parts. Sdly, When we speak of a muscular organ such as the intestine, we must admit spasm to be possible, nay, probable; and we cannot therefore admit the doctrine of spasm, as applied to this subject, to be " entirely gratuitous." No one denies the muscularity of the intestines, and that they are capable of con- traction, which implies an increase of innervation. If Dr. Abercrombie's idea were correct, the bladder should never fill, nor the heart, nor the feces pass through the intestine, unless muscular fibre could be stimulated to dilate. But it will be proper to allow Dr. Abercrombie to speak for himself. " If we sup- pose then that a considerable tract of the canal is in a collapsed state, and that a mass of alimentary matter is propelled into it by the contraction of the parts above, the series of actions which will take place, will probably be the follow- ing: When a portion which we shall call No. 1, is propelling its contents into a portion of No. 2, the force exerted must be such, as both to propel these contents, and also to overcome the tonic contraction of No. 2. The portion No. 2, then contracts in its turn, and propels the matter into No. 3; this into No. 4, and so on," p. 136. It will be readily seen, on looking at the parts, that the empty intestine is not in a state of " tonic contraction," as Dr. A. asserts, and that it offers no resistance to the alimentary mass, which is propelled onward by the contraction of the superior portion of intestine. 4thly, If the dilated intestine usually passes into inflammation and gangrene, and its seat be in the muscular coat, its first stage must be one of irritation. The effect of irritation on muscular fibre is, to suddenly and powerfully con- tract it. The parts may become dilated afterwards, but the first effect will be contraction—and the contracted, of course, the diseased portion. It follows then, as a necessary consequence, that if it be spasm, the contracted is the diseased portion; or if, according to Dr. Abercrombie, it be disease of the muscular fibre, still in the first instance the same will occur. Ileus, according to Dr. Abercrombie, is either a paralysis, or an irritation of the muscular fibres of the intestine, usually terminating in inflammation and gangrene. Could any two things be more opposite? If it be a paralysis, it is either general or local. It is not general, because all the symptoms are those of violently increased action, colic, vomiting, spasms of the abdominal muscles. and paroxyisms of tormina! Tormina and loss of power together] If it be local, it is at all events accompanied by increased muscular action-~-spasm. ILEUS. 185 If the primary diseased action be connected with irritation, as we imagine, the first effect will be to contract the parts. Lastly, It may be asked, does the treatment coincide with the doctrine of paralysis, or that of irritation and spasm? After describing the treatment, 1 shall return to consider this important question. Treatment.—The chief attention must be directed to prevent and subdue in- flammation, and to employ every means to move the bowels. For this purpose the milder laxatives, frequently repeated, assisted by tobacco injections, are to be had recourse to. If these fail, then we may entertain the question of bleed- ing, particularly if the case be not far advanced, and if there be pain on pres- sure. Leeches may be applied ; but still we must not lose a moment in en- deavoring to procure a stool. Although we may mitigate the symptoms by bleeding and leeching, yet we may rest assured that relapse will take place in the course of an hour or two, unless the bowels are opened. Dashing cold water upon the belly has sometimes succeeded. When the gut is supposed to be obstructed, mercury in its pure metallic state has been recommended to be poured into the stomach in considerable quantity, in order to force a passage. Once I was present at a dissection, when the obstruction existed at about six inches from the termination of the rectum; and since then I have met with two cases of ileus, which were produced by constriction of long standing of the rectum ; therefore, I think, in all severe cases of this sort, that a long oesopha- gus tube should be introduced into the rectum, and if possible, pushed forward into the sigmoid flexure of the colon. This is one of those diseases in which we frequently succeed in procuring passage from the bowels after bleeding, which had previously resisted the strong- est purgatives; it is also one in which large opiates may be advantageously combined with laxatives. Opium generally acts by confining the bowels; but in the case now before us, it seems to increase rather than diminish the laxative effect of medicines. During recovery it may be adviseable to apply counter- irritation. It has been already asked, if the most improved remedial means coincide with Dr. Abercrombie's hypothesis? Bleeding, tobacco enemata, full doses of opium, and counter-irritants, to cure a disease which is a simple loss of the muscular power of a portion of the intestinal canal ? The circumstances can- not be reconciled upon principles of pathology; neither will they bear the test of common sense. Had it not been for the' deservedly high reputation of the author, I would not have condescended to refute such an hypothesis. Much real injury is done to the advancement of medical science, by the construction of such distorted theories ; and I cannot resist quoting a passage from the pre- face of Dr. Abercrombie's work on the bowels, which bears on the present question. Speaking of the circumstances which have retarded the progress of medicine, he says there are two errors committed—the one is the " construction of hypothetical theories, [»petite is impaired in some cases, while it remains good in others; but the patient will be observ- ed to be worse after a moderately full meal, and occasionally there is nausea. Thirst is a pretty constant companion. The tongue presents various appear- ances, sometimes loaded, the fur being of a yellow color : at others it is loaded in the centre, and redish at the tip; sometimes rough, and often it has the ap- pearance which has been already described in this work, red, raw-looking, and quite smooth as if glazed. After these symptoms have continued from two or three to twelve or fourteen days, the stools are found to consist of whitish mucus, frequently mixed with undigested food, and are almost always passed with considerable straining; the tormina iucrcase ; borborygmus is troublesome; the patient loathes food more and more; nausea is more complained of, and bilious vomiting occasionally takes place; thirst increases, as well as debility and emaciation; hiccup is often very troublesome; and the pulse becomes quicker and quicker, gradually losing its strength, and the skin looks sallow; at last death takes place. In the latter stages, the abdomen sometimes becomes more tumid ; at others, it is flatter than usual. Occasionally acute peritonitis cuts off the patient, from the escape of the contents of the bowels into the ab- domen through an ulcerated opening. Appearances on dissection, xoith pathological re.aar'us.—In this country dys- entery is rarely fatal, unless it attacks individuals who have suffered severely from the same complaint in India. Nevertheless, my museum contains sufficient proof that it is sometimes fata!, and that the post-mortem appearances closely resemble those which are found in tropical climates. I have known several fatal cases in Edinburgh, which ran their course in from nine to twenty days, and in which the colon, the rectum, and part of the ileum, were in a state of complete mortification, the parts having the gangrenous fetor. In other in- stances, the colon and rectum, throughout their whole extent, were thickened and contracted ; the mucous membrane being soft and spongy, and dark colour- ed, looking more like a livid fungous excrescence than an ulcerated surface; DYSENTERY. 225 the colour being retained even after maceration. An opinion has been too pre- valent, that dysentery is always connected with a vitiated state of the bile, or actual disease of the liver itself; but the writings of modern pathologists have dispelled such delusions. Dr. Ballingall, in proceeding to give an account of the appearances found on dissection, in his excellent werk on fever, dysentery, &c, states, that in a great proportion of cases these appearances consist of an inflammation of that part of the intestinal tube situated below the valve of the colon, "without the smallest trace of disease in the structure of the liver." The following are the appearances described by Mr. Marshall, deputy in- spector general of hospitals, in his valuable work entitled, " Notes on the Medical Topography," &c. &c. I have great satisfaction in quoting from this author, because I know his descriptions were drawn from nature when standing at the dissecting table, with the morbid parts before him, and not copied from books :—Upon examining the bodies of Europeans who had died of dysentery, (says he,) the extent of structural derangement discovered is often very great." " Omentum. This organ is sometimes found greatly diminished ; more fre- quently it is found much thickened, interspersed with numerous vessels, turgid with dark-coloured blood, and easily torn. Sometimes it adheres with great firmness to the intestines, occasionally stopping up ulcers. Perhaps it adheres more frequently to the csecum than to any other portion of the intestinal tube. " Intestines.—The folds of the intestines are often found agglutinated to- gether. Sometimes they adhere to the liver, and occasionally to the bladder. The colon appears studded or streaked with dark red or plum-coloured epots. Sometimes the contents of the intestinal tube are found in the cavity of the abdomen, having passed through a gangrenous orifice in the coats. When handled, the large intestines feel thick, heavy, and lumpy ; they are likewise, in many instances, easily torn. " Upon removing the intestines from the body, and slitting them up through the whole extent, a great number of lumbrici are commonly found; but as worms exist so generally in the intestines of Europeans in this country, their appearance cannot be considered as connected with dysentery. The inner surface of the duodenum is found covered with a viscid, glairy, semi-fluid sub- stance, which has sometimes a yellowish, sometimes a greenish colour. To- wards the inferior half of the ileum, small quantities of fecal matter are occa- sionally found, having a bright yellow colour, and some degree of consistence. The contents of this intestine frequently resemble the healthy alvine evacuations of young children. The colour and consistence of the fecal contents of the ileum are suddenly changed immediately upon passing into the caecum. No- thing is ever found in the large intestines but a brownish offensive fluid, similar in appearance to the watery dejections which mark the last stage of dysentery. The intestines were never found to contain either scybalae or fecal accumulation. " The coats of the small intestines are generally healthy ; sometimes they are 29 226 DYSENTERY. redder externally than natural; this redness appears to originate from venous effusion, rather than from an actively excited state of the vascular system. " The mesocolon is frequently found much thickened, and containing a great number of vessels gorged with blood. " The chief traces of disease are found in the large intestines. The villous coat of the ccecum, colon, and rectum, when expanded, sometimes appears dark red, and extremely turgid; the turgescence is occasionally so great, as to resemble the tumid state of the inflamed conjunctiva during a violent degree of purulent ophthalmia. " Sometimes the villous coat appears, at a little distance, to be covered with a blueish puriform fluid, and thickly interspersed with dark grumous spots and patches. When more narrowly examined, the villous coat is found to owe the appearance of being covered with puriform matter to an extravasation of fluids into the substance of it, by which means it acquires a swollen and pulpy appear- ance. The dark red grumous patches are portions of* the villous coat in a gangrenous state. These spots are generally surrounded by a red circle, the areas of which are various ; frequently they are not more than about a third of an inch. Sometimes an individual slough may be compared to a tainted oys- ter. The mortified portion of the villous coat that is situated within the red circle is easily removed from the muscular coat, which is commonly found ap- parently not changed from a state of health. In some instances, the central portion of the slough had disappeared, leaving an excavation in the villous coat, as if a portion of it had been cut out. Even in these cases, the muscular coat was commonly sound. The villous coat was generally unattached at the mar- gin of the excavation, and the finger could often be easily pushed under it from one depression to another. Sometimes, however, the sloughing extended into the muscular- coat, and even into the peritoneal coat, which was rendered evi- dent externally by the mulberry-coloured patches. The dark spots on the peri- toneal coat are always much less extensive than the corresponding gangrenous portions of the mucous membrane. While one part of the large intestines has lost its natural tenacity from gangrene, another has sometimes acquired an in- creased power of resistance, and when cut into, conveys a semi-cartilaoinous feeling to the hand. Sometimes large portions of the villous coat are found sphacelated without any intervening living parts. In these instances, it is exten- sively separated from the muscular coat, and is sometimes found loose in the ca- vity of the intestine. The gangrenous shreds occasionally stretch across the di- ameter of the intestine, like a bow-string. The separated portions of the vil- lous coat are torn by the slightest force. They resemble, in appearance, pieces of dirty lint imbued with the ichorous discharge of a gangrenous ulcer. " Sometimes small collections of purulent matter are found between the villous and the muscular coats. This is, however, not a frequent occurrence. " Occasionally dysentery leaves traces of disease in the large intestines of a different kind, namely, tubercular ulceration. Ulcers of this character are not un- frequently found spread over portions of the villous coat, and, for the most part, DYSENTERY, 227 in a remarkably distinct and uniform manner. That portion of the villous coat which intervenes between the ulcers, has in general, a loose, pulpy ap- pearance. Sometimes it is turgid and reddish. Viewed at a little distance, the inner surface of the intestine appears to be sprinkled with a soft, curdy-like substance. These cream-coloured specks are of various sizes ; sometimes they are not more than a line, at other times they are an inch in diameter. Up- on examining a small speck, the whitish substance is found to protrude a little beyond the surface of the intestine, and adhering, but not very firmly, to the villous coat. After removing this substance, a depression or incipient ulcera- tion is exposed. The base and margin of the indentation are generally dark red. The depression eventually increases, and becomes an ulcer, which is al- ways encircled by a red portion of the villous coat. Sometimes the ulcers re- semble the ill-conditioned sores, with prominent edges, which occasionally oc- cur on the inside of the lips, particularly during a severe course of mercury. In general, the base and edges of the ulcers are indurated, unequal, and scab- rous. When a transverse section is made, a gristly feeling is communicated to the hand. The tubercular appearance of these ulcers is very remarkable. They sometimes resemble warty elevations with excavated apices, in a state, of ulceration. For the most part, ulcers of this kind are oblong : in length, they extend from half an inch to an inch; the breadth is seldom above half the length. The longest diameter is always in a transverse direction to the cavity of the intestine. " Such are the more common traces of disease found upon inspecting the bodies of individuals who have died of dysentery, more particularly among Europeans. Death rarely, if ever, occurs among this class of people before a certain degree of gangrene of the villous coat of the large intestines has taken place. " Abscesses and other morbid states of the liver are occasionally concomi- tants of dysentery. When traces of disease in the liver were discovered on dissection, the circumstance is noted on the table of casualties. The nature of the structural changes of this organ has been already mentioned. Upon ex- aming the bodies of Malays that have died from dysentery, traces of disease of a less active character are discovered. The mesentery and meso-colon are generally found massy and dark-coloured, from turgid blood-vessels and the lymphatic glands greatly enlarged. The coats of the large intestine are thick- ened and firm; frequently the calibre of the intestine is greatly contracted. The villous coat is, in these cases, unequal, puckered, and covered with a gela- tinous muco-purulent substance. Occasionally, however, instances occur where the inner surface of the colon is found sprinkled .with grumous spots in a state of mortification, and sometimes the sloughing portions are extensive." Some years ago dysentery was very prevalent and fatal in Ireland, which af. forded Dr. Cheyne and others the most extensive opportunities of making post- mortem examinations. They had the best proof that the primary and chief seat of the disease was in the mucous membrane of the intestines; the liver was 228 DYSENTERY. sound in a majority of casrs, but often otherwise. In two instances abscesses were found, and in many others great sanguineous congestion. According to Dr. Cheyne, the intestines were variously affected ; in some cases they were prodigiously distended ; the small intestines measuring from seven to nine inches in circumference; in some the coats were much injured without thickening ; in others considerably thickened as well as ulcerated. In some cases the inflammation of the mucous membrane was most extc nsive, extending from the stomach to the rectum ; the inflammation being always greatest towards the large intestines, the rectum being, however, sometimes sound. The morbid appearances discovered in the intestines in fatal cases of dysen- tery in this country, are considerable thickening of the large intestines ; some- times this thickening affects the whole colon and rectum; sometimes it is con fined to the caput caecum and part of the ascending colon, at others it involves also the arch, and even extends further. The peritoneal coat generally remains sound. The seat of the thickening is in the mucous coat and sub-mucous cel- lular tissue, which are infiltrated with blood, spongy with a rough and ragged surface. The colour varies from bright red, to a dark brown. On other occasions the mucous surface is spongy, n-agh, and ragged, with deep ulcerations here and there ; the ulceration running principally in the course of the transverse bands of the colon. The colour is sometimes very little changed, and there is little or no infiltration of blood into any of the tissues. I have likewise seen complete mortification and sloughing of the mucous membrane in two dissections. In these instances, there were large detached portions of the membrane, the sloughing condition being sufficiently well mark- ed by the colour and fetor. The rectum has been implicated in a variety of the cases that have fallen under my observation, but it escapes more frequently in this country than in warm climates. There are some specimens and draw- ings in my museum, from which this description has been taken. Causes.—Dysentery is a disease which attacks individuals of all ages and all classes of society; although those are more liable to it who are most exposed to vicissitudes of climate, and who are badly fed and clothed. Irregular habits also predispose to this disease. In warm climates it is found that Europeans suffer more than natives. Upon inspecting Mr. Marshall's tables, it will be seen that the disease is fatal during every month in the year; therefore it must occur in all kinds of weather. It is more peculiarly a disease of tropical cli- mates ; although we often see it in other situations, yet it is neither so preva- lent nor so fatal. It also seems to depend upon the same exciting causes as fever. Although diseased secretion of bile may occasionally produce both diarrhcea and dysentery, yet these diseases ought not to be so invariably impu- ted to this cause. Treatment.—The method of treatment which is generally found necessary in this country, shall be first shortly stated ; and then that which ought to be adopted in warm climates in the acute and chronic form of the disease. DYSENTERY. 229 1st, Treatment of dysentery as it occurs in this country.—The same plan is to be pursued as in severe cases of diarrhoea. The body is to be warmed in a hot bath ; and as we are anxious to get rid of any offensive matter that may be in the bowels, in the first instance, an ounce or half an ounce of castor-oil i3 to be given, with twenty, thirty, or forty drops of the sedative solution of opium ; but if the stomach be too irritable to bear the castor-oil, calomel with a small quantity opium, is to be given in pills every second, third, or fourth hour, till a feculent evacuation is procured, assisted by a large injection of warm milk and water, or thin gruel; or small doses of salts may be given by the mouth, and repeated at short intervals. It is wrong to suppose, that in all instances of dysentery in this country, there are hardened feces lodged in the bowels ; but as this is sometimes the case, and certainly more frequently than in warm cli- mates, the plan above recommended should in the first instance be adopted. This points out the necessity of a careful examination of the alvine evacuations, which has been already so much insisted upon in other diseases. If, however, a patient have considerable griping and tenesmus, hot skin, and a quick pulse, although it may not be particularly strong, it will be right to bleed him, especially if there be pain on pressure ; and perhaps it will be safest to draw blood before the laxatives are administered. One good bleeding will in general suffice; if there be much subsequent tenderness of abdomen, leeches may be had recourse to. After the diseased action has been thus reduced, and the scybalous matter got rid of, we may have recourse to large opiates by in- jection. It appears to me that the reason why opiates are not attended with more success, is that they are exhibited in too small quantity, and that they do not proportion the dose, in any degree, to the violence of the symptoms. If we suspect the liver to be disordered, small doses of calomel or blue pill may be given, but there is no necessity for greatly affecting the mouth. Counter-irritation to the abdomen is to be had recourse to, and the best me- thod of producing it, is by the frequent application of hot oil of turpentine; but should the disease be very severe, it will be adviseable to apply a blister. The attendants should be particularly cautioned to watch the heat of the ex- tremities, and to apply hot bottles when necessary. In the excellent clinical reports, with which Drs. Stokes and Graves have lately favored the profession, it is stated, that strychnine, in doses of one-twelfth of a grain, given in a pill twice a-day, was found useful in the Meath Hospital. They tried this remedy on the authority of a paper by Dr. Rummel inserted in the June Number (1825) of Hufeland's Journal. On some late occasions this remedy has been tried in my practice, and was found exceedingly benefi- cial, even in cases where there were most extensive ulcerations in the bowels. It succeeded after every other remedy had failed. I have also seen beneficial effects from the acetate of lead, given in two or three-grain doses several times a-day. The sulphate of copper has also been strongly recommended in such cases by Dr. Elliotson; I have given it a trial, and can speak favorably of the result. 230 DYSENTERY. The sufferings of patients are often much aggravated by flatuleut distension of the intestines, which may generally be relieved by turpentine, assafcetida, or tobacco injection. During convalescense, the greatest attention must be paid to diet, clothing, and exercise. 2d, Treatment of the acute disease as it occurs in warm climates.—The only . difference which is to be kept in view between the treatment of the disease as it occurs in this country and in tropical climates, is, that the disease being in the latter more severe, requires more active practice. It is also necessary to impress on the minds of those who are destined to practice in warm countries, that cases are frequently fatal, although the symptoms are apparently mild. That such cases are frequent, any reader may satisfy himself by consulting the works written upon this subject; and it has led some to divide the disease into two varieties. For instance, Mr. Annesley states that there are two varieties, the acute and erythematic. " The first," says he, " is acutely inflamatory, and if not checked by bold and decided practice, will very soon terminate fatally, or lay the foundation of that chronic stage of dysentery which disables so many men. The second is more obscure, and consequently more dangerous. There is dull, deep-seated pain in the bowels, sufficient to distress a patient, but not so severe as 1o excite alarm. There is no external pain, the pulse is not ma- terially altered, neither is there any increased febrile action. This disease," continues he, " is confined to the mucous membrane of the colon, and con- sists of a less acute form of inflammation of this membrane. If not treated successfully, it runs at once into ulceration throughout the whole intestines." These extracts are taken from Mr. Annesley's octavo work, which contains much valuable information. It appears to me, however, that the term erythe- matic is most unhappily chosen, at least in contradistinction to the first variety, as the inflammation in both cases may be said to be erythematic. Great prejudices have prevailed in India, and I fear still exist among the older practitioners, against the employment of general bleeding both in fevers and dysentery; and the action of calomel is too much trusted to in these diseases. Drs. Johnson and Ballingall were among the first who, by example and precept, endeavoured to root out this error, by an appeal to the morbid appearance? which I have already described. In later times, we have received additional tes- timony of the advantage of general bleeding. Mr. Annesley, in detailing the treatment of the acute form, when it occurs in plethoric individuals, recommends general bleeding, and states, that much is to be done in a few hours, and if it be not got under controul in that time, the patient is either lost, or the basis of a broken constitution is laid. But in those who have been long in India, and, I suppose he means, who have shattered constitutions, he says leeches will answer better, because they " diminish action without destroying power; and any quan- tity of blood may be taken by them." I cannot agree with this too sweeping statement; for I am certain, by experiment and careful attention, that individu- als will bear the loss of blood better, ounce for ounce, by general bleeding, than by leeching. The cause of this remarkable circumstance cannot be determined, DYSENTERY. 231 although it appears probable that it may in part be attributed to the long con- tinued unpleasant sensation produced by the biting of the animals, and to the fatigue of the operation; but I am satisfied of the fact. Leeches are certainly to be preferred, however, when the disease is of long standing; they operate be- neficially in many cases, when general blood-letting would no doubt prove in- jurious. Two great advantages which the lancet possesses over leeches, are, that we can stop the bleeding from a vein in a moment, and promptly alter the determination of blood. At page 278 of Mr. Armesley's octavo work, the following passage will be found:—" Full doses of calomel, with such other purgatives as act upon the mucous glands, are required here, and should be continued without intermission till healthy action is produced." To those who have seen the morbid changes produced on the intestines, who know and are acquainted with the dreadful mor- tality which is caused by dysentery among Europeans, and who have seen in- dividuals reduced to premature old age sent to this country on the pension list, will join me in stating, that much injury has been inflicted by the mercurial treatment too generally pursued by medical men in the east; and upon which the passage last quoted affords me an opportunity of commenting. At this mo- ment, I have before me the detail of many cases, which have been corroborated by frequent communications with practitioners who have served in India, of the baneful effects of the practice which seems still to be inculcated by Mr. An- nesley. It is the custom in India to give calomel in large and frequently repeated doses, which is followed by the daily exhibition of drastic purgatives, which are given, to use Mr. Annesley's words, " to act upon the mucous glands, and are to be continued without intermission." Under this treatment, the proportion of deaths is sometimes so great as 20 per cent., and on some occasions, it has been known to be about 30 per cent. Thus, Dr. Ballingall has shewn, that in his Majesty's 59th regiment, during eight months of the year 1806, ninety-seven men were affected with dysentery, of which number twenty-eight died. In his Majesty's 30th regiment, during seven months in 1807, four hundred and ninety- one men were affected with dysentery, of whom eighty-five died. And in the Royals, during eight months in 1808, five hundred and forty-one men were af- fected with the disease, of whom ninety-eight died. I have also some details of the result of the mercurial practice in India, in my possession, which shew the enormous quantities of calomel exhibited in dysentery of late years, with the bad success of the practice. It is no uncommon thing for an individual to take three hundred grains of pure calomel, before he dies under the digestion of it. One individual took the enormous quantity of five hundred and twenty-three grains; another six hundred and ninety-five; a third, seven hundred and sixty; and a fourth, nine hundred and seventy-four, which last is somewhat more than sixteen drams! So far from curing inflammation and ulceration of the mucous membrane of the bowels, I know no plan more likely to produce these states; but it is doubtful, whether the calomel, or the continued use of drastic purga- 232 CHOLERA. tives, is most injurious. The generality of purgatives operate by producing ir- ritation and increased secretion on the whole mucous surface, which is the very circumstance that ought to be carefully avoided. It appears that many practi- tioners act upon the principle of getting rid of the mucous discharge, as if it were lodged in the bowels, acting like a poison; whereas it is to be regarded as the effect of increased action. Let it not be supposed, that I object altogether to the use of calomel; on the contrary, I believe that, combined with opium, its occasional use is most advantageous. My observations are only intended to prevent our trusting entirely to its operation, and to guard against its abuse. I shall conclude, by quoting the result of Dr. Cheyne's experience in the treat- ment of dysentery, with respect to mercury, stated in the Dublin Hospital Re- ports. " Mercury (says he,) could not be depended upon, and did not relieve in numerous instances when the mouth was affected, and sometimes seemed to increase the disease; and even when the symptoms distinctly pointed out a mor- bid organization of the liver, the result of this treatment was unsatisfactory." My own experience in this country, as well as within the tropics, enables me to confirm the above statement. Treatment of chronic dysentery.—It must always be recollected, that no case of dysentery is to be regarded as altogether hopeless. From the recoveries which I have seen made, and from the dissections at which I have been present, of individuals who have been long afflicted with the disease, it may be stated as a fact, that the mucoifs surface heals and becomes restored, if not to its primi- tive healthy state, at least in such a degree as to preserve life for many years. It is rare in chronic dysentery that we shall be called upon to take blood from tne arm, but the occassional application of leeches is most serviceable, together with counter irritation, gentle laxatives, an occasional opiate, and astringent medicines, such as catechu, and solution of sugar of lead, and sulphate of zinc. Great care must be taken of the bowels and the diet, small quantities of light and digestible food are to be allowed at each meal, and the patient should not be permitted to eat oftener of any thing than once in five or six hours. I have been very successful in the treatment of chronic dysentery, by following this plan, together with an occasional warm bath, and long perseverance in the tar- tar-emetic ointment, as well as by the occasional use of mutton suet boiled in milk, which is to be strained immediately after it is taken off the fire ; sugar is then to be added, with a little spice to make it palatable; about four ounces of this are to be taken once or twice a day, mixed with rice,* if the patients sto- mach will bear it. CHOLERA. This term, together with the adjunct morbus, is used, even in common language, to express that a patient is affected with vomiting and purging. I shall first describe the disease which we see in this climate in hot weather, and •This is an old remedy: it is mentioned by Sir John Pringle.—The patient should, in general, be kept ignorant of the nature of the preparation, for fear of exciting disgust. CHOLERA. 233, which is frequently denominated cholera morbus; and afterwards the form which prevails in India. In this country, the disease presents the following phenomena. The first symptoms are, nausea and griping sensations, which, generally speaking, come on suddenly, and soon terminate in vomiting and purging. In very severe cases, the body, and particularly the extremities, become cold, the breathing hurried, the features shrunk, the eyes hollow, with an expression of great anxie- ty in the countenance ;£ causes of the disease; it is perhaps only an effect of the im- peded respi*ati011. It is said that the cardiac portion of the stomach and the lower ead of the oesophagus have always been found inflamed, and attempts have been made to connect the occurrence of the disease with this appear- ance • but were this a cause of tetanus, it would be a disease of very frequent occurred m these latitudes. A similar remark applies equally to worms hav^S been occasionally found in the alimentary canal, but they may pffribly ,ive rise in some constitutions to symptomatic tetanus. Treatment of tetanus.—After a careful review of the cases recorded in the annfJ* of physic, no plan of treatment, hitherto employed, seems to have been ...tended with much benefit. Bleeding, purging, cold and warm bathing, all the most powerful narcotics, and mercury, have each had its warm supporters ; but with little success. The following is the plan which I would adopt in cases of tetanus, including those of locked-jaw, in previously healthy sub- jects. If called early, the strength being good, and the pulse not very rapid, I would bleed from the arm, till the near approach of syncope ; by this means, plethora will be reduced—any determination of blood will be altered—and any tendency to inflammation, if such exist, so far at least subdued. But V. S. ought not to be employed, if the disease had made much progress, or if the pulse were very rapid, the tongue dry, and the strength reduced by the diseased action. In an hour or two after the general bleeding, blood should be abstracted locally in the course of spine, either by applying a con- siderable number of leeches, or by means of cupping-glasses, which ought to be repeated from time to time according to circumstances. The bowels must be kept freely open; but much mischief has been done, and the spasms ren- dered more violent, by the constant exhibition of drastic purgatives. Tobacco enemata have long been used,* and have of late years been again strongly re- * Vide Observations by Mr. Duucan, 11th vol. Ed. Med. and Surg. Jour. p. 198. 444 JWEASES OF THE SPINAL MARROW. commended in this diseu«~ ^y Dr o>R„;rDOj af Dublin. Opium in 5-grain doses *"~w M De exhibited every ad or 3d or 4th hour, according to cinum- •uraces; or what is better still, a hundred drops of lau'W--*,, sixty or seventy of Battley's sedative solution, or half-grain doses 'l°" t- ■ of morphia. From the beneficial effects produced by colchicun ^rism in both of which the nervous system is very muc' ^'^'. .f that medicine might be conjoined with opium. Patic ^r te- tanus appear to bear immense doses of opium; many cases are recorded, in which twenty and thirty grains have bt*n exhibited daily, and persevered in for two or three weeks without causing ai^ apparent bad consequences. Mercury has been much in favour among medical m^ jn tjje treatment of th's disease, and it has been asserted that those patients have recovered in whom salivation had been excited; but there is a great deception likelv to arise from this statement. It is difficult to excite this action in violent diseases which run on rapidly to the destruction of life; the very s^ere cases run through their course in too short a period of time to allow the mev.urv to act therefore it can only be in the slighter varieties of the disease, in which the action of the remedy can take place, and which might be cured bv oth means. The remedy, however, has been too strongly recommended to be passeiover. A large blister should be applied to the spine. As to %0\ft and warmbathing, it may be shortly stated, that I have no faith in either, a*. the least motion will very generally produce a paroxysm. The strength must 1* carefully watched, and nourishment, with or without a little wine, should be given at short intervals, long before there is any decided appearance ol ^nk. ing. When the stage of collapse approaches, stimulants must be had k course to, and there can be no doubt that their judicious exhibition has occa- sionally saved lives. Among other remedies which have been recommended, I may mention assafetida, musk, camphor, valerian, bark, sudorifics, ammonia, carbonate of soda, &c. TRISMUS NASCENTIUM. I have now to say a few words respecting the locked-jaw of infants. It is a disease seldom seen in this country, and is more peculiarly an affection of negro children in warm climates; attacking them between the 7th and 15th dav after birth, seldom later than the 17th, and, in general, neither preceded nor accompanied by any febrile movement. The disease steals on in the fol- lowing manner. Children lose flesh and strength, and are affected with drowsiness and frequent yawning; they suck with increasing difficulty, and at last are unable either to suck the breast or to swallow ; the skin gradually puts on a yellow appearance; by and by the jaw is observed to become stiff, its muscles rigid; general convulsions sometimes precede death, which often happens in two or three days from the first attack. The true pathology of this affection has evaded the efforts of all inquirers. It has been attributed to irritation, produced by tying the naval-cord, to the HYDROPHOBIA. 445 irritable state of the umbilicus upon the separation of the cord at the natural period; while others maintain, that it is owing to some diseased state, or re- tention, of the meconium. No treatment hitherto tried appears to have had much effect in controuling the disease after it is fairly established ; but that which has been, found most beneficial, is the application of turpentine to the naval. If the child survive the ninth day without the occurrence of any symptoms of the disease, it is considered safe. At one time, in some of the West India Islands, this disease was so common and so fatal, that on an average, two out of three infants perished. HYDROPHOBIA. This is a disease happily of rare occurrence, particularly in this country ; and as already mentioned, it is probable it is still of rarer occurrence than is generally imagined, being frequently confounded with tetanus, when,.along with that disease, there & a dread of liquids; but there can be no doubt that such an affection does exist. I once saw a patient many years ago, but before T *vas abb? to judge of such matters for myself, who was said to be affected with hydrophobia ; it terminated fatally, but I have never met with a medical man who could say he had seen even one case in this country. Hydrophobia is produced by a morbid poison generated in the dog, wtlf, fox, and occasionally, although rarely, in the cat. The poison appears to be mix- ed with the saliva; and the characteristic of the disease produced, is a dread of liquids. That such a disease does exist, and that it is capable of being communicated from one animal to another, has been satisfactorily proved by experiments performed in the year 1813, by Magendie and Breschet. The saliva of a man affected with hydrophobia, was collected and inserted beneath the skin of two dogs, which were at the time in excellent health, and in thirty-eight days one of the two dogs became rabid, and bit two others, one of which died in a month after of the same disease. Experience has proved, that all the animals bitten are not necessarily affected with hydrophobia. Of this fact, Mr. Hunter gives a striking example. Twenty persons were bitten by one rabid animal, of whom only one suffered. It is generally admitted, that the state of the mind has a powerful influence in the production of dis- ease ; and it is probable, that hydrophobia may be sometimes produced by the constant agitation into which timid nervous persons are thrown after having been bit. Some allege, that the virus may remain dormant in the system for years before the disease appears; but the general opinion is, that it shews itself in between twenty and sixty days from the occurrence of the accident. During this period there is no constitutional derangement, unless the individual is depressed by fear. Symptoms of hydrophobia.—The disease is ushered in by rigors, languor, las- situde, severe mental depression, irritability, anxiety, restlessness, and watchful- ness. Occasionally a shooting pain is felt in the neighbourhood of the injured 446 DISEASES OF THE SPINAL MARROW. part. As the disease advances, the anxiety of the countenance, the irritability and watchfulness, the oppression at the praecordia, the sense of contraction of the chest, increase; slight tremors affecting every part of the body appear, and difficult deglutition; a considerable quantity of viscid phlegm is observed in the mouth and fauces ; stiffness in the jaws now and then takes place ; as also general spasmodic paroxysms, resembling those in tetanus, but it is asserted, that on careful examination, the convulsions will be found to be of the clonic kind. In pure hydrophobia^ the body is said to be affected more with tre mors then convulsions. At length the water-dread increases so much, that the sight of any thing liquid, or merely an allusion to it, produces a paroxysm of tremors, at the time too when the thirst is very urgent. On some occasions, the dread only takes place when the patient attempts to drink. As the dis- ease goes on advancing, the least noise or motion made by any of the attend- ants produces a paroxysm, as well as every effort on the part of the patient either to move or speak. He manifests increasing terror and watchfulness. As in tetanus, the mind generally remains entire till towards the termination of the disease. The thirst and sense of constriction increase in urgency : respi- ration becomes painfully hurried and short; the pulse and heat of the skin au generally about the natural standard; but the former increases in frequency, while the latter sinks towards the fatal termination, and the surface is covered with a clammy sweat. Debility, in the proper sense of the term, is scarcely ever present till toward the last stage, when the eye becomes hollow, and the countenance pale and haggard. The duration of the disease in slight cases is about a week, but in those of a more violent nature, two or three days. Mr. Marshall informs me, that the last case of this disease which came under his notice, died in twenty-two hours from the occurrence of the first suspected symptom. Two hours before death, his patient eat bread and jelly with an appetite. Another case, which Mr. Marshall attended, terminated fatally in a shorter period. Appearances on dissection in hydrophobia.—A great many discordant state- ments will be found in different works, respecting the seat of the disease. Some pathologists, after the most careful examination, have not been able to discover any morbid appearance whatever, in any part of the body; while others have seen vascularity in the pharynx, oesophagus, the cardiac extremi- ty of the stomach, and even in portions of the intestinal tube, particularly the ileum ; and these parts have been even in a gangrenous condition. Magen- die found no diseased appearance in the brain. Professor Trolliet of Lyons, published a work on this subject in the year 1820." He seems to have had ample experience in the treatment of this dreadful malady ; and the following are the diseased appearances which he discovered on dissection in different cases. Vascularity and inflammation of the mucous membranes of the air passages, which was coated over with a frothy matter, (according to his view,) * Nouveau Traite" de la Rage. HYDROPHOBIA. 447 of a peculiar kind, and which he supposes, to contain the spicific virus; the ungs were gorged, and apparantly emphysematous; in some instances air was discovered in the heart, and large blood-vessels; the blood was black, uncoag- ulated, and had an oily appearance. This gentleman found the membranes of.the brain, and more especially the pia mater, very vascular. One fact has been established by all the individuals who have investigated this disease,—that the salivary glands, and the surrounding cellular substance, have always been found healthy. Treatment of hydrophobia.—Bleeding even to syncope, and large doses oi opium, have been employed, together with camphor, musk, mercury, and al- most every other potent remedy in the materia medica, and without success. To shew the extent to which bleeding has been carried, I may mention a case treated by Professor Trolliet. The patient was bled to the extent of five pounds, when the water-dread first appeared. In a few hours afterwards, the operation was repeated to the extent of eighteen ounces, when syncope again took place. In four hours subsequently to the last bleeding, fourteen ounces were abstracted; and in four hours after that, the patient died; being twelve hours from the commencement of hydrophobia. It was remarked, that the symptoms became more aggravated after each bleeding. Notwithstanding the result of this and other cases, I would still be disposed to recommend a similar plan of treatment to that I have proposed in tetanus at page 443. The injection of tepid water into the veins has been practiced without suc- cess. But from the experience we have had of the safety of throwing even ten pounds of saline fluid at a time into the vascular system in cases of epi- demic cholera, there is little doubt that the practice in hydrophobia will be conducted with greater boldness, and probably will be attended with better effects. CHAP. IV. EPILEPSY—HYSTERIA—CHOREA: NEURALGIC PAINS. EPILEPSY. This is a convulsive disease which effects the voluntary muscles, and is characterized by the suddenness of the attack, loss of sense and voluntary mo- tion. Symptoms of epilepsy.—The fit generally comes on suddenly, sometimes with a frightful shriek, and the patient falls down, and immediately loses sense and voluntary motion; convulsions follow on the instant; the muscles on one side of the body are generally more violently affected than those on the other; all the muscles connected with respiration, and those of the face, are always involved. The pupils are sometimes dilated; the eyes roll about in a most frightful manner, and at last become fixed. The face is frequently of a dark purple colour, but occasionally it is pale and haggard. The tongue is some- times thrust with violence out of the mouth ; it is occasionally caught between the teeth, and severely bitten; a considerable quantity of phlegm is collected in the mouth, and expelled with violence in a frothy state, with considerable noise. The respiration is always hurried and laborious, which is often pro- duced or increased, by patients breathing through the clenched teeth, and the frothy saliva. The pulse varies much, in some cases it is very rapid, in others preternaturally slow. The affected muscles are not constantly rigid, but occasionally become relaxed, and then rigid again; this is the state termed by nosologists " clonic spasms." The duration of the attack varies from a few minutes to half an hour; the convulsions cease; the face becomes pale; and the patient may recover his senses, and power of voluntary motion, either im- mediately, or very slowly; his judgment is, in general, for a time impaired, and he is left debilitated, with the feeling of weight in the head, or actual headache. The paroxysm sometimes terminates by violent vomiting. Oc- casionally it happens that one fit succeeds another, till the patient becomes comatose, and dies; but comparatively, few die during a fit, unless the dis- ease has existed for a considerable period of time. An epileptic paroxysm is occasionally preceded by a peculiar and painful sensation in a distant oart of the body, as in the fingers, toes, or some part EPILEPSY. 449 of the abdomen, and is described as proceeding in a gradual manner, like something creeping towards the heart, in other cases towards the head, when the convulsions commence. This is called the aura epileptica. The attack is also occasionally preceeded by certain symptoms which announce its approach to the patient, but which he has usually no time to communicate ; these are headache, imperfect or erroneous vision, sparks of fire before the eyes, and tinnitus aurium. Females appear to me to be more liable to this disease than males; and it is not entirely confined to man. I have seen it in horses,—in dogs, particu- larly of the Newfoundland breed,—in poultry and pigeons. Causes of epilepsy.—Epilepsy appears to be occasionally hereditary. I have known it to be the cause of death in both father and son ; but it is more frequently an acquired disease. Idiots are often also epileptics; and insanity frequently terminates iu epilepsy. Fright is said to be a cause; and every kind of mental agitation. Thus, it was formerly called the electioneering disease in England, because it so often occurred at such periods from violent mental excitement, aided, however, by another cause, the abuse of intoxica- ting liquors. Indigestible articles of food and constipation, by occasioning irritation in the stomach and bowels; the irritation produced by worms in the intestinal tubes, are also very frequent causes; as is likewise excessive venereal indulgence. This complaint has been attributed to tumors in the brain, and projections of bone arising from the inner table of the skull. Appearances on dissection in epilepsy.—A great variety of organic lesions have been discovered in the brain and spinal marrow of epileptics. Conges- tion of the vessels of the brain; thickenings and indurations of the mem- branes ; inflammations; exostoses: tubercles and tumours of different kinds, and in different parts of the brain—sometimes situated externally to the membranes; at others, occupying the very centre of the cerebral mass. Some assert, that these disorganizations are exclusively confined to the cerebellum; others to the spinal marrow; but these are to be regarded only as assertions made by individuals, whose observations have been made upon a limited scale. It must be observed, that any one of these morbid appearances may exist, and even several of them combined, without producing that combination of symptoms which constitutes the disease under consideration; and further, that in some instances, upon the most careful examination, no morbid appearance whatever has been discovered, either in the brain or spinal marrow. Worms have frequently been found in the intestines; and this has led several pathologists to assert, that their presence is the sole cause of epilepsy ; but in a great number of instances, not a vestige of these animals could be discover- ed, or any lesion in any part of the body. So that, notwithstanding all the attention which has been paid to the investigation of the nature and seat of this disease, we are left very much in the dark. Epilepsy appears to be a functional disease of the brain and nervous sys- tem, produced by a variety of causes, sometimes by mental emotions; at 57 450 EPILEPSY. others, by various irritations affecting the digestive organs; and very fre- quently by some of the above mentioned organic lesions of the brain and spinal marrow. Treatment of epilepsy.—Experience has convinced me, that much can be done for epleptics in preventing attacks; but almost every thing must be done by the patient himself in the intervals. I have seen little benefit from any mode of treatment during the paroxysm, except by placing the sufferer in the horizontal posture, and taking such precautions as will prevent him from being injured by the violence of the muscular commotion into which the body is thrown. One of the first circumstances to be attended to, is to put something between the teeth to prevent injury to the tongue, and the gar- ments must be loosened, particularly stays and neck-cloths; and it is often very serviceable to sprinkle the face with cold water, particularly when the convulsions are confined to the muscles connected with respiration. After the paroxysm is over, the patient should be kept quiet; the heat of the body supported, the bowels opened as speedily as possible, and light nour- ishing food in moderate quantity allowed. At no time should a patient load the stomach. The abuse of stimulants is to be abstained from, and every cause, corporeal as well as mental, which can possibly have the effect of dis- turbing the balance of the circulation, or exciting the nervous system. If there be marks of diseased action in the brain, the treatment must be more rigid; occasional cupping may be had recourse to, and if there be considera- ble plethora, a bleeding from the arm may be serviceable, together with keep- ing the head shaved, and the introduction of a seton in the neck, or a drain is to be made by means of an issue applied to any other part of the body. If worms be suspected, turpentine and other anthelmintics should be ex- hibited. With respect to blood-letting, I have often seen it had recourse to, both during the paroxysm and in the intervals. It certainly has been sometimes ser- viceable in plethoric subjects; but, in general, it does not appear to have any beneficial effect, and occasionally has been injurious; therefore it is a remedy which ought to be used with great discretion. It has been mentioned, that irritation in the stomach and bowels is a fre- quent cause of epileptic paroxysms. Some individuals seem to be born with very irritable mucous membranes; and I have seen several epileptics so con- stituted, that the irritation produced by a laxative medicine, or diarrhcea coming on without any assignable cause occasioned a recurrence of epilepsy. A ladv affected in this manner with epilepsy, was recommended by one of the most learned physicians of the present day, to use dram doses of the pow- der of misletoe, which she persevered in without any apparent benefit for some months; at last happening to be passing through a country town, and being in want of a supply, an apothecary sent by mistake dram doses of pow- dered oak-bark, which proved of more service than any other remedy she had HYSTERIA. 451 previously taken. The only inconvenience experienced, was the subsequent difficulty of getting the bowels opened without producing irritation. Since this case presented itself to my notice, I have used astringents several times in similar instances with apparent benefit. The ammoniuret of copper has been much lauded in the treatment of epi- lepsy, as also the nitrate of silver. The latter remedy has been pushed to an extent, which would almost surpass belief were the facts not well authenti- cated. It has been given to the extent of from one to eight grains a day, for weeks, without producing any effect, except slight griping pains, which ceased when the preparation was conjoined with opium. I have seen only two cases in which the remedy had any beneficial effects; and it is remarka- ble that they had been under the care of the late Dr. Baillie; the skin of both was changed from the natural colour to that of indigo, but they were cured of the disease. Several patients have been under my care, who were able to prevent an epileptic paroxysm if they had time to apply a ligature tightly round the arm, the moment the aura epileptica was felt in the hand. This is a curious cir- cumstance ; but I can testify to the truth of it. One of these patients was found dead, having, it is supposed, died in the paroxysm ; one end of a cord was in his mouth, and the other in the hand, shewing that he had been at- tempting to apply it round the affected arm. The only disease with which epilepsy is likely to be confounded, is hysteria; but it is a matter of very little consequence in actual practice; it being the slightest cases of epilepsy about which there can be any doubt, when the remedies applicable to the one disease, are exactly those which should be employed in the other. Catalepsy is a form of epilepsy which ought here to be mentioned. There are generally no convulsions, the patient remains for a shorter or a longer time insensible, deprived of the power of voluntary motion, remaining in the po- sition in which the body happens to be placed at the moment of attack; or if an extremity be moved into a particular position by an attendant, there it remains. This form occasionally runs into the true epilepsy with convulsions. It is, however, a disease of very rare occurrence.* HYSTERIA. Hysteria is another disease of the nervous system, the nature and seat of which have not in any degree been explained. It is a disease almost exclu- sively affecting females; but males are not entirely exempt. I have myself seen several well marked instances in gentlemen, apparently of very different constitutions and habits; but the attacks came on in all of them under the influence of depressing passions. * An excellent article on Epilepsy by M. Esquirol will be found in the "Diet, des Se. Med. ,• but the most profound work on this subject, is that published by the Baron Por- te), entitled, " Observations sur la Nature et la Traitement de VEpilepsie." 452 HYSTERIA. Phenomena of hysteria.—The invasion of hysteria is sudden and irregular, sometimes periodical. In the slighter forms, the patient, without any as- signable cause, bursts into a fit of weeping, which perhaps is soon followed by convulsive laughing, which may last for a few minutes; and before com- posure takes place, the patient gives several loud sobs. One of these fits may quickly succeed another, till the patient falls asleep. In more severe in- stances, complaint is made at first of pain in the abdomen or chest; a sensa- tion is felt as if something were in motion in the abdomen, owing probably to flatus ; it moves upwards, producing in the epigastrium a sensation of tight- ness and of suffocation ; and a feeling is experienced as if a ball were ascend- ing to the throat. The belly is tense ; the surface is generally cold ; the ex tremities exceedingly so. The contenance varies; sometimes it is red and swollen ; or pale, and the features contracted; the pulse is also very variable; and in some cases, palpitations are violent and troublesome. In the more severe instances of hysteria, there are symptoms shewing the existence of affections of the head and spinal marrow, indicated by spasmodic, and even convulsive affections of different muscles, particularly of the hands, face, jaws, and those connected with respiration; they are of the clonic kind. The pupils are dilated; and occasionally the paroxysm has a very dose re- semblance to epilepsy, only that the insensibility is rarely complete, unless the attack be combined with syncope. Occasionally there is retention of urine, but for the most part, there is a copious limpid discharge, in either case at- tended by symptoms of ischuria. Sometimes the disease commences with shrieking, which may continue from time to time during the whole paroxysm, and often terminates in hiccup of the most violent description. In some cases, dyspncea is a very urgent symptom. Dyspeptic symptoms often pre- cede the attack; and the bowels will, in general, be found in a very bad con- dition, with a tympanitic state of abdomen. Some diseases of a very aggravated nature seem to be ushered in with violent hysterical symptoms, and require a very experienced eye to form a correct diagnosis. In many cases, however, the symptoms of hysteria do not take place till the patient is recovering. When the practitioner is in doubt as to whether any severe organic affection is going on, thus obscured, the patient should be seen at short intervals ; and the treatment cautiously con- ducted in such a manner as to remedy and not aggravate the more severe malady if it exist. Causes of Hysteria.—It is rare to meet with this disease before the age of puberty, or after the period of life when menstruation finally ceases; in most instances, women are attacked during the time of menstruation; therefore many have attributed the disease to the uterus. Girls of high passions, and those who have been over-indulged when children, are most liable to hyste- ria ; as also those who become impressed with strong religious feelings, un- accompanied by a sufficient share of common sense to guide them. Women CHOREA.- 453 when pregnant, and those who labour under the disorders of menstruation, seem strongly predisposed to hysteria. It appears to affect women of all con- stitutions,—that is to say, those who are robust and plethoric, as well as the pale, weak, and emaciated. Some attribute hysteria to the bowels; and there are not a few who consider it as a disease of the nervous system, Emotions of the mind, together with irregularity of bowels, seem to be the chief causes. My own opinion is, that it is a complicated disease, and tha* the supporters of these different pathological views are all partially correct. Treatment of hysteria.—This is difficult at all times, and a radical cure in many cases almost impossible, unless we had the power of changing the temper, altering the disposition, subduing the passions, and relieving the mental distresses, of the fair sufferers. It is of great consequence, however, to attend to the bowels, and to improve the powers of digestion. The diet should be light and nourishing; cold should be avoided, and particularly cold feet; exercise in the open air should be advised; and the patient's mind should be gradually strengthened, by being directed to healthful and inte- resting pursuits; and much is to be done by a proper intermixture of innocent and rational amusement. During a paroxysm, the stays and all tight strings should be loosened, plenty of air admitted into the apartment, and sixty drops of the spiritous ammonia aromaticus, or the same quantity of volatile tincture of valerian, may be given in a wine-glass full of water. If the bowels are distended by flatus, laxative medicines will do much to produce its expulsion; these may be assisted by injections, containing a dram of the tincture of assafoetida, or a table-spoonful of the spirit of turpentine. Opiates are in many cases serviceable after the bowels have been fully opened. Bleeding has been strongly recommended, and is oft^n had recourse to in this disease; but in pure hysteria, it is scarcely ever justifiable. Bitters, and more particu- larly the sulphate of quinine, will be found very serviceable in restoring the functions of the stomach and bowels. Should the disease be found to depend on any of the disorders of menstruation, the case must be managed accord- ingly, as will be pointed out in a subsequent part of this volume. CHOREA. This is a disease of the nervous system, characterized by sudden involun- tary motions of various muscles of the body, without being necessarily con- nected with f«ver, or any severe constitutional derangement. The appetite is generally unimpaired, and all the functions natural, except that, in many cases, the bowels are observed to be unusually tardy. But after the disease has continued for some time, the general health becomes impaired, and the functions of both mind and body are at last undermined. It most frequently appears between the age of eight and fourteen, but has been known to occur late. an(j severai instances have fallen within my observation, where the disease ^tacked individuals after the age of twenty-one, and in two cases 454 CHOREA. between thirty and forty. The later in life the disease appears it is generally found to be comparatively more slow in its progress, and difficult to cure. Generally speaking, convulsive movements, or rather twitches, of the fingers and muscles of the face are first observed. The convulsive movements become in time more decided; strange contortions of the features take place; the disease extends to the voluntary muscles of all parts of the body, and frequently those of the lower extremities are so continuously excited, that the patient appears to be dancing. His walk is very unsteady, and he is most affected when he wishes most anxiously to control his actions. Another curious circumstance is worthy of being mentioned, that however violent the convulsive motions may be, they cease the moment the patient falls asleep, unless in severe cases of long standing. Articulation and deglutition are frequently difficult, more particularly the former. In young subjects, a more acute form of the disease is occasionally met with. The intellectual faculties are more impaired; the general health sooner gives way; the stomach and bowels appear much deranged, as is indicated by hardness, sometimes unusual softness, and swelling of the belly, together with constipation ; the stools have a very offensive smell; and there are sometimes evidences of the existence of the disease denominated tabes mesenterica. Causes of chorea.—The causes of chorea are very imperfectly known. The opinion broached by Dr. Hamilton senior, that chorea depends on a collection of feculent matter in the bowels, is so decidedly erroneous, that I need not say a word upon the subject. It attacks people of both sexes, more particularly children who are scantily fed, imperfectly clothed, and prevented from taking a proper degree of exercise in the open air. There can be little doubt, that those of an irritable nervous frame are peculiarly the subjects of chorea, and it has some resemblance both to hysteria and epilepsy. Treatment of chorea.—This should consist in keeping the bowels regularly open, by means of mild but frequently repeated laxative medicines, never allowing a day to pass without producing at least two alvine evacuations. The diet should be light and nourishing ; every indigestible substance shonu be carefully avoided. All means should be had recourse to, which w-:i1 im" prove digestion if it be impaired, and restore the general health. in the two instances which I have met with above the age of thirty, the functions of the stomach and bowels were much impaired. But superadded to these, the chief existing cause in these cases, was the abuse of ardent spirits. The occasional application of leeches to the head when pain i« complained of, and the administration of a narcotic when there is much nervous excitement, will be found serviceable. Good effects sometimes follow the use of warm, at others that of the cold bath. The oxide of zinc, castor, and many other tonics and anti-spasmodics, have been at various times in high repute. NEURALGIC PAINS. 455 NEURALGIC PAINS. Those neuralgic pains of which I am now to treat, are not produced by any appreciable organic lesion ; they occur in every part of the body, and often return periodically. The disease is most frequently partial, sometimes, though rarely, it is general, and is not necessarily attended by fever. The tic doloureux is a striking example of this affection; it is generally classed as a surgical disease, but is more frequently relieved by medical, than by surgical treatment. The bladder, the stomach and bowels, and, it would appear, the heart also, are liable to be affected with neuralgia. The most troublesome and most frequent forms of the disease which I have met with in practice, are those abdominal pains which affect women, more particularly at the menstrual periods, which shoot down the thighs. They sometimes appear to begin in the back, and extend towards the abdomen, in which case the bowels are generally found obstinately constipated. The discharges by stool consist either of very hardened feces, or of gelatinous matter, resembling half-digested worms ; at other times, they have a frothy yeasty appearance. Affections of the bladder frequently supervene, particularly if the attack come on during the menstrual period. This affection is of a different nature from that which is called dysmenorrhoea. In this disease the menstruation may be copious, of a natural appearance, and not attended with pain. Causes of neuralgic pains.—Frequently unknown, and for the most part obscure. They may be occasionally traced to disorder in the organs connected with digestion ; and in some instances may probably be connected with dis- ease in the spinal marrow, or in the nerves themselves. Treatment of neuralgic pains.—In tic doloureux, I Ijave seen the knife used very often, and but seldom with permanent advantage. If the pain have left the part affected, it has attacked another nerve in the vicinity,—a strong proof that the disease is generally more deeply rooted in the system than is commonly imagined. In the treatment of neuralgic affections, proper regu- lation of the bowels, diet, and habits of the patient, and avoiding exposure in cold damp weather, are all points of the utmost importance. Almost all tonic and narcotic remedies have been successively in great repute; thus we find that the bark, iron, zinc, and other tonics, as also opium, musk, cicuta, hyosciamus, belladonna, and stramonium, have each had their advocates. If the pain be periodical, the use of large doses of quinine will sometimes be found beneficial. Many severe and long-standing cases have been much benefited by dram doses of the precipitated carbonate of iron; but to subdue a paroxysm of pain, and produce a long interval of ease, I know no remedy so immediately serviceable, whether the neuralgia be partial or general, as the sedative solution of opium, given in small quantities (15 or 20 drops,) by injection, or the acetate of morphia, in doses of l-4th of a grain every 3d or 4th hoMr. Several very bad cases of general neuralgia have fallen under my observation, and these remedies were found beneficial after all others had failed. One cas«>, in particular, may be mentioned: A gentleman who had 456 NEURALYIC PAINS. been frequently liable to partial attacks, was seized with general neuralgia during the period when he was preparing for graduation. His general health became much impaired; and not being acquainted with any medical man iu particular, he sent for one of the gentlemen whose lectures he was attending at the time, but who offended him very grossly, by discrediting the account of his sufferings, and by terming his complaint "a graduation sickness." After a lapse of a month or six weeks, I was requested by a family who were interested in his welfare to visit him. He was much emaciated, bad a pale and haggard countenance, and was almost worn out by pain and want of rest. The disease was general, but the part most severely affected was the neck, where the pain was so much aggravated by the slightest touch, that he was obliged to sit with his neck and shoulders bare. He had almost abandoned the intention of graduating. After putting his bowels into proper order, I gave him, while suffering a very severe paroxysm of pain, a dose of the sedative solution of opium ; and in less than ten minutes he felt more relief than he had experienced for several months; and by repeating the dose a few times upon the threatening of a paroxysm, he got rid of the disease, his health and strength soon recovered, he renewed his studies, and passed his examinations with considerable eclat. In the affection to which I have alluded, as occurring in women, I have seen considerable benefit from the occasional use of a draught composed of turpentine, with an equal part of castor oil, and conjoined with twenty or thirty drops of the sedative solution. One of the most potent measures, after the diet has been regulated, and the bowels have been put into good order, is to produce,, from time to time, an eruption on the abdomen or loins, by means of antimony oitment. In an obstinate case which lately occurred, much relief followed the use of strychnia, in doses of one-twelfth of a grain, repeated four times a day, till it produced imperfect vision, with some degree of headache ; it was then intermitted for a few days, and when resumed, was given only twice a day. Some practitioners speak highly of cold bathing, while others do the same of warm ; but I cannot say that I have seen either of them beneficial. Routine practitioners are too much in the habit of bleeding when- ever the pain is severe, and of giving calomel or blue pill when the pain is refer red to the right hypochondriac region. I have been consulted by individuals whose constitutions were injured by the frequent repetition of powerful reme- dies, and by some who never can regain the loss of blood, or recover from com- plaints thereby produced, and the too frequent use of mercurial preparations. About the year 1812, Mr. William Wood of Edinburgh, called the attention of the profession to a neuralgic affection which was denominated "Painful sub-cutaneous tubercle," and has lately published further observations and cases in the 3d vol. of the Transactions of the Medico-Chirurgical Society. But as this is avowedly connected with an enlargement of the affected nen«*> requiring surgical, rather than medical aid, I will conclude by recommend- ing the perusal of Mr. Wood's learned and interesting essay. CHAP. V. APOPLEXY—PARALYSIS. APOPLEXY. Apoplexy is generally characterized by loss of sense and voluntary motion, the patient continuing comatose for a shorter or a longer period. It is sometimes attended with convulsions, and frequently followed by paralysis of some part of the body. Phenomena of apoplexy.—To detail the varieties of apoplexy, with a view to make minute symptomatical distinctions, would be an endless and really an unprofitable task ; as practical men are well aware, that at the commence- ment of the attack, experience does not enable them to tell whether the case is to be slight, terminating in recovery, or fatal. This is well exemplified, by observing the termination of those cases in which the loss of sense and re- collection exist only for a few minutes, and in which the recovery appears as complete as it is sudden; yet perhaps in a few hours afterwards coma takes place and death soon follows. In my lectures I usually divide apoplexy into two varieties: 1. That in which no lesion of the brain has taken place, and after death no morbid appearances can be discovered ; this has been called simple apoplexy. 2. That in which serous effusion, or extravasation of blood, is found upon dissection, and which has been termed extravascular apoplexy. Although this plan is open to many objections, yet I am disposed to adhere to it for the present. Apoplexy very rarely comes on without precursory symptoms, which, how- ever, are sometimes so slight as to be disregarded. These are vertigo—head- ache—a sense of pressure applied to the head, and fulness, or a feeling as if the head were a great deal larger than natural—irritability of stomach- singing in the ears—occasionally impaired vision, double vision—some degree of deafness—impaired powers of articulation—weakness of memory and judg- ment, sometimes slight incoherency—restlessness or lethargy—startings, and a weakness of the limbs, which gives to the patient a staggering gait as if he were inebriated; these symptoms may take place with or without rigors. 58 45S APOPLEXY. Should an individual complain of several of these symptoms at any period of life, he may be regarded as on the very brink of a serious affection of the brain. If they occur in a person of a full habit with a short neck, the danger will be still greater ; and if in the decline of life, it might be safely said that he is in immediate danger of an attack of apoplexy, although by care and good treatment the disease may be warded off for an indefinite period. The form of the disease which I shall venture to term the slightest, is that in which the loss of sense and voluntary motion are very transient. It con- tinues for a few minutes only, and leaves perhaps a slight paralytic affection of the muscles of the mouth; the patient is commonly thought by the attend- ants to have been only in a feint, from which he quickly recovered. The variety which may be called the most severe, is that in which the patient has for some time complained of some of the premonitory symptoms already no- ticed, is suddenly seized with loss of sense and voluntary motion, accompanied perhaps by convulsions, the respirations being stertorous, the pulse weak and frequent, and the patient never recovering from the state of coma. In prac- tice, we meet with every variety betwen these two extremes. During an attack, the limbs are generally flaccid, although occasionally some of the muscles may be found rigidly contracted; and in other cases, as has been already mentioned, general convulsions take place. The face is red, sometimes of a very dark colour; but occasionally it is pale and ghastly; the features are swollen, and the mouth perhaps drawn to one side. The respiration is sometimes stertorous, at others, not in the least so. Pupils are occasionally dilated ; sometimes contracted, but almost always immoveable. The pulse is sometimes full and slow, not exceeding thirty beats in the minute; at other times it is weak, easily compressed, and quick, beating per- hap, one hundred and fifty in a minute. In those instances in which death does not take place, and no organic lesion is produced, the patient soon recovers some degree of sensibility, and the power of muscular motion, when it may be discovered that one half of the body is paralyzed; the pulse, if previously slow, now rises to the natural standard; he then recovers his senses, perhaps very quickly, and looks about him with an expression of surprise; he also gradually recovers his speech, although he may have difficulty in articulating. In some hours, these symp- toms will be found much diminished; he will gradually recover the power of his limbs, and in ten or twelve days, although weak, he may be pronounced to be nearly well. Instead, however, of recovering sense and voluntary mo- tion immediately, patients sometimes continue comatose for some hours, and then recover more or less quickly in the manner already stated, being how ever at times lethargic for several days. In other cases, the patients remain much longer comatose, and recover much more slowly, with some degree of loss of memory and of speech, which may be temporary or permanent, together with paralysis of one half of the body, or APOPLEXY. 459 only of one limb, the use of which may be either never or partially restored. I have seen several cases in which both mind and body were permanently reduced to a state of childhood. In other cases, patients remain for months in a lethargic, paralytic state, from the time of the attack till death takes place, without the least appear- ance of amendment. The period between the first appearance of any symptoms which can be called premonitory, and the actual apoplectic seizure, varies much ; sometimes years intervene, at others an instant after complaining for the first time of violent pain in the head, or of giddiness, the attack comes on. The period between the attack and the return of sense and voluntary motion, also varies greatly. The period between the occurrence of the first symptom and re- covery, is also very various. The intervals between the attacks are by no means uniform; sometimes only a few minutes intervene, at others hours, days, weeks, and even years. Many people survive fits of apoplexy even when small effusions of blood have taken place into the substance of the brain, and so far recover as to be able to transact their ordinary business; but it very frequently happens, that if the patient survive an effusion of blood for a few days, a new train of symp- toms will be excited,—symptoms produced by inflammatory action in the brain, or membranes immediately in contact with the effused fluid. Causes of apoplexy.—Apoplexy is said to be hereditary. It may come on at any age, but in the great majority of cases the age is above fifty ; certainly it may be said to be a disease of the decline of life. The individuals most pre-disposed are those of a full plethoric system, who have what is called a stout frame and short neck. Full living, idleness, sedentary occupations, late hours, and sleeping on soft pillows, increase the tendency to this disease, together with every other cause which disturbs the balance of the circulation. Diseases of the blood-vessels of the brain lead to rupture of their coats, and the consequent effusion of blood; viz. ossification of the arteries, aneurism,* and obstructions in the sinuses; and it is also well known that hypertrophy of the heart sometimes produces apoplexy. Appearances on dissection in apoplexy.—On cutting through the scalp of persons who have died of apoplexy, a considerable quantity of blood generally issues from the incisions. On removing the calvarium, the membranes are sometimes observed to be very vascular, with some fluid beneath the arach- noid ; occasionally, although rarely, blood is effused between the arachnoid, and the pia mater, giving an appearance of ecchymosis; or the effusion may have taken place into some part of the substance of the brain. The parts which I have most frequently found affected, are the corpora striata and the * There is a splendid preparation in my museum, of one large and two small aneu- risms of the sylvian artery; the largest of which, about the size of a hazel-nut, burst, and a large effusion of blood took place with instant death. The patient was only 23 years of age, and the brain was very much broken down by the effusion. 460 APOPLEXY. thalami nervorum opticorum. The ventricles are sometimes found distended with coagula; and the cerebellum occasionally suffers. Effusion of serous fluid in greater or less quantity is found in the ventricles. It however some- times happens, that no morbid appearance whatever can be detected. In old apoplectics, who have survived many shocks, cysts are occasionally found, enclosing a clot of blood, or a fluid resembling pus, and sometimes they are empty, the contents having probably been absorbed. Some writers have described an appearance which they suppose to be a cicatrix, an almost complete restitution of parts having taken place. Sometimes we find con- siderable portions of the brain surrounding the effusion in various stages of inflammation, either shewing marks of increased action or complete ramol- lissement. On some occasions most extensive destruction from inflammation has been discovered in the substance of the brain, a remarkable instance of which is subjoined. A gentleman, aged 51, stout in make, plethoric in constitution, having a tendency towards obesity, and accustomed to full living, was found dead in his bed after having had eight or nine apoplectic attacks, some of which were succeeded by temporary paralysis. The fit which preceded that which proved fatal, took place seven or eight weeks previously; it was severe, with a pulse as slow as 30 beats in the minute. Medical aid- was promptly obtain- ed, and he was saved by timely loss of blood. Subsequently to this attack, he was able to transact ordinary business, and actually attended a public meeting. Nay, on the night previous to his death, he played for some time at the game of backgammon, and evinced his usual acuteness of mind. On examining the head, the apoplectic attacks, and the paralytic symptoms of which this gentleman had so long complained, found a very sufficient solution in the mass of disease within the brain. The dura mater was found to adhere round the corona with such firmness, that it resisted every attempt at separation without tearing, and the skull itself was rather more than usually dense. On the upper surface of the brain a quantity of serous fluid was effused, while at the base both of the skull and brain, the blood-vessels yvere unusually numerous and full, giving an appearance of redness to the base of the skull, not often to be met with. The principal arteries of the base were enlarged in size, and presented numerous points of ossification, as did also the minute branches in every part of the brain. The ventricles were found to contain a small quantity of fluid, and their whole surface was red and vascular. In the third ventricle part of the thalami firmly cohered; but neither here, nor at the base of the brain, did the fulness of the vessels ex- tend much beyond the surface. On cutting into the substance of the brain, the traces of much disease and an evident softening became apparent, parti- cularly in the ganglions of grey substance called corpora striata and optic thalami, in which the softening had passed on one side almost into suppuration; and several regular cysts were discovered, four on the right side of the brain, and three on the left; but none of them were of large size; and although APOPLEXY. 461 both hemispheres were diseased from about the centre of the middle lobes forwards, yet the right had suffered considerably more than the other. Such anatomical evidence is rarely found of life having been protracted with the preservation of intellect, till the whole centre of the nervous system under- went such a change as that described in the above case. Treatment of apoplexy.—Some routine practitioners will be found invaria- bly to bleed in cases of apoplexy, without reference to the period of the dis- ease and the state of the pulse. I have little doubt, from what I have seen, that valuable lives are occasionally lost, which otherwise might have been saved, by avoiding the lancet. If the pulse be slow and strong, a happier result may be expected from V. S. than if it bfc quick and weak. The feet should be put into hot water, in which mustard has been mingled ; the gar- ments should be loosened; the head shaved, and cold cloths applied. Active purgatives must be speedily administered, to be assisted by injections of tur- pentine, particularly if there be evidence of flatulent distention of the bow- els ; and blisters are to be applied to the lower extremities. Should a patient be fortunate enough to recover from the immediate effects of the attack, much may be done by subsequent treatment, to prevent a return of the disease. It is of vital importance to keep the bowels daily and freely open, to avoid cold feet, and exposure to cold damp air. Regular hours and exercise are to be enjoined, and a seton in the neck will be found very bene- ficial. Frequent bleeding, whether by the lancet or by cupping, cannot be too strongly deprecated ; our business being rather to prevent plethora by the above means, and by a proper regulation of the diet. I know no plan more likely to create constitutional distress, and to promote the quick formation of blood in the system, than frequently repeated bleedings. A great deal of mischief is done by keeping patients too long upon slops; it is far better, in many cases, after the first danger is over, to allow a small quantity of animal food for dinner, and toasted bread or biscuit in moderate quantity for breakfast and tea, than to give them a general order to live on farinaceous food, which, after all, many will not long adhere to, or if they do, they will take a large quantity to counterbalance the quality of the food. Restrictions should be made respecting the amount of fluid to be consumed in the course of the twenty-four hours ; and, in all cases where valuable lives are concerned, and when the patients move in that rank of society where they can obtain every comfort and attention, it will be found of great consequence to regulate the quantity of food and diluents by weight and measure. All causes of anxiety should if possible be removed, the patient should sleep in a large well-aired room, upon a hair mattrass; he should use the patent air-pillows, with the head and shoulders somewhat elevated. PARALYSIS. Paralysis appears to have been generally confounded with apoplexy by the older writers, who thought apoplexy was a complete paralysis and looked upon the latter as a partial apoplexy. 462 PARALYSIS. This affection is a frequent result of apoplexy, as well as of inflammation of the brain, and of disease of the spinal marrow; but it often exists without any apparent organic lesion. Paralysis has been divided into several varieties. 1. Paralysis of the nerves of motion, which take their origin from the anterior part of the spinal mar- row ;__2. Paralysis of the nerves of sensation, which take their origin from the posterior parts of the spinal marrow;—3. Hemiplegia, which implies the existence of paralysis in one half of the body ; 4. Paraplegia, which signifies that the lower extremities are paralyzed; and, 5. Partial Paralysis, as of the muscles of the mouth or of an extremity. Paralysis of the motive powers may exist in very different degrees ; it may be complete or incomplete ; in the latter case, the individual uses the affected limb awkwardly, and it sometimes feels weaker and heavier than the other. Paralysis of sensation may also exist in various degrees. Sensation is scarcely ever altogether destroyed, but is rendered more obtuse than usual; but in some instances of paralysis, the sense of touch is very acute, so much so as to be a source of considerable suffering to the patient. At all ages individuals may become paralytic. I have seen several children born hemiplegic, and young subjects are sometimes attacked with the disease ; but it is more frequently an affection of advanced age, and of men than women. Phenomena of paralysis.—When palsy takes place without being preceded by apoplexy, it is not generally accompanied by marked disturbance of the vascular system, or of the respiratory organs. Frequently there are pre- monitory symptoms, similar in many respects to those which oftentimes precede apoplexy, and to a practised eye announce that a serious affection of the nervous system is at hand. We sometimes perceive weakness of an extremity or numbness, together with coldness; and occasionally there is violent pain in a limb. I have known paralysis to affect many people who had been subject for years to violent headaches, sudden pains in the course of the spine, and tingling in the extremities. As the disease advances, the weakness is more apparent; the patient easily loses his balance, he always feels unsteady, and experiences increasing difficulty in going down stairs, and walking on an inclined plane. By and by he is obliged to use a stick; at length he cannot walk without receiving support from an attendant; and at last he is unable to move from one apartment to another. Although the disease sometimes approaches so slowly, that I have known persons to be seriously threatened for years previous to the paralytic attack, yet at other times it comes on very suddenly. Frequently there is momentary insensibility, and the patient's mouth is found to be drawn to one side ; or the disease may attack an arm, or a leg; or one half of the body may be affected. Sometimes the patient becomes paralytic without any affection of the brain. Violent cramps sometimes take place in the extremity, which soon after is found paralytic. The bowels are generally very torpid; sometimes PARALYSIS. 463 the muscular powers of the bladder are paralyzed, at other times those of its sphincter; in the former case, the patient cannot expel the urine, in the latter it is passed involuntarily; frequently the rectum is similarly affected. The pulse will be found in different states; frequently quite natural; but in the affected limb it is generally observed to be weaker than in the sound one. The limb generally becomes emaciated, although to the patient's feelings it may be considerably larger than natural; it is usually colder, although in rare cases it is found to be above the natural heat. The mental faculties continue in many cases of paralysis quite unimpaired; in others, they are slightly affected, the patients being sometimes a little incoherent, or they betray some weakness of judgment; occasionally a state which has been called second childhood is produced, and continues till death. Of all the mental faculties, memory appears to be the one most frequently affected; the names of individuals and of countries will be forgotten, while circumstances connected with them may be often alluded to by the patient, who will.be found in the course of conversation to forget words; and it is curious that the memory will be more perfect respecting transactions which occurred twenty or thirty years before, than of those which took place during the previous day. These circumstances, together with the appearance of the patient, particularly the expression of countenance, which is frequently silly, too often give an impression to a stranger, that his mental faculties are weakened or destroyed, and the more so if, as sometimes happens, the saliva be running out of the corners of the mouth, and the speech is affected. This is most important, as a will was lately made by a gentleman when in this state, which was afterwards disputed by the heir-at-law ; all the witnesses who had fre- quent intercourse, and several who had occasion to transact important business with him, were able to swear that he was of sound mind at the time, and for some time after the will was executed; whereas, on the other hand, some who only saw him occasionally, judging from his appearance, and the lethar- gy with which he was at those times affected, swore that he was neither capable of thinking nor of acting properly. Causes of paralysis.—There can be no doubt that paralysis of every kind and degree maybe produced by disease in the brain and spinal marrow. It is, however, more frequently produced by disease of the spinal marrow. Facts seem to prove that paralysis may be produced by direases of the nerves of the affected limb, without any lesion in the central parts of the nervous system; and I also believe, from the effects of certain remedies, that the disease under consideration may be the consequence of functional derangement of the nerves of the part affected, as well as of the brain and spinal marrow. Too much sexual indulgence, and certain noxious and disgusting habits, occasion palsy, particularly paraplegia. Treatment of paralysis.—We should be guided in the treatment of para- lysis, by the duration of the disease, and by the pathological condition of the w* PARALYSIS. body on which this symptom depends. If the disease be recent, and the individual not weakened, blood may be drawn both generally and locally, care being taken not to carry the bleeding too far. Strong laxatives must be exhibited at first, at short intervals; but subsequently, during the progress of the case, they are to be given at longer intervals, so as to produce one or two evacuations daily, keeping in mind, that in most paralytic affections, the stronger purgatives are required to produce even a moderate effect. Emetics have been recommended, but they should not be employed unless there are evidences of a loaded stomach; little danger need be apprehended from the temporary increase in the determination of blood to the head which is supposed to take place in the act of vomiting. Frictions on the affected part, with or without stimulating embrocations, are said to be ser- viceable, as well as counter-irritation in the course of the spine, produced either by any of the ordinary rubefacients, or the tartar-emetic ointment; caustic issues, as recommended long ago by Mr. Pott, may be applied; or moxas, which have been much praised by Dupuytren and Larrey. Elec- tricity and galvanism have been used in the paralytic affections; but I cannot say that I have ever seen them beneficial. Some employ the hot bath, and others the cold. If one can be commanded, the patient should sleep in a well-aired apartment; and it is of great consequence to keep his mind amused without being fatigued. The nux vomica has been much employed of late years in paralysis. It has been tried to a considerable extent in the hospitals at Paris; and there can be no doubt that it has occasionally done good. It is exhibited in the form of powder, and of spirituous extract; of the powder two grains, of the extract three, repeated from two to six times daily, constitute a proper dose for an adult. It has also been given in the form of injection. In some cases, a tendency to muscular contraction appears in half an hour after its administration'; and it is curious that the sound parts remain unaffected. It is said to increase the appetite, and sometimes to produce stupor, with a feeling of intoxication, and in an over-dose, tetanic convulsions. Still more recently, the active principle of nux vomica, called strychnia, has been employed. I have used both preparations in a number of cases, and as yet have seen only one case in which the nux vomica was decidedly beneficial; it was increased in doses of from two to eight grains daily, and its use per- sisted in for several weeks. Of the strychnia, I have exhibited four or five twelfths of a grain daily in several instances; and in two cases the drug seemed to produce spasmodic muscular contractions of the paralyzed limbs. The strychnia, in particular, is worthy of further trial, as in many cases which do not depend on organic lesions in the central parts of the nervous system, it will probably be found very beneficial. Dr. Bardsley, (Manchester,) states, that he employed the strychnia in some cases of paralysis with no benefit, in others with only partial advantage, but PARALYSIS. 465 in the majority with complete success. He considered that it may be an efficacious, though not a certain remedy in this affection.* Dr. Bardsley has given thirty-five cases,—of which twenty-two were cured—ten relieved— in two it had no effect—and one patient left the hospital. * Hospital Facts and Observations, page 38. 59 CHAP. VI. INSANITY—HYPOCHONDRIASIS—AND DELIRIUM TREMENS. , INSANITY. This, I am aware, is a term of very extensive application. Under it, I mean to comprehend every alteration of the functions of the brain from a state of sanity, with the exception of the delirium which so frequently ac- companies fever and intoxication, and hypochondriasis. There are many degrees and shades of insanity. Some persons may be affected with the most violent delirium and incessant raving, furiously threat- ening the attendants with destruction, wrong alike in their perceptions and reasoning faculties. Others may have some excentricity, produced by an error of perception, a wrong impression, or some slight derangement of judg- ment. Cases are frequently met with in practice, where there is diseased percep- tion with more or less derangement of judgment, or the former may exist without any such complication. For example, an insane person frequently perceives objects which do not exist, or he may see a post which his diseased perception transforms into a monarch; he will kneel before his majesty, deliver an address, and kiss hands; every act as it is done at court will be correctly imitated. Nothing can be said to be wrong about the insane per- son, except the first erroneous perception ; all his actions tally with the situation in which he supposes himself to be placed. We meet with others, where an erroneous impression is taken up, the reasoning faculties being per- fectly sound, so that a man may conceive that a minister of state has been guilty of some dereliction of duty. He will write upon the topic, make out charges against the individual, and reply to letters received upon the subject; and yet no one, upon reading his correspondence, or from conversing with him, could discover any error of reasoning, or any expression which would lead him to conclude that he was insane; nothing is incorrect but the first impression. In some instances, we meet with errors in the reasoning facul- ties which frequently lead men to ruin their fortunes, and bring an accumu- lation of distress upon their families, by following out some castle-building INSANITY. 467 speculation, the absurdity of which is too apparent to every one but them- selves. In others, we can only discover a disordered state of the association of ideas, or a disproportionate emotion from the application of slight causes. On other occasions we find individuals believing the fancies of a wild im- agination to be realities; they transform themselves into kings and peers, or fancy themselves reduced in circumstances, even to beggary. In other cases, complete fatuity takes place. These different states may be variously mingled and modified into endless varieties of insanity, as it is usually treated of in books; and the symptoms may be still more diversified by the degree of excitement or depression which co-exists, together with the peculiarities of constitution, and the state of the patient's health. Insanity sometimes makes its attack suddenly; but in general it is slow in its progress, although decided in its precursory symptoms, which, however, develope themselves differently in different cases:—One patient shews eleva- tion of spirit, speaks loud, is easily irritated, and some eccentricity of conduct is sooner or later observed; at last he will be found to follow out some par- ticular hallucination, which will occupy his thoughts more and more com- pletely as the disease advances. Another individual will shew depression of spirits; he will be observed to be more cautious, timid, or shy in his manner; he thinks he hears the voices of individuals planning his destruction, or rob- bing him of his property; or his depression of spirits may be owing to reli- gious doubts as to his own worthiness, or to the existence of a future state; or he fancies himself haunted by evil spirits. We sometimes meet with an intermediate condition, where an individual shews his ordinary state of temper and disposition, he evinces neither increased excitement nor depression, while an erroneous notion, religious, political, or professional, haunts his imagination for weeks, months, or even years, which shews itself occasionally, but never disturbs his health, or alarms his friends, till some accidental circumstance gives the mental disease activity, when it breaks forth in a most decided manner. Some individuals shew a great desire to quarrel, litigate,'and to take per- sonal revenge for imaginary insults and injuries; but all these propensities may exist separately :—A man may be extremely quarrelsome, but, if properly managed, easily appeased, and may never shew any tendency to take the life of a fellow creature, nor would he do any thing to hurt him. Another will take revenge only in one way, by litigation; while the third, but happily this is the rarest case, would murder all and sundry in the most cold-blooded manner, and when under restraint, will glory in the thought of murders he has committed only in his own imagination ; or in the most ingenious way he will endeavor to excite hatred between his keepers, so as to induce the one to murder the other. Others shew a "most determined propensity to commit suicide, and sometimes follow it out with so much pertinacity, as to elude at 466 INSANITY. last the vigilance of the most attentive keeper, and, what is very curious, each will have his reason for the act. The vanity of one has received a blow which has lowered him in the eyes of the world, and he destroys himself be- cause he cannot live dishonoured, degraded, or even laughed at. The fear of another induces him to commit the rash act with a view of escaping from some evil spirits, or of disappointing the machinations of some relatives who have conspired either against his peace, his life, or property. I have known a few instances also of men committing suicide, who could not survive the loss of a wife or child, and it would appear that the act was committed under the impression that their departed spirits were to be immediately afterwards re-united. Several curious circumstances quickly attract the attention of those who are in the habit of attending this unfortunate class of patients. 1. A hatred of, or indifference towards those to whom they were previously most attached, because these are the individuals who, the maniacs suppose, have conspired against them, and have ultimately deprived them of liberty. 2. Their physi- cal powers are frequently not at all affected. Thus a body of insane soldiers under confinement, not completely fatuous, will fall into the ranks upon the usual signal being given, and will perform a number of mechanical acts at the word of command, with nearly as much attention and precision as if they were sane.* 3. The natural functions are generally not materially impaired, unless it be in those cases where insanity supervenes upon some other disease, or is produced by an injury of the head-, some organic lesion in the brain, or by long-continued indulgence in the use of intoxicating liquors, when there may be heat of skin, quickness of the pulse, and a train of nervous and other symptoms, which need not si present be more particularly alluded to. Causes of insanity.—Unfortunately there can be no doubt that insanity is hereditary, at least under certain limitations; but I believe it may be warded off for many years, and in some cases entirely prevented, by proper manage- ment- which principally consists in keeping all the functions of the body in a natural state by diet, exercise, and attention to the bowels, as well as by avoiding all excesses, keeping the passions under controul, and the mind pro- perly exercised. Gluttony and drunkenness are too frequently the causes of insanity, and particularly the latter, in cases where no hereditary predisposi- tion can be traced. Individuals seem also to be more and more predisposed to the occurrence of insanity as age advances, it being rare before the age of puberty. Among the passions, love, " by which the young and tender wit is turned to folly," may be particularly mentioned as a fertile source of the *tW«T had an opportunity of seeing at Chatham, where a large establishment has h^n formed for the insane officers and soldiers of the British army Fort Clarence r,K'L. exclusively used for this purpose, and the unfortunates there have the en- •3' ™ of rood air and exercise, are well fed, kindly used, and carefully superintended. joymeiitof goodar anu , ^ beneyol which character. •L°^-TtlVoTH^E *e Duke of York, and to the zeal and* exertions which Sir James'M^rigorL fc displayed to increase the comfortsof the British soldier. INSANITY. 469 malady under consideration, particularly in females. It is rare to meet with a case of insanity from this cause in men, for reasons which are too evident to require being mentioned. Intense and long-continued anxiety respecting the results of extensive mercantile speculations, as also the pernicious vice of gambling, are frequent causes of insanity. It is likewise a disease which sometimes attacks females after parturition, and also, when the predisposition is strong, during the diseased states of menstruation. Appearances on dissection in insanity.—Nothing satisfactory has yet been discovered, for, although many organic lesions have been found in the brains of individuals who have died insane, yet the same lesions have been observed where no insanity existed; and in many cases of insanity, no diseased appearance whatever has been detected in the.head. Hence, in the present state of our knowledge, I am inclined to attribute the various and ever-varying phenomena which occur in insanity, to functional disease of the different parts of the cerebral mass. So far for the symptomatical description of insanity, which, in my opinion, teaches nothing of the nature and seat of the disease. But if it be true that the brain is a congeries of organs, that each performs a peculiar function, and if we admit insanity to be a disorder of function, then indeed there seem to be sufficient grounds to warrant my departing from the usual beaten track, and submitting to my readers a short account of insanity, founded upon the phrenological principle that the brain is a congeries of organs. According to Dr. Andrew Combe, in his able work on Insanity, insanity is not a specific disease, but a symptom of disordered action in the brain or organ of mind, and, like every other disorder of function, it may proceed from a variety of different states. The delirium of fever is one form of^ disordered mind, which is always viewed as a symptom, and so ought all other forms to be. The brain being to the mind what the eye is to vision, it follows that, just as vision is deranged by many pathological states of its organ, such as ophthal- mia, irritis, cataract, &c. so may the mind be deranged by many states of the brain. The sufferers on the raft of the Medusa became mad from starvation and exposure, while many become so from excess, particularly in stimulants. The asylum at Milan is filled by lunatics from bad feeling, and almost all recover by nourishing food; while Bayle, at Charenton, finds many cases arise from chronic meningitis ; and Broussais declares, that in the early stages it is so obviously from inflammatory excitement, that it may often be cut short by free leeching, as certain as pleurisy is by blood-letting. Hence it is not the same disease in all. Insanity, being a symptom of morbid action in the brain, springs naturally from causes affecting its health, and hence a great affinity between the causes of acute cerebral affections, and of those on which insanity depends. The hereditary tendency depends on a peculiarity of nervous constitution, and is of primary importance. Excess of some mental qualities leading to eccen- tricity predisposes in irritable constitutions, from the high action into which 470 INSANITY. the corresponding predominant organs are thrown ; and hence the latter are generally those whose manifestations are deranged, as proved in Dublin, by Mr. Combe having, in so many instances, pointed out correctly from develope- ment, the probable form of the mental affection. Other predisposing causes, such as age, sex, profession, &c. are referable to the same principle. The exciting: causes are. whatever disorders the action of the brain. That organ requires regular exercise for its health and preservation, and for the improvement of its functions, just as other parts do, as the muscles in fencing or dancing. Practice in the latter instances increases nutrition, and conse- quently, power ; and it gives facility of combination to produce a given end. The same organic laws preside over the brain. Consequently, excess of exercise, as in intemperate study, excitement of passion, anxiety and strong mental emotion long sustained, leads to morbid cerebral action, with derange- ment of function, in irritable subjects. Deficiency of exercise, or idleness, leads equally to diseased action and manifestations, as exemplified in the melancholy and ennui of the retired merchant, or soldier, and in the nume- rous victims in the unoccupied classes of society. Local causes act by disordering the brain. Blows on the head, coup du soleil, intense cold, drunkenness, meningitis, &c. shew this. Dyspepsia, and other disorders of the abdominal viscera, excite it seconda- rily in some instances in predisposed subjects, but, in general, mental causes have preceded. The same remark applies in nymphomania and erotoma- nia, in which the affection of the generative organs is generally the effect, and not the cause, of the cerebral disturbance. The brain, in short, is more frequently disordered by direct than by indirect causes, and in this respect the analogy between it and other organized parts is preserved. The symptoms indicative of insanity consist of deranged cerebral functions and local phenomena. Every sense, every nervous function, and every faculty of the mind, may be involved in the disease or not, and hence inde- scribable varieties occur. The true standard is the patient's own natural character, and not that of the physician or of philosophy. A person, from excess of developement in one part of the brain, may be eccentric and singu- lar in his mental manifestations, and yet his mental health be entire. Before we can say he is mad, we must be able to shew a departure from his habitual state, which he is incapable of controuling. An irascible man may be very boisterous without being mad ; but if a mild and timid creature become equally boisterous and irascible, we may fear for his wits. One may be naturally suspicious, jealous, and cunning, without being insane; but if a man of an open, generous, and unsuspecting nature, becomes so, danger to his cerebral health is at hand. The derangement may consist in excitement of the patient's predominant qualities, in diminished action, or in perversion or vitiation of function. A proud man, who, during disease, fancies himself a king, is an instance of the first condition, or that of excitement of func- tion;—one who humbles> himself in the dust, and fancies himself unworthy INSANITY. 471 of regard, is an example of the second, or diminished function;—while one who fancies himself something out of the ordinary course of nature, is a specimen of perverted or vitiated function;—or one who is attached to friends when in health, may, when insane, either have inordinate love for them, be indifferent, or have a hatred and aversion to them ; and so on with every feeling and faculty of the mind. The existence of digestive derangement modifies the mental state, and gives greater anxiety and irritability than when the stomach, liver, and bowels act well. Other complications modify in other ways. Monomania, religious, erotic, and other manias, are not different diseases. One organ or faculty being chiefly affected, and the rest entire, give rise to monomania; but the proximate cause may be, and often is, the same as when all the organs and faculties are affected. Religious despondency is a mere symptom also, and appears because the function of some cerebral parts is to manifest religious feelings, and those being sick, the function necessarily suffers, and the feeling is altered. But the same pathological state affecting combativeness and destructiveness, would produce furious mania. Monomania and melancholy are less easily curable, not from the proximate cause being more serious, but from the other faculties and reason succeeding ;n longer concealing the existence of aberration; whereas in mania, it betrays itself early in spite of the patient. Insanity is not a state separated by a broad line from sound mind. Every gradation is observable, and we perceive morbid action before we can venture to say that the patient is insane. Some are cured at home of mental affections in a few weeks, who, if sent to an asylum, would become mad, and remain so for months or years. Treatment of insanity.—The first important question which naturally sug- gests itself in the treatment of insanity, is what combination of circumstances ought to exist, before a medical man is entitled to commit any individual suspected of labouring under it to an asylum, or to any other place, where he is not only deprived of his liberty, but is placed under some degree of restraint. This is a duty which I fear is still too generally performed without sufficient attention to all the features of the case. Medical men should take care not only to be themselves satisfied of the necessity of such a serious step, but that they have sufficient proof, which cannot fail to convince a jury that it was most necessary. If an insane person evince a propensity, either to take away his own life, or threaten that of another, there can be no doubt that confinement is absolutely necessary. If an individual, in a state of mental aberration, disturbs the public peace, and is a source of annoyance to any one, a medical man, if consulted, should recommend, as a preliminary step, the interference of the local authorities. If a patient act in such a way as to offend the public morals, he being insane, or even eccentric, I also think an appeal should, in the first instance, be made to the same source for pro- tection. If a person be unable to manage his own affairs, if he enter into 472 INSANITY. such speculations as none but a madman would think of undertaking, which must be connected with some striking aberration of mind, or if he squander away his money, as in buying a pack of hounds, or expensive paintings, which neither his fortune nor his rank in life entitle him to do, a medical man, consulting his own safety, and the respectability of his character, will take care that he is able, by the evidence of a sufficient number of disinterested witnesses, to prove the fact to the satisfaction of judge and jury, before he signs the committal of any lunatic. A man may be perfectly mad on one point, and yet be quite able to man- age his own affairs. Thus he may suppose, that his legs are made of glass, and that if he attempted to stand they would break into a thousand pieces. A. second may fancy, that if he attempted to pass through a door, he would be crushed to pieces; a third may imagine himself to be a king; and yet they might be able to manage all the transactions of ordinary life, and be wrong upon no other point. Surely it would not be justifiable in any medi- cal man to commit such patients to a mad-house. Individuals are frequently under some religious delusion, which may be quite innocent in itself, either as it relates to the individual, or the public at large. One man may fancy himself to be of divine origin; another may be in constant communication with angels and holy spirits; and a young lady may innocently enough em- ploy herself from morning to night in writing love letters to angels; and yet a medical man would not be entitled to send them to a mad-house, unless public decency were offended; indeed, were it otherwise, the one half of the world might be for committing the other, who think differently on religions matters. Perhaps there are more religious than any other class of lunatics; and at present, there are a dozen or two of young ladies, who are too well fed, and have too little to do, praying by detachments, day and night, for the conversion of some of the highest, the most pious, and the most rational mem- bers of the Scotch church. There are others who, in the wildness of their diseased imaginations, fancy, that a proclamation for a universal pardon, alike to saint and sinner, has been received from heaven ; and that a power has been imparted to them, in virtue of prayer, to perform miracles; in short, that they can make the lame walk, renew the lungs of consumptive patients-, and even raise the dead! Yet I suppose they consider themselves perfectly sane, and would be very much surprised to find themselves safely lodged within the pre- cincts of an asylum; but it would not be difficult to shew, that they, as well as the followers of Johanna Southcote, and sundry other wild enthusiasts, are at least not very wise, and that a few weeks' work on the treadmill, with scanty fare, would probably cure them of such fantasies. The second point of importance is, supposing an individual is considered insane, ought he to be sent to a proper establishment, or treated at home? After considerable experience in the treatment of insanity, I am disposed most un- hesitatingly to declare, that removal from his own house, if not actually ne- cessary, is the step best calculated to produce a speedy recovery, and more particularly if he be the head of a family, it being the most difficult thing to INSANITY. 473 gain a sufficient degree of authority over a person in the house where he has been always obeyed. But I entertain great abhorrence at the idea of con- signing any person to a private mad-house, where the money received for board and medical attendance is an object to the individuals who keep the establishment. In a case where the liberty of the subject, and the peace and happiness of so many individuals are at stake, should not private mad-houses be put down by law? Although, then, a decided preference should be given to a public establishment, yet I am not preparad to say that they might not be improved ;*and if an investigation were instituted by Parliament, it would be discovered, that the duties which the directors of such institutions take upon themselves, are generally very slovenly, and sometimes very imperfectly performed. In the treatment, more is to be done by moral management, and by attend- ing to the bowels, to the regimen, and to the temperature of the patient's body, than by heroic remedies, such as bleeding and blistering, exhibiting digitalis, and persevering in the use of strong drastic purges. As to general bleeding, it is necessary only when there is considerable plethora, vascular excitement, determination of blood towards the head, or more especially signs of inflammatory action in the brain; but local bleeding should be, if possible, substituted, unless the balance of the circulation be much disturbed, when the lancet must be used. In a considerable number of cases, shaving the head, and the occasional application of cold, by pouring water in a small stream upon it for a considerable length of time, will frequently diminish excitement, and produce tranquility, without having recourse to bleeding. Opiates have been so often found injurious, that by some they are laid aside entirely; but I imagine this has happened from their indiscriminate employ- ment, as well as from the insufficiency of the doses. I have seen the best effects from the exhibition of eighty, and even a hundred drops of laudanum, repeated every third hour, in cases where there were great irritability and want of sleep, and where there were no marks of organic disease within the brain. Blisters are rarely serviceable, and they oftentimes irritate a patient till he becomes unmanageble. Large doses of tartar-emetic will sometimes be found useful, having the double effect of controuling the circulation, and keeping the bowels open. The moral treatment consists in obtaining complete power over the mind of the sufferer, if possible, without the application of any violent means. This can be effected only by studying his character, avoiding argumentative conversation, and keeping a sharp look-out, that he may have neither excuse nor opportunity to aggress. In short, a soothing system, and frequent acts of indulgence, as rewards for quietness and good conduct, are most conducive to recovery. The high and ferocious maniac, however, requires to be secured during the night, by means of straps and strong gloves, which are fastened in a peculiar way, so that the patient cannot do himself or his keepers any injury; 60 474 INSANITY. and during the day, to be confined in a large well-cushioned chair, which u fixed to the floor, and even here the soothing system is of decided advantage. The superintendents and keepers should possess great prudence, and imper- turbable tempers; and are never, on any account, to be allowed to exercise any harshness, either in action or expression, towards a patient. In many establishments there is a chair fixed in a box, very much like a sentry-box, which is whirled round with great rapidity by machinery; and I am told, that it has been found of great service in those cases where, great violence exists with a considerable share of reason. The remedy has to be used only once; subsequently the mere threat of it is quite sufficient to make the patient controul himself. Every ward should be heated with warm air, which will render fires in the apartments unnecessary. Comfortable clothing, and pre- serving warm feet, ought to be strictly attended to. Unless a patient have fever, his food should be substantial, and at the same time nourishing; a din- ner of good roasted or boiled fresh meat should be allowed. A proper share of exercise in the open air is highly necessary; and nothing is more benefi- cial than a minute attention to a proper classification of patients; yet I fear, from negligence and laziness, this is either much neglected, or very imper- fectly and irregularly performed. In a receptacle for the insane, this last should be insisted on as a daily measure. The number of directors should be increased in each establishment, and two should be compelled, under a severe penalty, to visit the insane every day at the hour of dinner, to satisfy themselves with respect to the food when presented to the patients, both as to its quantity and quality, and to see that an individual with some returning sense, is not horrified by the presence of others in a much worse state than himself. Some means should also be contrived to allow the visits of friends as often as may be wished, without the patients being aware of their presence. It often becomes a difficult matter to decide when a patient is in a fit state to be discharged, and return to his friends. If I might be allowed to insist upon any particular line of conduct, it would be, not to dismiss a patient till he has been for at least two months without shewing any aberration of mind: and it is even justifiable, before his dismissal is determined on, to converse with him, touching the chord of his previous illusion. This should be done by the medical attendant, whose responsibility is great, who should be well remunerated, and be chosen as much for his honorable and benevolent feeling, probity, and strait-forwardness, as for his talents. It would be perhaps an ad- ditional safeguard if this examination were conducted in the presence of a magistrate. In addition to these remarks respecting the management of the insane, the following valuable observations by Dr. Combe are annexed. " Besides what you notice with regard to treatment, every thing demonstrates that employ- ment to the patient is not sufficiently studied. The brain loses its health from vacuity of mind, and yet we shut up in scores, in perfect idleness, men who, when well, were accustomed to a bustling and active life, and whom, at any HYPOCHONDRIASIS. 475 time of their lives, idleness would have driven mad. Manual labour and oc- cupation are also of immense consequence, and the moral influence of keep- ers and superintendants acquainted with human nature, and interested in their avocation, is prodigious, in producing quietude, and accellerating re- covery, just from giving to the brain that healthy exercise which it requires. Lunatics retain a good deal of reason even in their worst condition, and hence are more accessible to the influence of reason and example than might be supposed. In every point of view, it is best to act towards them with the same consistency, firm honesty, and good feeling, as if they were quite in possession of themselves. They are quick in detecting deceit, and when once deceived, they never give confidence again. I mention this, because I differ from what------once said to you on this subject, in having flattered D----'s predominating vanity, and led him by it, and from what you said in accordance with his views. My experience says, never advance a word which you cannot conscientiously stick by when the patient recovers, and you will retain your ascendency. Do not thwart his delusion, but neither give it any countenance. Our friend is now satisfied I am right in this, and I have decidedly proved it in practice. Remove all provocatives, and allusions to the morbid feeling or idea, and exercise the rest as much as possible on their own objects. " In subjects not delicate, and not beyond middle life, I find many who are greatly benefited by cupping, and free and repeated leeching, followed by tepid bathing, and cold to the head while in the bath. Many, of course, do not require depletion, but it may be advantageously used when the usual in- dications exist. General bleeding I know little of, and do not like it. After the irritability and excitement of the immediate explosion are over, a great deal of exercise in the open air seems most useful in diminishing irritability, relieving the head, and procuring sound sleep ; but if used too soon, it injures. The ordinary principles of pathology ought, in short, to regulate medical treatment, and adapt it to the state of the individual patient, for the latter is the only safe and successful plan." HYPOCHONDRIASIS. This disease, when severe, is synonymous with monomania, and might very properly have been comprehended under insanity. Hypochondriac symptoms affect two classes of individuals: 1. Those whose ailments are only imaginary or functional; and, 2. Those whose complaints are produced by organic disease. The first class of patients embraces the idle, the wicked, the dissipated, and those who are brought up without a profession, who, when left to their own resources, know not how to kill time. The minds of such persons are enervated from a want of due exercise of the faculties they may actually possess, till at last the vital actions become weak- ened; some of the natural functions, particularly those performed by the stomach and bowels, may be impeded; at which time, should a friend die, 476 HYPOCHONDRIASIS. * or the history of a disease fall in their way, they will immediately fancy themselves affected with the same disorder. Or they may have a hundred and fifty different complaints, and think they experience a thousand strange sensations and unaccountable feelings, till bodily disease is in the end engraft- ed on the mental. The organic disease acts upon the mind, producing a state which, to say the least of it, is far from one of sanity. The primary disease may be functional or structural. If the former, the stomach and bowels will, in general, be found to be the parts at fault; and I have sometimes discover- ed, on dissection, diseased states of the liver, lungs, kidneys, bladder, heart, blood-vessels, and also of the brain and its membranes. I have often been surprised, while attending hypochondriacs, to hear the animated description they give of their feelings, and as one impression is driven away, another quickly appears in its place. They sometimes declare that they have no appetite, and cannot eat, while they may be in the very act of taking a hearty dinner. In the same way with regard to sleep; according to their own account, they never close an eye night or day, although it is well known that they sleep ten hours out of the twenty-four. Some of them never have any passage from their bowels, although they pass two or three evacuations daily ; and on one occasion, a lady told me that she had not had a stool for thirty-eight years, and wished for something to relieve her, although her bowels were quite regular at the time ! Now surely persons cannot be said to be sane under circumstances such as these. Patients affected with hypo- chondriasis are not always in the same state; perhaps without any assignable cause they become quite well, and again relapse; so that the disease is inter- mittent and irregular until it acquires some duration and intensity, when it continues, the patient becoming progressively worse. Causes of hypochondriasis.—These are to be detected in a more satisfactory manner, by studying the character of the individual, assisted by observing the phrenological developement of the brain. The character of the individual will be found in general to be timid, either from having been weakened by previous bad habits, or in consequence of a total want of moral courage. Hy- pochondriasis almost never makes its appearance before the age of puberty, and it should be made extensively known, that it more peculiarly affects aged bachelors and old maids! Treatment of hypochondriasis.—Both classes of patients are objects of pity and compassion, and alike demand strict and decisive medical treatment. We should never have any doubts, nor should we attempt to persuade a patient, that he has not the disease which he supposes himself to labour under. Our language should rather be, that we possess a remedy which will most undoubt- edly effect a cure; and we should use every exertion to inspire the sufferer with hope. To all patients we should be regular in our visits, and guarded in conversation; but more particularly so when attending a hypochondriac. The bowels should be kept open; the diet should be regulated according to circumstances; and if the patient labour under local disease, it should be DELIRIUM TREMENS, 477 treated accordingly; counter irritation produced by frictions with antimony ointment, will be often found beneficial, as well as the occasional use of warm and cold bathing. Air, exercise, and every kind of innocent amusement, should be strongly urged; and the physician should take the trouble to ascer- tain that his directions are properly followed ; but he must not be at all sur- prised, or put Out of temper, on finding that the patient, if wealthy, is in com- munication with twenty other medical men. DELIRIUM TREMENS. Whenever a person has delirium, accompanied by a tremulous motion of the body, or even of a part of the body, he is said in common language to be affected with delirium tremens. Two pathological conditions of the body are often confounded by practitioners, as well as by writers, under this term. The one is delirium accompanied with trembling, the consequence of the combined influence of irritability, and general functional disease of the ner- vous system, with positive weakness of the whole frame. In the other, simi- lar symptoms exist with irritation and increased action, sometimes inflamma- tion in the brain, the patient having a robust, perhaps a plethoric, at all events an unweakened state of body. Both are the consequences of excessive indulgence in strong potations; but a distinction between the two is, in gene- ral, not very difficult, if we can depend upon the history given of the patient's previous habits, by comparing these carefully with the immediate cause of the attack, and the existing symptoms. If we are told that the patient has had many similar attacks, has been long addicted to the excessive use of ardent spirit, and that the immediate cause of his present condition is great excess; if he display no great bodily strength; if his pulse be frequent and weak, his tongue dry and dark-coloured, with a pale subdued countenance, a different line of practice ought to be pursured from that which I would recommend in a patient whose health had been previously unbroken, and who was not ha- bitually addicted to drinking. If such a person as the last mentioned, were seized with delirium and trembling after a solitary debauch; if the delirium were furious; the strength greatly increased; the limbs being sometimes spas- modically contracted; the pulse of moderate strength, and not above 100; and particularly if the tongue were moist, depletion must be employed. Whereas in the first case, the hope of recovery must depend upon the judi- cious and timely exhibition of stimulants. The kind of stimulant should be adapted to the rank of life and habits of the patient; but upon the whole, wine is the best, repeated in the quantity of a small glassful, every half hour in urgent cases, or every hour or second hour according to circumstances; attention must be paid to the bowels, and opiates and blisters used if neces- sary. A patient labouring under this form of the disease, would in all proba- bility be destroyed by the loss of four ounces of blood. In the second variety which has been quoted, if the disease have not ex- isted long, a bleeding from the arm, in such quantity as the case requires, will 478 DELIRIUM TREMENS. be found highly beneficial; but should the disease have gone on for any length of time, the same objections we're made against bleeding in the former case are equally applicable to this. But instead of stimulating, we must trust to the exhibition of powerful purgatives, shaving the head, and applying cold to it, with sinapisms to the feet, or blisters to the legs. In some instancei local bleeding will be proper, when that from a vein is totally inadmissible. The observations already so frequently and so pointedly made in different parts of this work, with respect to vensesection, and the difference in the results to be expected from that remedy according to the period of the disease, need scarcely be repeated in this place. But it may be again stated, that bleeding is often a doubtful, and sometimes even a dangerous remedy in this affection, when the pulse is exceedingly quick, say 130 or 140, and still more so, if at the same time the tongue be dry and parched; whereas it is at least a comparatively innocent remedy, if the opposite state of the pulse and tongue exist. Considerable caution is also required in exhibiting opiates; if the patient be restless and watchful, an opiate can at least do no harm, and is often of signal service; but if there be a tendency to coma, an opiate will, in general, prove hurtful. PART VI. DISEASES OF THE EYE AND EAR. CHAP. I. GENERAL REMARKS ON THE DISEASES OF THE EYE. The eye is one of the most sensible and delicate organs of the body, and from its situation and functions is liable to many accidents and diseases, the nature and treatment of which are now happily much better understood than formerly. It is my intention to avoid noticing the surgical diseases of the eye, and to confine myself entirely to the consideration of those strictly me- dical, which will include inflammation of the different tissues of which the eye is composed, and the lining membrane of the eye-lids, together with the diseases of the optic nerve. In the last century, uneducated quacks were chiefly employed in treating diseases of the eyes, which was no doubt owing to the general ignorance which prevailed on the subject. In the present day, we find a class of well educated men called oculists, who devote their time and attention exclusively to this branch of the profession. There can be no doubt that advantages are gained, both by the profession and the public, from a division of labour ; but every individual, whatever particular department he may choose to cultivate and practise, should have previously gone through a good general .nedical education. Many of the diseases of the eye depend upon a variety of con- stitutional causes, which must be understood before we can cure or alleviate the diseases which they produce. It is now generally admitted, that every individual in the profession should be able to treat the diseases of the eye with the same facility with which he can manage those of any other organ. The surgical diseases of the organ of vision are certainly more complicated, requiring a delicacy of hand, and quickness of eye, which many do not pos- sess ; but those which fall under the care of the physician are similar to dis- eases of other parts of the body, though at first perhaps somewhat more diffi- cult to understand and treat. Students of medicine of the present day will have themselves to blame, if they undertake the responsibility of general practice without a competent knowledge of this subject, as at every school of medicine in this country, an establishment especially devoted to diseases of the eye exists, superintended by medical men of eminence in this depart- ment. I am happy to have this opportunity of speaking in terms of high 61 462 GENERAL REMARKS ON commendation of the arrangements of the Eye Dispensary of Edinburgh, under the able management of Drs. Robertson and Farquharson. The Germans are exceedingly and needlessly minute in their classification of diseases of the eye. According to Plenck's arrangement, there are one hundred and nineteen genera, and very nearly six hundred species. Dr. Mason Good, in noticing this division, observes: " A regard to our own ease may dispose us rather to take with the abbreviating spirit of Dr. Cullen, than the discursive genius of Dr. Plenck." I think, that a regard not only to our own ease, but to the ease, comfort, and safety of our patient, ought to induce us to do so; as it is scarcely to be believed, that any practical man can carry in his head the one hudredth part of the distinctions of the Germans. Inflammation of the eye may be divided into external ophthalmia, or in- flammation of the conjunctiva in its principal modifications; and deep-seated opthalmia, or inflammation of the other tunics, including the disease called amaurosis, which, although not always, is sometimes produced by inflamma- tion. These are subdivided into acute and chronic inflammation of the part affected. I shall now give a general but brief account of the phenomena of inflam- mation of the eye, its causes, and treatment, before proceeding to consider the individual diseases. The general symptoms differ little from those of inflam- mation in other parts of the body, and only in as much as they undergo mo- difications from the peculiar structure and functions of the organ. Inflamma- tion of the eye may be confined to one tunic, whence it often extends to sur- rounding tissues, and may spread in this manner till the whole organ is affect- ed ; or it may attack the whole eye-ball at once, although this must be an ex- tremely rare occurrence. The disease may be confined to one eye, or may affect both simultaneously ; or first one eye, and then the other, may be af- fected. Almost universally the disease attacks the same tissue in each eye, whether it be the iris, the conjunctiva, or the retina. Inflammation affecting one particular tissue of the eye, whether it be of an acute or chronic charac- ter, if not invariably, is generally characterized by some peculiar symptom or appearance ; thus, inflammation of the conjunctiva may be readily distin- guished from inflammation of the retina, and both from that of the iris. Symptoms of inflammation of the eye.—These may be divided into local and constitutional. The local symptoms are first a sensation which would be produced by a grain of sand in the eye, followed by a sense of heat, and pain in the eye-ball, increased secretion of tears, intolerance of light, and a feeling as if the eye-ball were swollen. On making an examination, a net-work of vessels transmitting red blood is seen, although in a state of health they con- tain a colourless fluid. If all these symptoms be present, and continue for any length of time, no individual, however uninformed, can be in doubt re- specting the existence of inflammation. But it often happens, that very severe inflammation of the internal parts of the eye may be going on without any external redness or unusual vascularity; and cases occur, which termi- THE DISEASES OF THE EYE. 483 nate in the total destruction of vision, unaccompanied by much pain. Thus, Dr. Robertson was called to a case some years ago, in which both eyes were completely disorganized within twenty-four hours from the commencement of the inflammation, and yet the patient complained but slightly of pain. In- tolerance of light is not always complained of in an external ophthalmia, at least at the beginning of the attack, in proportion to the intensity of the in- flammation, but it is a prominent symptom of inflammation of the internal parts of the eye. Instead of an increased flow of tears, a preternatural dryness of the eye may take place, particularly when the diseased action is intense. Swelling of the eye-lids take place when the inflammation attacks their lining membrane; they then sometimes become very much tumified, which is by no means an unfavorable symptom. The observations which have been so often repeated in this work respect- ing other inflammatory affections, viz. that symptoms vary much according to constitution, and that an important organ may be undergoing considerable changes of structure, without producing the regular train of symptoms, either as to number or intensity, apply equally to ophthalmia. Severe inflammation of the eye is frequently attended by headache, nausea, prostration of strength, constipation, and febrile symptoms. When the inter- nal coats of the eye-ball are inflamed, there are generally more pain, head- ache, and fever, than in conjunctival inflammation. These are termed the constitutional symptoms. Causes of inflammation of the eye.—These causes are numerous and diver- sified ; few can be said to be peculiar, the great majority being such as are well known to occasion disease in other organs of the body. They may be divided into two clasises:—1. External or local; 2. Internal or constitutional. Among the first are included sand, dust, lime, small insects, the irritation produced by tumors growing within the eye-lids, and inversion of the eye- lashes. Of these, the application of lime is the most injurious, from its well known property of destroying the vitality and texture of animal tissues. In all of these cases, a very minute examination of the eye should be made. Morgagni relates the case of Thomas Mangelli, a relative of his own, who had a dangerous and protracted ophthalmia. His physicians and surgeons believed that an ulcer had formed in the cornea from inflammation, and a variety of internal as well as external measures were adopted, but without the least advantage, until one of the surgeons discovered the wing of a small fly in the bottom of what had previously been considered an ulcer. The patient recollected that an insect had flown into the eye a little before the in- flammation commenced, and that it had been killed by the application of his hand; the wing had remained closely applied to the cornea, where it brought on inflammation, and the surrounding swelling represented the lips of a small ulcer. Soon after the foreign body was removed, the eye recovered. Acid fumes and vapours are fruitful sources of ophthalmia; as also the ap- plication of gonorrhoea! virus, the discharge from a syphilitic ulcer, or indeed, 484 GENERAL REMARKS ON acrid matter of any sort. These are powerfully aided by intemperance. There can be no doabt of tlio influence of climate in producing inilamniation of the eye; the colder regions of the world are comparatively exempt from these diseases, while they are frequent and peculiarly severe in warm coun- tries. Many writers have accounted for this circumstance, by attributing it to heat, light and dust. It cannot be disputed that any sudden exposure of the eyes to great heat or light, is very hurtful to vision ; and under all circum- stances, long continued exposure without intermission to light and heat, even when neither are very intense, must be injurious. Egypt appears to be the country which of all others is most favourable to the production of ophthalmia. The English and French troops employed in that country in 1801, were haras- sed by the general prevalence of the disease; and in the subsequent expedi- tion the English troops were equally affected. Nevertheless I am inclined to believe that these causes are very much overrated, and that sudden atmos- pheric changes, and the disgraceful intemperance of British troops, have far more influence in producing inflammation of the eyes, not only in warm climates, but in our own, than is generally admitted. It is not uncommon for ophthalmia to appear like an epidemic in this country during the spring and autumn months; and it has been remarked to take place in seasons when there were considerable and sudden changes from heat to cold, more particu larly if attended by moisture. In warm climates these vicissitudes are mort severely felt by the constitution. It will not require any laboured argument to shew that these causes affect the eye by producing alterations in the bal- ance of the circulation, and not so much in consequence of any direct effect on the eye itself. It is but fair to mention, however, that I have myself ex- perienced considerable annoyance from the effect of light in warm climates, but not so much from the sun's rays falling upon the eye, as from the reflec- tion produced by white sandy roads, and white-washed houses, the sensation being quickly removed upon getting into the shade, or walking upon grass. Among the constitutional causes may be enumerated general plethora, dis- ordered state of the bowels, suppression of any discharge which had previous- ly existed for a considerable time, including the constitutional discharges pe- culiar to the female, dentition, general chronic disease of the mucous mem- branes, the diseased state called scrofula, acute and chronic diseases of the skin, the retrocession or metastasis of inflammation to the eye during the pro- gress of gout and rheumatism. Some of the most severe and intractable diseases of the eye take place dur- ing the decline of small-pox, scarlatina, measles, and other diseases of the same class, and constitute one of the numerous evils commonly denominated the "dregs" of these diseases. Treatment of inflammation of the eye.—After the sketches which have been given of the symptoms and causes of inflammation of the eye, it is necessary in this place to give a very short account of the remedial means; but it must be premised, that some remedies are applicable to inflammation of one tissue, THE DISEASES OF THE EYE. 485 and some to that of another. Inflammation of the iris may be adduced as an example, in which the action of mercury is peculiarly beneficial. The treat- ment must vary also with the cause of the disease ; if it be produced by acrid vapour, by the damp or exposed situation of the residence of the individual or by particles of dust engendered during a person's trade or occupation, re- moval from the cause must in general be insisted on, before we can promise success. If any foreign body be lodged in the eye, it must be extracted; and this frequently requires some nicety, if it be imbedded in the coats of the eye, or in the cornea. Foreign bodies, however most frequently lodge under the superior palpebra, and when their existence is suspected, the eye-lid should be completely everted. Cases are sometimes met with, particularly of slight inflammation of the conjunctiva, in which a spontaneous cure takes place; but as such a termination is doubtful, and always slow, we ought to pursue the proper course of treatment. Many cases yield to the application of warm va- pour, warm anodyne fomentations, or astringent washes. These simple reme- dies, together with due attention to the bowels, and confinement to an apart- ment moderately lighted, will often have the effect of subduing the inflamma- tion. But in severer cases of external inflammation of the eye, and in all deep-seated inflammations of that organ, more powerful measures must be used. Of these, general bleeding stands the foremost, and is more particularly indi- cated when the symptoms of inflammation run high,—when the eye cannot bear a moderate light,—and when there is a darting pain through the head.— The indication is still more obvious, if there be fever with a hard pulse ; and more particularly still if the patient be plethoric. The quantity of blood drawn should be proportioned to the urgency of the symptoms, the age, pecu- liarities of constitution, and habits of the patient. The importance of gene- ral bleeding in many cases of ophthalmia, has been long known to the profes- sion ; but, like most of the potent remedies employed for the cure of this and other diseases, it has sometimes been held in great estimation, and at others sadly decried. It is now above twenty years since the disease called the Egyptian ophthalmia created such ravages in the British army, having the double effect of crippling its exertions, and entailing a heavy expense upon the' nation, in the shape of pensions to soldiers who had lost their sight; and when I first entered the army, in the early part of the year 1808, I soon observed sufficient to convince me, that the bad success was owing to injudicious treat- ment, particularly relating to four most essential points :—1. The older mili- tary surgeons, upon whom the treatment devolved, did not seem to be acquaint- ed with the different seats of the inflammation. I never saw any distinction made by one old surgeon, whose wisdom and knowledge were generally ad- mitted and highly extolled, between inflammation of the conjunctiva, and that of the iris; 2. It was matter of surprise to find that eyes were lost in the course of a day or two, when the symptoms were apparently mild, and they seemed to expect to meet with a severe and rapid disease only when there were violent symptoms, and the chief symptom they depended upon was pain; 486 GENERAL REMARKS ON 3. They appeared to be unable to discriminate between acute and chronic in- flammation, which often led them to apply local stimulants most injudiciously; 4. A great deal of the bad success was owing to a systematic plan of taking from all subjects, whether old or young, weak or strong, exsanguined or plethoric, the precise quantity of twelve or sixteen ounces of blood. While acting un- der an old surgeon, the plan of treatment ordered to be pursued, when a man came into hospital was,—" Bleed him, Sir, to 16 ounces, and give him salts." If the patient happened to be better at the next day's visit, an order was giv- en to apply a stimulant, generally the vinum opii. On the following day, if he were worse, the order was,—"Bleed him again, Sir,'! and this alteratioa of practice,—bleeding one day only to weaken the system, without making any decided impression on the disease, and applying local stimulants the next, before the acute inflammation was subdued,—appeared a most decided error in the treatment. So strong was the impression made on my mind, that one day three men were received into hospital, whom I was desired to bleed, and not considering, or perhaps disregarding the consequences of deviating from the regular plan, I bled each of them to syncope, which required the abstrac- tion of from 25 to 35 ounces of blood. The men made rapid recoveries; but the transaction would have cost me my commission, had I not had powerful friends at court. I knew another surgeon, who,although he used to bleed in cases of ophthalmia, place his chief dependence on Dover's powder. To shew how much the Government was alarmed for the state of the army, it may be mentioned, that a male and female quack was hired to take charge of the cases in a cer- tain military hospital; but, as might have been expected, their mysteries and mummeries failed altogether in checking the ravages of the disease. On a subsequent occasion, a medical gentleman joined the army with high pretentions as an oculist. He introduced the practice of everting the eye- lids, which was done in all cases, for the purpose of applying stimulants; and I attributed the loss of a great number of eyes to the indiscriminate employ- ment of this operation, together with not distinguishing the difference between acute and chronic inflammation, as well as between superficial and deep-seat- ed inflammation of the eye. One bleeding will in general surffice, but it should be carried far enough to affect the constitution. Drawing blood from the temporal artery has been strongly recommended by many. I have seen it often practised, but was never sensible of any superior advantage derived from this method; and it may be mentioned, that some practitioners of reputation consider it rather in- jurious. The application of leeches is the most gentle method of taking blood from the vessels in the neighbourhood of the eye; they may be placed either upon the forehead, the temple, or the cheek immediately below the eye. Some object to this means, because the leach-bites occasionally produce considerable swelling, and inflammatiou of the eye-lids, now and then assuming a erysipe- latous character; but it should be recollected, that this will only happen in THE DISEASES OF THE EYE. 487 cases where there is a bad habit of body, in which circumstance the applica- tion may be avoided. Cupping the neck may be had recourse to, either when leeches cannot be obtained, or when it may not be convenient or pro- per to employ them. In conjunctival ophthalmia, particularly when the lin- ing membrane of the palpebra is vascular, the application of the sacrificator to the everted lid will be found very beneficial, and is a speedy method of-taking a considerable quantity of blood from the part affected; but is only to be had recourse to in certain cases hereafter to be noticed. A modification of this last practice has been recommended by Mr. Crampton, (3d vol. Dub. Hosp. report,) which is, to apply leeches to the everted mucous membrane'of the lower palpebra. The beneficial effects of thfe most judicious a copious abstractions of blood will, however, soon be lost, unless followed by other important means, such as, the keeping up a moderately brisk discharge from the bowels, and the use of antimony. Blisters applied either to the neck, or behind the ears, are of- ten serviceable; and in cases of chronic inflammation of the conjunctiva, when the mucous membrane of the intestinal canal is in a state of great irritation I have found it very beneficial to apply the tartar-emetic ointment to the abdo- men, alternately with leeches to the epigastric region; it is in such cases that the frequent use of the warm bath proves beneficial. In acute and even sub-acute inflammation of the eye, the employment of the antiphlogistic regimen is indispensably necessary; but I apprehend that practitioners too frequently run into an extreme, by preservering in the use of slops and low diet for too long a period to the injury of the functions of the stomach. With respect to local applications, some practitioners have great faith in cold lotions of different kinds, and others in warm fomentations, consisting merely of warm water, or its vapour ; a decoction of chamomile flowers, or of poppy-heads. Whether applications are to be warm or cold may be safely left to the feelings of the patient, although the former appear in a majority of instances to be the most soothing. Poultices are used by many, but they are not so serviceable as fomentations; and if there be any tenderness, it is increased by the weight. In pustular ophthalmia, as well as in chronic inflam- mation of the conjunctiva and cornea, stimulants are most conducive to the cure, and perhaps the best is the vinum opii. In such conditions, astringent washes are also used in the proportion of one or two grains of the accetate of lead,or sulphate of zinc, or from one to seven or eight grains of the sulphate of alumina, to the ounce of water. A solution of the nitrate of silver is also employed in different conditions of the eye, as in chronic inflammation of the conjunctiva,, and inner membrane of the eye-lids, as well as the ulce- ration of cornea. Emetics have occasionally been found serviceable in some long-standing cases of conjunctival ophthalmia. Experience has proved that the action of mercury is almost indispensable in inflammation of the iris; but is by no means to be depended upon, to the exclusion of general and local bleediners. 488 GENERAL REMARKS Notwithstanding the general opinion which prevails against the administra- tion of opiates in the disease under consideration, I would strongly recommend them in cases where there are great pain and want of sleep, after the employ- ment of proper depletion. The dose must be proportioned to the urgency of the pain, as well as the degree of constitutional irritation; in severe cases, I have given, with benefit, 60 drops of laudanum, or 30 of Battley's sedative solution; but in either case the dose should be repeated, with half the quan- tity, in the course of two or three hours, if necessary. So long ago as the year 1807, Mr. Wardrop recommended the evacuation of a part of the aqueous humour, by making a puncture in the cornea, in cases of very violent inflammation of the eye-ball, when the pain is intense, the eye prominent, and the cornea slightly opaque; and more particularly when the case appears *to resist other treatment. I cannot speak of this operation from experience; but it appears to have been performed in a few instances with benefit. CHAP. II. INFLAMMATION OF THE CONJUNCTIVA. 1. Simple inflammation of the external covering of the eye, including what is termed by authors ophthalmia mitior et gravior; 2. Simple catarrhal oph- thalmia; 3. Purulent ophthalmia, the description of which will be drawn from the disease as it occurs in infancy ; 4. Pustular ophthalmia. 1. Simple inflammation of the external covering of the eye.—The conjunc- tiva, from its situation, is of all parts of the eye most liable to inflammation. In the natural state, it is rare to see vessels carrying red blood, but on the slightest irritation the vessels of this membrane become injected. It is only in the most intense inflammation of some days continuance, that we see ves- sels on the surface of the cornea. Symptoms of simple inflammation, fyc.—A sensation of itching takes place, sooner or later succeeded by pain, resembling that which is known to be pro- duced by sand .or dust when applied to the eye; redness, heat, tension, and throbbing fjollow, aggravated when the eye is moved, and upon the admission of light. An increased flow of tears is observed, sometimes scalding the cheek, or an unusual dryness of the eye from suppression of tears, which last adds greatly to the pain. In severe cases, the pain shoots from the eye-ball, as it were through the head, or affects the scalp on the forehead over the affected eye. In some instances, there are febrile symptoms, with a full, strong, bound- ing, or hard pulse, generally preceded by rigors or slight chilliness. If the symptoms are mild, the disease is called ophthalmia mitoir; if severe, ophthaU mia gravior. On examining the eye in the acute stage of the disease, the vessels are ob- served to be superficial and distinct, running in straight lines, leaving the in- tervening spaces of a slight pinkish colour; and when the small branches are also well injected with red blood, the conjunctiva has a uniform red appear- ance ; whereas, when the disease is chronic, the vessels become tortuous in their course, assume a purple colour, and are capable of being rolled about from the looseness of the connecting cellular tissue. We judge also of the change in the character of the inflammation by the cessation of the severe throbbing pain, and by the greater tolerance of light. In some cases of the description now under consideration, as well as in those of the affection which 62 490 INFLAMMATION OF has been denominated purulent ophthalmia, the conjunctiva becomes swollen, having a red, granular, somewhat fungous appearance, and considerably ele- vated above the cornea; this state is called chemosis, and is frequently con- founded with ecchymosis, which also takes place occasionally, not only in chronic, but in acute inflammation of the eye. Chemosis is occasioned by thickening and vascularity of the conjunctiva, with an cedematous state of the subjacent cellular tissue. We see on some occasions also an accompanying oedema of the eye-lids, which become much swollen, and occasionally a red fungous state of their lining membrane takes place. In these circumstances, there is some puriform secretion. Treatment of simple inflammation, eye.—In the milder forms of the disease, general bleeding is unnecessary; but if the complaint do not yield to other remedies, it would be wrong to delay opening a vein, particularly if the pulse, be hard, or if there be much excitement in the system. In severe cases, one prompt and copious bleeding will be necessary, followed by the application of leeches, fomentations, strong purgatives, the solution of tartar-emetic, and blisters, as the urgency of the symptoms may require. It is important to con- sider what the circumstances are which we have to dread;—puriform effusion into the cornea, together with opacity, thickening, and ulceration; and the extension of the inflammation to other tissues. Chronic inflammation of the conjunctiva may take place under two different circumstances, viz. either as a consequence of previous acute disease, or as a slow inactive inflammation. In either of these cases, the eye has the appearance formerly described ; and the practice which I would recommend, is to pay more attention than is ge- nerally done to the constitution; the condition of the mucous membrane of the stomach and bowels should be carefully investigated in the manner so fully pointed out in this work. In chronic inflammation, it may some- times be found of great service to scarify the eye-lids, if there is much vascu- lar turgescence of their lining membrane; astringent and stimulating washes must be had recourse to; it is in these cases that the solution of nitrate of sil- ver is found useful, together with the wine of opium, and an occasional blis- ter. It has been recommended to divide the trunks of the small vessels just before they enter the cornea, when there is any tendency to opacity, and when red vessels are seen on that part; and although it may be beneficial in some cases, yet I have seen it injurious in many, by producing additional irritation. SIMPLE CATARRHAL OPHTHALMIA. The particular affection which I wish to denote under this term, is one of very common occurrence in this country, being the effect of sudden alterations from heat to cold; it is in fact called by the vulgar, "a cold in the eye," and generally speaking, is to be considered as a mild description of purulent ophthal- mia, which disease, in its more aggravated form, is known by the appellation, Egyptian ophthalmia—occurring after the application of gonorrhoeal virus to the eye, gonorrheal ophthalmia—and taking place in infants, infantile puru- THE CONJUNCTIVA. 491 lent ophthalmia. They are all the same disease, requiring the same treatment modified by the patient's age and peculiarity of constitution, and by the ur- gency of the case. Symptoms of simple catarrhal ophthalmia.—After exposure to cold, soreness of the eye is complained of, either preceded or accompanied by dullness, and a feeling of general uneasiness, with lachrymal discharge, sneezing, and some- times aching pains in the bones, and some degree of fever. It is a slight in- flammatory affection of the conjunctiva; but the inflammation is in some cases so very great as to destroy the eye. In addition to pain, intolerance of light, and the other symptoms described in the last section, we find a puri- form discharge, and some swelling of the eye-lids. The eye-lids, though frequently washed, quickly become glued together by the drying of the mat- ter, so that, in making examinations, as well as in cleaning the eye, great mischief is frequently done by forcibly opening the lids, and thereby produ- cing additional inflammation. After the disease is a little advanced, the eye, upon examination, will sometimes be found in a state of chemosis, and we should make at least one daily inspection to ascertain the state of the cornea. If there be no opacity or dimness of the cornea, and no vascularity or ulce- ration on its surface, the case may be regarded as doing well; but should any of these circumstances be observed, the loss of vision may be dreaded. Treatment of simple catarrhal ophthalmia.—The same general plan of treat- ment as recommended in simple inflammation of the conjunctiva should be had recourse to. Attention must be paid to discover when the disease has passed into the chronic stage, that we may have recourse to remedies of an astringent nature; care should be taken to keep a small piece of linen twice folded constantly applied wet to the eyes; at all events the eyes should be well soaked with some tepid fluid, before any attempt is made to separate the palpebral. I shall have to speak hereafter of the proper plan of treatment, when ulceration of the cornea takes place ; I shall now only further mention, that the inner membrane of the eye-lids is frequently left, at the termination of the disease, in a soft, swollen, spongy condition. Should the ordinary as- tringents fail, the scissors of the surgeon, or what perhaps answers fully better, the application of a piece of lunar caustic, may be used once every^hird day, taking care to evert the eye-lid completely, and to bathe the part with a little milk the moment after the caustic has passed over its surface; this renders it innocent to other parts of the eye. In the acute stage, the warm bath and an- timony will be found peculiarly serviceable, as well as repeated doses of Dover's powder. In cases where the introduction of syphilitic virus into the eye is suspected, it must be left to the discretion of the practitioner whether to use mercury or not. Perhaps it ought not to be given in the first instance; but in the case of syphylitic, gonnorrhceal, or any other acrid matter producing inflammation, the knowledge of the fact should lead us to watch the progress of the case more anxiously, and be ready to apply the most potent remedies speedily, 492 INFLAMMATION OF should they be necessary from the extent and intensity of the inflamma- tion. An interesting case may be mentioned, which terminated very fortu- nately :—A young man came to the hospital with violent inflammation in one eye, attended with slight purulent discharge ; he complained of excruciating pain both in the eye and head, and a large ulcer was discovered on the cornea. Upon examination, a purulent discharge was observed coming from the urethra, although he had previously denied the existence of gonorrhoea. Notwithstanding the advanced stage of the disease, I instantly resolved to open a vein, as he was stout and plethoric, and as his pulse was strong and hard. There was little probability of saving the eye, and it was fully ex- pected that the contents of the eye-ball would escape in twenty-four hours; but it was necessary to mitigate his sufferings, which he described to be ago- nizing. The blood was allowed to flow till the approach of syncope. Slight epileptic convulsions followed, which went off immediately upon his being laid down on the floor ; he was now in an extreme state of weakness, and was threatened with a return of the convulsions upon making the least exertion, as well as when he was raised for the purpose of being placed in bed. When in this state, it was a matter of surprise to me, to find scarcely a trace of one vessel upon the eye, which had a few minutes before been exceedingly vas- cular, and the ulcer on the cornea already appeared as if it had received a death blow. The blood was accurately weighed, and the quantity found to be fifty-six ounces. In a day or two a slough separated, and the ulceration was found to have extended throughout the whole depth of the cornea; the only part which remained was .its lining membrane, which was pushed out by the aqueous humour, forming an appearance like a hernia. From this time the healing process continued ; the cicatrix which afterwards formed, at first interfered with the sphere of vision, but the patient could see all objects above him ; gradually,, however, the cicatrix diminished in size, a very slight speck is left on the lower part of the cornea, and vision is now quite perfect. PURULENT OPHTHALMIA OF INFANTS. The disease of which I have now to treat, is an inflammation of the tunica conjunctiva of the eye; occasionally attacking children soon after birth, and frequently, when unopposed by proper means, rapidly destroying the struc- ture of the eye, by producing alteration of texture of the cornea, and some- times, though rarely by extending to, and injuring the deep-seated parts of the eye. It is now many years since this disease first attracted the notice of medical men, but we had no good description of it till Mr.Ware,a celebrated ophthalmic writer and practitioner, published an account of it, and he was soon followed by several continental writers, particularly by Reilius and Schmidt in Germany. The tunica conjunctiva, and the reflection of it forming the lining mem- brane of the eye-lids, has been considered, and I believe very properly, as a mucous membrane. It is the principle seat of the disease, and undergoes a change, when inflamed, analogous to that of other membranes of the same class. THE CONJUNCTIVA. 493 Symptoms of purulent ophthalmia.—The date of the attack after the birth of the child varies. I have detected it on the second day, and it may occur at any subsequent period; but, generally speaking, it takes place before the sixth week, usually during the course of the first fourteen days. It may attack one eye only, but it commonly happens that both eyes are simultaneously affected. It is often difficult, if not impossible, to write a good description of the symptoms of a disease in infancy, but I shall here record nothing but what I have noted down at the bedside. A child affected with purulent ophthalmia, is observed to be very restless and fretful, particularly when exposed to light, although it keeps the eye-lids firmly closed; it never opens them to look about, as infants usually do, who are readily attracted by the light of a candle or the blaze of a fire. At the onset of the disease, a slight redness is first observed on the conjunctiva lining the eye-lids, especially about the inner canthus, attended with a secretion of whitish matter. There are generally observed also some heat of skin, and a foul tongue. The eye-lids soon ap- pear red and swollen, or the eye-lashes are found matted together by a gluti- nous exudation. Whenever any of these appearances are observed, the eye should be minutely examined, after it has been properly soaked with warm milk and water, so as to soften the matter which seals tiie lids together. On no account ought the examination to be proceeded in before this preparatory step is fully accomplished, as I have seen great mischief done by nurses, and impatient medical men, by forcing open the eye-lids, thereby occasioning great immediate suffering, and subsequently increasing the inflammation. I hope to be excused by those medical men who largely indulge in the filthy habit of taking snuff, for urging upon them the necessity of taking care that the fingers employed in opening the eye-lids are clean, and that they keep their noses in such a situation, that none of the noxious herb may fall into the eyes of the poor little sufferers. As the disease proceeds, a discharge of tears mixed with the secretion takes place when the eye-lids are separated, and the itching is so great that the fingers of the child can scarcely be kept away from the eyes; swelling of the eye-lids soon follows ; the discharge in- creases in quantity, becomes more puriform, and sometimes so acrid as to excoriate the cheeks. The inflammation, if it have not already affected that part of the conjunc- tiva which covers the eye-ball, soon extends to it; numerous blood-vessels are seen of a bright scarlet colour, sometimes giving the appearance of chemosis; the quantity of matter is occasionally very great indeed, and when the eye-lids are allowed to be glued together for some time, it collects, pro- ducing great distention, and when they are opened, a tea-spoonful or two of puriform matter gushes out. In neglecting cases we discover disease in the cornea, perhaps on the first examination, or that it is already destroyed. The external skin of the eye lids in some cases become affected, being red, swollen, and of a livid colour, particularly when the infant struggles or cries. The inflammation in some instances extends to the lachrymal sac and duct, 494 INFLAMMATION OF and lining membrane of the nose, from which a similar puriform fluid is dis- charged. As the complaint advances, portions of the cornea put on a dusky appear- ance, become elevated, and in the course of perhaps twenty-four hours, a pro- cess of separation commences. The slough, when thrown off', leaves a rag- ged ulcer of an ash colour, the bottom of which is coated with a brownish matter. These sloughing ulcers vary in number, generally there is only one, sometimes there are several, and occasionally the whole cornea sloughs at once. As soon as one slough separates, another begins to form, which process goes on, if the disease be not arrested, until the ulcer penetrates into the anterior chamber of the eye, when the aqueous humour is discharged and the iris pushed through the opening. The ulcer on the cornea may not be disposed to heal, or may enlarge, allowing more and more of the iris to protrude, which in its turn ulcerates; at last it happens in some neglected cases, that the lens and vitreous humour are expelled, and vision is forever destreyed. In some rare instances, with or without opacity, or ulceration of the cornea, the in- flammation extends to the deep-seated parts of the eye, and vision may be de- stroyed by internal disorganization. Such is a general outline of this disease in its most malignant form, when allowed to run its course, or when the inflammation is aggravated by impro- per treatment,—a disease which, when early opposed by proper means, is sel- dom productive of any bad effects. When the inflammation is arrested at the period that the cornea first begins to slough, opacities or small specks are ge- nerally left; but when it advances still further, and the iris is protruded, sta- phyloma is generally the consequence. It has been supposed by some authors, that the acrid discharge produces the ulceration of the cornea,—by others that the cornea begins to ulcerate from within ; but I believe the best informed practical men are convinced, that both opinions are erroneous, and that the disorganization of the cornea arises solely from the violence of the inflammation; and it is highly important to keep this fact in view. Much irritation and discharge are sometimes kept up for a considerable pe- riod by a diseased state of the lining membrane of the eye-lids, which, when examined, present a swollen, spongy, granular appearance, and more or less of a red colour. This state of parts frequently occasions relapses, till at length chronic inflammation steals slowly on some tissue of the eye-ball itself, which ultimately impairs or destroys vision Causes of purulent ophthalmia of infants.—These are stated to be various. The most common are cold and damp, exposure to too much light and heat, to which infants are very liable when nursed in the lap, and to smoke or acrid vapours; and I believe it is occasionally produced in consequence of mechani- cal injury inflicted on the conjunctiva by the child's own nails. Purulent Ophthalmia is said, by some, to be produced by the direct application of acrid matter to the eyes of the infant during parturition. This is very probable THE CONJUNCTIVA. 495 if the mother be affected with syphilitic chancres, or gonorrhoeal discharge; but on the other hand, I have known many women so diseased, whose chil- dren were not attacked by purulent ophthalmia. Others maintain, that it is invariably produced by the peculiar discharge called the whites ; but experi- ence completely disproves this assertion, for if it were the case, scarcely a new-born babe could, by possibility, escape, as a very large proportion of women are affected with whites during pregnancy, particularly in the latter months. Treatment of purulent ophthalmia of infants.—Regarding the disease, in severe cases, as one of intense inflammation, the treatment is easily understood. The only difficulties with which practitioners have to contend are, first, to determine whether or not the disease be too far advanced to admit of any hope of success ; and secondly, whether or not the inflammation has yet become chronic. With respect to the former, it may be stated, that long standing and most unpromising cases occasionally do well under the active management which is here recommended. We must not allow ourselves to be guided by the number of days the disease has existed, but by the state of the eye itself after minute and careful examination, comparing that with the constitutional symptoms, together with the strength and peculiarities of the patient. With respect to the second difficulty, some experience is no doubt required. The appearances presented by chronic inflammation, however, have been already fully described, and must be kept in recollection. It has been already stated, that both eyes are generally simultaneously inflamed, but one eye is found to be more intensely affected than the other; young practitioners must be upon their guard not to fall into a common, but very natural error, of directing their sole attention to that organ which is in the most dangerous condition, to the comparative neglect of the other, which, when subsequently examined, is too often found to be irreparably lost. Gene- ral bleeding in early infancy is altogether out of the question, therefore we must have recourse to leeching; and most infants stand the effects of the application of two leeches remarkably well, if the draining of blood be not allowed to go on too long. If both eyes be affected, a leech may be put on each temple, within about half an inch of the external canthus of the eye, for when applied too near the part, the loose tissue of the eye-lid becomes swol- len, inflamed and ecchymosed, creating alarm, and an impression in the minds of those most interested, that the. abstraction of blood has done harm. This opinion may make them unwilling to repeat the application of the leeches, which should be done, perhaps, every four or six hours, according to the strength of the patient, till the violence of the disease is subdued. The bowels are to be acted upon by two or three smart purgatives repeated at short intervals, such as one grain of calomel combined with two grains of scammo- ny ; but subsequently milder means may be had recourse to. It is of great consequence to keep the eyes clean, not because the matter, if allowed to lodge, would injure the cornea, but to prevent it from sealing the lids together. 496 INFLAMMATION OF This is best effected by keeping the infant upon its back, while a small piece of wet linen rag is applied to each eye, and a little milk and water dropped occasionally upon the inner canthus. The necessary precautions already mentioned, before any attempt is made to separate the lids, must be carefully observed. I have seen much mischief done by the incautious and too frequent use of the sponge, as well as by injecting fluids between the eye-lids, an ope- ration which ought never to be confided to a nurse. With respect to the operation of scarifying the lining membrane of the eye-lids, I have often had doubts whether it did not do more harm than good; and in many instances, I have seen it decidedly injurious. Experience has taught me, however, that it is one of the most effectual parts of the treatment, not only in the chronic, but in the acute stage, after the intensity of the dis- ease has been somewhat mitigated by the application of leeches, and the ad- ministration of purgatives. The scarfiications are to be made very slightly, as their edges sometimes suffer from subsequent irritation and inflammation. To procure the full effects of scarifying, the eye-lid should be carefully everted, the child steadily held, and a large quantity of blood allowed to flow before the part is returned; to effect which, the scarificator should have a very fine edge; and instead of wiping the surface with a warm sponge, it should be done with a piece of dry soft linen. Scarifications are also occasionally of great use in the chronic stage, when the part is very vascular; but they are seldom serviceable, and often injurious, after the membrane becomes soft, spongy, and granular. The light should be excluded from the apartment. In bad or doubtful cases, the state of the cornea should be minutely examined twice a-day, and once when the case is going on well. The warm bath ought to be used morning and evening; the diet should be restricted at this early period of life to the breast-milk. We judge of the effect of the remedies in reducing the disease, partly by the diminution of the constitutional symptoms, and quiet- ness of the infant, and partly by the diminution of the discharge, as well as by the child opening the eye; but in order to ascertain this last point, it is necessary to watch its motions before light is admitted into the apartment, because the moment this takes place, the eyes will be closed, and the child will forcibly resist their being opened. An occasional opiate will be found useful in allaying pain and irritation, and producing sleep. One drop of the sedative solution of opium forms a good full dose. The state of chronic inflammation has been already frequently alluded to, but perhaps in the circumstance now under consideration, it is a term not very happily chosen. After acute inflammation of the eye has sub- sided, the vessels are left in a gorged state; the swelling in the surrounding tissues gradually diminishes, leaving the vessels tortuous and loose, the blood contained in them being of a darker colour; the inflammation is destroyed, but the vascularity remains, and the remedies which subdue the previous action will, if continued, rather tend to increase than diminish it. At the THE CONJUNCTIVA. 497 same time, I have to urge the remark which was made in the first volume, and which applies with double force to the diseases of such a delicate organ as the eye, viz. that practitioners are too meddlesome, and do not give suffi- cient credit to the restorative powers which a living organ possesses; or per- haps, from their own physiological and pathological dimness, they must always be doing something for appearance's sake. I have seen much mischief done by officiousness; therefore as soon as the inflammation is either nearly or altogether subdued, I follow a passive plan with respect to applications, and content myself With keeping the eye tolerably clean, and the eye-lids unsealed, at the same time that the precautions with respect to light, diet, and state of the bowels, are strictly attended to. In a day or too after convalescence has been established, an astringent, nay, even a stimulating application, may be necessary and serviceable, should the vascularity still exist, or should the mu- cous membrane be in the fungous granulated state already mentioned. Many use the application as a matter of routine practice, whether these conditions exist or not, so that they often irritate the eye, and produce relapses. Should the fungous granular state resist the use of ordinary means, caustic must be applied, or surgical aid obtained, and the part clipped or cut off, at first recom- mended by Reid, who, by the date of his work published in 1706, appears to deserve the merit of the originality of the plan, which has been of late years again brought before the profession by Mr. Saunders, and claimed as a dis- covered by Sir William Adams. Immediately on the decline of the disease, some insist much upon the bene- fit to be expected from tonic medicines; but whatever may be said in their praise in old worn-out constitutions, their effects in early infancy are very questionable. In some cases, where considerable debility prevails, particu- larly where there is a somewhat exsanguined appearance, I find considerable benefit from the occasional exhibition of one, two, or three drops of brandy, mixed with a little milk from the nurse's breast. To many great and pom- pous practitioners, who depend much upon mystery, this plan may appear vulgar and unscientific,—let such people give a few drops of "Huxara's tincture of bark." The experienced reader will have remarked, that the effect of blistering has not hitherto been noticed in the treatment; but it was purposely avoided, to be made the subject of my concluding observations. In the general remarks, I have already spoken of the advantages to be derived from the application of a blister to the temples, behind the ears, or to the back of the neck, in in- flammation of the eyes; the same benefits may be expected in purulent oph- thalmia ; but in young infants, the blistered surface is liable to slough, and death will so frequently follow such an occurrence, that I entertain considera- ble repugnance at applying a blister to a new-born child ; and it is impossible I shall ever forget the fright experienced on the last occasion I applied one in purulent ophthalmia. The case was severe; the parents had heard of the good effects of blistering, and I was urged by them to apply one. My objections 498 INFLAMMATION OF were honestly mentioned, but they still insisted; and a blister was accordingly applied, with the precaution too of placing a piece of fine gauze between it and the skin'; a deep slough took place and the child made a narrow escape from death. PUSTULAR OPHTHALMIA. This disease appears to be a chronic, or perhaps, rather a sub-acute inflam- mation of the conjunctiva, speedily terminating in the formation of pustules. At the commencement these pustules have a red or yellowish appearance, slightly elevated, surrounded by a considerable turgescene of vessels, varying very much in size, number, and situation, and sometimes attended by consi- derable pain; but at other times no inconvenience is complained of, either local or constitutional. It is a disease produced by exposure to cold. Treatment of pustular ophthalmia.—In general this is a very manageable disorder, and is quickly cured by dropping into the eye a little vinum opii, or a solution of nitrate of silver twice a-day. But should the pustules be very painful, attended by headache and febrile symptoms, and, more particularly, should they be situated upon the cornea, where they sometimes leave ulcera- tions, more active means should be employed. A number of leeches must be applied, perhaps a vein opened, a few strong purgatives exhibited, and recourse had to the other means which are employed in cases of severe inflammation of the eye. After the acute inflammation is subdued, which we are to judge of by the diminution of the symptoms, the vinum opii may be used. Should ulceration take place upon the cornea, it is to be treat- ed in the usual manner. I have been assured by Dr. Robertson, that much greater advantage has been derived from the application of blisters behind the ears, or to the nape of the neck, than from any other means. CHAP. III. INFLAMMATION OF THE EYE-BALL. 1. Inflammation of the Sclerotic Coat.—2. Inflammation of the Iris.—- 3. Amaurosis. 1. Inflammation of the sclerotic coat.—Inflammation of the sclerotic coat is distinguished from that of the conjunctiva by the vessels being of a more pinky hue, by their lying deeper, and by their not being moveable on mak- ing the conjunctiva slide upon the sclerotic, by pushing the former membrane from side to side with the finger, the eye-lid being slightly interposed between the finger and the membrane. The pain complained of in this disease is of a rheumatic kind, and more uneasiness is felt in the different motions of the eye-ball; it is also in many instances vicarious with gouty and rheumatic af- fections of other parts of the body. In such instances, remedies which prove useful in rheumatism and gout are to be used, in addition to those required in simple inflammation. Of these I may mention, that I have seen great ad- vantage result from the exhibition of colchicum, and Dover's powder. In almost every case of iritis, the sclerotic is found to participate in the inflam- mation.* 2. Inflammation of the iris.—Inflammation of the iris received the denomi- nation of iritis from Dr. Schmidt of Vienna, and by that term it is now generally known. The symptoms are of a very violent nature when the in- flammation is acute, particularly after it has existed for twenty-four or thirty hours, when the patient's sufferings are often agonizing; severe pain over the eye-brow is rarely wanting, it commonly comes on in paroxysms. The con- stitutional symptoms are very similar to those which occur in other acute in- flammations of the same organ, but there are local appearances which are highly characteristic. In iritis, vessels are seen running in straight lines towards the cornea be- neath the conjunctiva, but they suddenly disappear before they reach the * I have thought it unnecessary to treat of inflammation of the sclerotic coat at much length, because it is a disease which rarely takes place unless the inflammation be con- nected with gout or rheumatism, or have spread from other tissues. Neither shall I treat of inflammation of the choroid coat, although I believe it sometimes occurs uncompli- cated. I must therefore refer my readers for more minute information on these subjects, to any of the numerous works upon the eye, and particularly to the " Compendium of the Diseases of the Human Eye," by Mr. Watson, of Edinburgh. 500 INFLAMMATION OF cornea, leaving a whitish zone round it. This appearance is peculiar, and no doubt arises from the vessels passing at this part through the sclerotic to be ramified on the inflamed iris. As soon as the zone appears, the iris loses its proper colour; in some rare cases it becomes distinctly red. Jannin relates a case in which the iris resembled a piece of raw flesh ; Beer saw it of a blood-red colour, and Conradi observed it of the same colour after a wound of the eye. Dr. Robertson states, in a paper on iritis in the Edinburgh Medical and Surgical Journal, that more than once he has seen spots of a blood- red colour upon its surface. When the iris changes its colour, it first com- mences at the pupillary margin, and the colour it assumes when inflamed, is that which would be produced by a mixture of red blood with the natural pigment of the iris. The pupil becomes contracted and irregular, being slightly drawn upwards and inwards. It is also worthy of being mentioned, that the vessels in iritis, as in inflammation of the sclerotic coat, present a pe- culiar pink colour. The retina sometimes becomes affected. This is indicated by greater sen sibility to the impression of light, deep-seated pain darting through the head, and an appearance of sparks of fire and flashes of light before the eyes. If iritis be not speedily cured, it terminates by the effusion of small masses of lymph, sometimes even of blood, and more rarely by the effusion of puriform matter. The first mentioned terminations probably take place when the serous membrane covering the iris is principally affected, the last, when the substance of the iris suffers a high degree of inflammation. The effusion of lymph sometimes produces adhesions between the margin of the iris and the capsule of the lens, by which its motions are completely lost, the pupil subse- quently remaining immoveable under every change of light. When the effusion is considerable, it is seen hanging in tufts from the pupillary margin, or stretching in bands across the pupil, and sometimes exists in such quantity as to destroy vision. Occasionally this effused lymph becomes organized, and red vessels may actually be traced by the naked eye. Another termination of the disease is by the formation of the abscess in the substance of the iris itself. Its situation varies, but for the most part is found on or near the pupillary margin. This abscess may terminate in two ways,—by bursting, as most fre- quently happens, and discharging its contents into the anterior chamber, form- ing the appearance which is called hypopion,—or, as the disease declines, by the absorption of the matter. In some rare instances it has happened, that ulceration has taken place after the discharge of the matter from the abscess. In this disease the iris is sometimes pushed forward towards the cornea, assuming somewhat of a conical shape; and occasionally it comes in close contact with the cornea, now and then adhering to it by the pupillary margin, and generally by a single point. It has often been remarked, that when the iris of one eye is affected, the disease frequently attack the other, and sometimes both eyes are affected simultaneously. THE EYE-BALL. 501 Causes of iritis.—Cold is no doubt the most frequent cause of iritis; it may be also produced, as has already been stated, by the extension of inflam- mation from other tissues, as well as by external injuries, and the application of too stimulating remedies for the cure of acute external inflammation. It is alleged by most authors, and is very generally believed, that iritis is most frequently excited by the action of mercury, and it is rather a curious cir- cumstance, that mercury is nevertheless exhibited for the cure of the disease, which it as alleged to have excited. This erroneous impression seems to have originated in the fact, that people, when taking mercury, have been attacked with iritis. If mercury were a cause of iritis, I ought to have been very fa- miliar with the disease, when the use of mercury was more in fashion than it is in the present day; it ought then to have been a hundred times more frequent than at present; but this is not the case. There can be no doubt, however, that iritis, is apt to occur when a person under the influence of mercury, or any other debilitating remedy, has been exposed to cold. Treatment of iritis.—At the commencement of the attack, one determined bleeding will do more good in checking the diseased action, than repeated small bleedings. The quantity of blood to be drawn must be determined by the peculiarity of the case, and by the circumstances already so fully mention- ed. Subsequently, recourse is to be had to topical bleeding, repeated or not according to circumstances, and blistering. After the violence of the inflam- mation has been reduced by one general bleeding, our chief dependence is to be placed on the use of mercury, so as to affect the system very rapidly. This is a most important improvement in the treatment of iritis, for which we stand indebted to Dr. Farre, but it seems to have been known to Beer and other German oculists, long before its introduction into this country. The plan which I generally follow, is to give a grain of calomel every hour during the day, and five grains at bed-time in a pill, with a grain or two of opium; per- haps Dr. Robertson's plan is preferable—to give two mercurial pills every hour, combined with opium, if they affect the bowels with griping or purging. As soon as the system becomes affected with mercury, the patient experiences a very considerable abatement of the pain, as well as of the feeling of fulness and tension of the eye ; the sight becomes improved and clearer; the redness diminishes ; the iris assumes its natural colour; and the irregular and contracted state of the pupil, as well as the effused lymph, (if any exist,) begin to disap- pear. I can most conscientiously join those who state that they have often seen cases of iritis in which it was to be regretted that mercury had not been given, and that they never had occasion to regret having prescribed it. When the " hydrargyrophobia " was in greater vogue than at present, I knew several surgeons who were temporarily affected by it, till they lost the eyes of patients from iritic inflammation, which they had never done before, when they used mercury. They bitterly regretted having forsaken a plan which they had previously found so generally successful, to adopt another from the false assu- rances of its invariable success. Dr. Robertson thinks that mercury can 502 INFLAMMATION OF scarcely be praised too highly in this disease, which, when allowed to proceed, more especially after lymph has been effused, too frequently ends in the loss of the finest sense we possess. When once the pupil has been obliterated by the effused lymph, and time has been allowed to glide on, it is next too impossible to restore sight by any remedies we possess, for it becomes so completely organized, that even mercury loses its influence over it. The only resource that remains for the patient is the formation of an artificial pupil, at all times a difficult operation, and in such cases exceedingly apt to be unsuccessful from the recurrence of inflammation of the iris. Indeed no attempt should be made to form an artificial pupil as long as the slightest susceptibility to inflammation exists; perhaps it ought never to be performed till one or two years after the occurrence of the iritis. In some constitutions, Dr. Robertson assures me he has derived great benefit from the use of colchicum, particularly in gouty and rheumatic habits, in which iritis is by no means unfrequent; so great indeed has been his success with this remedy, that he generally tries iti> effects before having recourse to the mineral. It is only, however, where the disease has not proceeded far, that he has been thus successful with this medicine. When lymph has been effused, we have no resource but mercury. He has tried iodine in such cases, and he thinks with some benefit, but they are not suffi- ciently numerous and precise, to allow him to give a decided opinion with regard to its utility. He would, however, recommend its employment, together with that of the colchicum, to those who can see nothing but poisonous qualities in mercury. The extract of belladonna is to be rubbed over the eye-brow and forehead or on the temple or cheek, early in the disease; or a strong solution of it may be inserted between the eye-lids every second or third hour. If no effusion have taken place, the pupil will be regularly and considerably dilated in the course of a short time ; but if adhesions exist between the iris and other parts, the dilatation will, of course, be only partial. It is often necessary, when lymph has been effused, to continue the belladonna for some length of time after other remedies have been discontinued, in order the better to secure the natural functions of the iris. When the inflammation is severe, scarcely any dilatation is occasioned by the belladonna; its use will, however, prevent the pupil becoming still more contracted; but as the inflammation subsides, the advantage resulting from its application becomes more apparent. Some say, that as soon as the dilatation of the pupil is produced, the pain and other symptoms disappear, from which they infer that belladonna is a powerful re- medy in destroying the inflammation ; but this is not the case, the dilatation merely indicates the cessation or diminution of the inflammation, towards which it does not contribute. The extract of hyosciamus seems to possess the same qualities as that of belladonna; so that, should the one lose its powers; the other may be substituted. THE EYE-BALL. 503 AMAUROSIS. The term amaurosis, as at present used, is employed to denote a partial 01 total loss of vision affecting one or both eyes, arising from various causes which destroy the functions or structure of the optic nerves and retina. The symptoms of amaurosis are so very various, depending upon the cause of the affection, that it is impossible to give a good general description of the pro- gress and termination of the disease in this work, from want of space. I shall therefore be obliged to deviate from the general plan, and commence the subject by describing the causes, as far as they are known, upon which amaurosis depends. Causes of amaurosis.—1. Amaurosis may be produced by inflammation of the retina, which is fortunately a rare disease, as the severity of the symptoms occasions great suffering to the patient, and is frequently followed by loss of vision. The inflammatory action may be acute or chronic, a primary or a secondary disease; generally it is a secondary disease, the inflammation spread- ing from the choroid coat. 2. It may be produced by congestion of the ves- sels of the retina. 3. By congestion of the vessels of the brain, as in apo- plexy. 4. By destruction of those parts of the cerebral mass, upon the healthy state of which vision depends, blindness being well known to be the consequence of many affections of the brain,—as of inflammation with extensive effusion into the ventricles,—inflammation of the substance of the brain,—ef- fusions at the base of the brain,—and tumours pressing on the parts on which vision depends; blows also, on the supra-orbital region, have been known to produce the disease. 5. Narcotics, and the abuse of ardent spirits, are so well known as the causes of temporary loss of vision, that they need not be men- tioned. 6. Amaurosis has been known to be occasioned by gastro-intestinal irritation, produced by worms,—by indigestible matters,—and by particular articles of food. During the time of Buonaparte's political influence on the continent, he prohibited the importation of our colonial produce, and we are told by Professor Beer, that amaurosis became more frequent than it had been formerly, owing to the substitution of a vegetable matter, called chicoree, for coffee. 7. Amaurosis is sometimes vicarious, with cutaneous af- fections, and with discharges of various kinds. 8. Some cases are on record. where it took place during pregnancy. 9. It is also said to occur during den- tition, whether in consequence of determination of blood to the head, or of disordered state of the stomach and bowels, does not appear. Symptoms of amaurosis.—It will be seen from the preceding statement of the various causes of amaurosis, that it is impossible to devote a sufficient number of pages in this work to a minute description of a disease, the symp- toms of which must be so very various, occurring under such different circum- stances. I may mention, however, that imperfect vision, pain in the eye-ball and in the head, flashes of light and illuminated sparks, dark spots, or other optical illusions, appearing before the eye, accompanied with a preternatural Btate of the pupil, which is generally dilated and immoveable, announce the 504 INFLAMMATION OF existence of this disease. But this state of the pupil is not always present, and when present does not, exclusively considered, justify the inference that the eye is amaurotic, such states being also produced by the condition of the iris itself and the ciliary nerves, independently of disease of the retina. An irregular, dilated, and commonly immoveable pupil, together with the loss of its jet black colour, and a tremulous motion of the diseased eye, are the more common appearances of amaurosis. Sometimes amaurosis comes on suddenly ; at others gradually and partially, the patient recovering vision en- tirely, and losing it again and again, till at last it becomes permanently de- stroyed. Squinting with the diseased eye takes place in amaurosis, but it is not in general permanent; it is only remarked for a short time, after a per- son looks at another object, it being some time before the muscles of the dis- eased eye are able to place it in the same direction as the other. Treatment of amaurosis.—The remedial agents must vary according to the cause of the disease. It is quite evident that, in the first three causes enume- rated, viz.—inflammation of the retina, congestion of the vessels of the retina, and congestion of the vessels of the brain, depletion by opening a vein, and applying leeches or cupping glasses, more or less actively pursued, must be had recourse to ; the chief circumstance of consequence is promptness. In the fourth case, viz. disease of the cerebral parts on which vision depends, as concussion, inflammation, and tumours, I have to remark, that in the two former states of the brain, the treatment necessary for the removal of such disease must be had recourse to, but in the latter no treatment can have any effect. In the cases produced by narcotics and intoxicating liquors, the amau- rosis is only temporary; if the patient recover from their effects, the sight for the most part is restored. In cases depending upon gastro-intestinal irritation, the offending cause must be removed, and the bowels subsequently attended to. Should the disease be connected with cutaneous affections, and with dis- charges, bleeding may produce relief, but it will only be temporary ; the chief dependence must be placed, either on restoring the cutaneous disease—or the discharge, or using means to enable the constitution to do without them, viz. by the occasional application of leeches, but especially free purging, and a dry unstimulating diet. Occurring during pregnancy, it will in all probability vanish, like many other unpleasant symptoms, after delivery; but minute in- vestigation should be made, in case the amaurosis should depend upon some of the other causes, when suitable remedies are to be used. If the disease should ever take place during dentition, leeching and purging will be neces- sary ; but lancing the gum will be found to be the most certain remedy. Nux vomica has been long known to possess considerable powers in pa- ralysis, and since its active principle strychnia has been discovered, it has been found of more service in the same set of affections. Strychnia has been lately tried in France in amaurosis by Lembert, and in some cases with marked benefit. It is evident, however, that as a cure is not to be looked for in pa- ralysis of a limb if its structure be destroyed, or the brain and spinal marrow THE EYE-BALL. 505 or principal nerves be diseased past recovery; so neither can. we expect to cure amaurosis by strychnia, or any other remedy, if the structure of the eye be destroyed, or if any organic lesions exist in those parts of the brain, which are known to be connected with vision. But I have no doubt strychnia will be found serviceable in amaurosis depending upon different functional de- rangements. It has been lately introduced into this country, and has been used in the royal infirmary of Edingburgh by Dr. Shortt and Mr. Linston. The manner of employing it is to sprinkle a quarter of a grain daily upon a newly blistered surface on the temple, increasing the quantity gradually till some manifest effect is produced. The blister requires to be renewed every third or fourth day; a little smarting is felt on the application of the strychnia, and it has produced erysipelatous inflammation of the part. The constitu- tional symptoms occasioned by the strychnia, are head-ache, agitation, and tremors of the whole body; sometimes shooting pains in the eyes, and occa- sionally cramps and convulsions have followed. When any unpleasant symp- tom takes place, the dose is to be lessoned or intermitted. It is stated that the best antidote is the application of the acetate of morphia to the blistered part, or the internal use of opium. The reputation of the remedy is likely to be very much injured by the indiscriminate and empirical use which may be made of it. The experiment has been tried by Dr. Shortt, and with complete success in three cases; but out of five cases treated by Mr. Guthrie in the Westmin- ster Opthalmic Infirmary, in one instance only was evident and considerable benefit observed. I have lately had occasion to try strychnia in a case of amaurosis in a young gentleman. The disease succeeded a severe blow on the left temple; considerable inflammation of the corresponding eye followed, and vision was destroyed. The organization of the affected eye looked perfect when he fell under my care; the pupil contracted on the application of light; and he could always perceive the difference between night and day. Daily for a week, a quarter of a grain of strychnia was applied upon a recently blistered surface on the temple. No effects were produced except preventing strabis- mus. During four days, half a grain was used daily. One day half a grain was applied twice; a pricking sensation was felt in the hands and feet: on this occasion, during sleep, he was observed to be affected with slight spas- modic twitches and general startings. For two days after this, half a grain was applied daily, and on the third a whole grain was used, without any benefit. 64 CHAP. IV. DISEASES OF THE EAR. In this chapter I shall treat, and that shortly, of Otitis and Ottorrhoea. OTITIS. The symptoms of this affection may be considered under three heads, viz. 1. Common ear-ache; 2. Inflammation and suppuration external to the tympanum; and, 3. Inflammation and suppuration of the internal ear, which are sometimes connected with caries of the petrous portion of the temporal bone, the disease spreading even into the brain 1. Ear-ache.—This affection most frequently occurs during infancy and childhood; but adults are by no means exempt from it. It is a very painful, but not a dangerous disease, and is often ushered in with threatening symp- toms, such as violent head-ache, fits of screaming, flushed face, quick pulse, great restlessness, and sometimes delirium. 2. Inflammation and suppuration external to the tympanum.—This disease is generally accompanied by more severe symptoms, and unless the inflamma- tion be immediately checked, is of longer duration. It generally commences with rigors, followed by smart fever, flushing of the face, headache, severe paroxysms of pain darting through the ear, and occasionally some degree of delirium; the ear is tender to the touch, and sometimes pressure cannot be borne. On examination, the inner membrane is found to be swollen, and of a red colour; and in consequence of the swelling, and inflammation, more oi less deafness is produced, with an occasional hissing sound. 3. Inflammation of the internal ear.—The symptoms, both local and consti- tutional, are generally although certainly not always, more severe ; and it is more important to subdue the inflammation in an early stage. If allowed to go on unmolested, the disease advances rapidly or slowly, according as the in- flammatory action is acute or chronic, partial or extensive; the tympanum becomes ulcerated and destroyed, together with the lining membrane of the different parts of the internal ear; the small bones are detached and discharg- ed, and the hearing, on the side affected, becomes irreparably lost. When the bone is affected, the matter has a corresponding appearance and odour; and as the disease advances in the bone, chronic inflammation of the mem- brane of the brain succeeds, subsequently affecting the brain itself; so that on THE EAR. &07 dissection the bone is found to be carious, with serous or purulent effusion, and extensive softening of the base of the brain. In some instances, the dis- ease is very insidious in all its stages, attended with very little pain, and per- haps no discharge from the ear, till at last violent pain suddenly takes place, speedily followed by delirium and coma. In other instances in which the at- tack is very acute, the painful symptoms cease, and coma gradually steals on; so that the patient may be supposed to be recovering and enjoying sleep, when in fact he is in the very jaws of death. Sometimes spasmodic symptoms, and even convulsions, precede death. All modern writers on the brain no- tice such cases, and several interesting examples are to be found in Dr. Aber- crombie's work on the brain, as well as in that of M. Itard, entitled " Traites des Maladies de 1'Oreille." Causes.—All these varieties often take place in the course of ulcerated sore throats, as also during the progress of the exanthematous diseases, where there is for the most part an affection of the throat. The three varieties may also be produced by cold, particularly when applied to the part. Thus I have seen some severe cases, from the ear having been exposed to a small current of air; but a more common cause proceeds from the bad trick which children have of putting pieces of paper, peas, &c. into the external ear. Another frequent cause of the two first varieties, and perhaps occasionally of the third, is the pernicious and disagreeable habit of picking the ears, by means of various well known contrivances. These complaints sometimes arise from a cuta- neous inflammation, generally of an erysipelatous character, which extends into the ear. A collection of indurated wax in the ear, producing irritation and inflammation of the part, the larvae of insects, and even insects them selves, sometimes produce serious inconvenience and pain. Treatment.—The treatment of ear-ache is well understood in the nursery; medical men are therefore seldom consulted, unless in severe and obstinate cases, to which the following observations will apply. If the pain and other symptoms be not very severe, and should the inflammation of the inner mem- brane be slight, fomentations assiduously applied during the day, and a soft light poultice during the night, together with the use of a small quantity of laudanum mingled with oil dropped into the ear, will generally suffice. When the symptoms are severe, and the pain excruciating, I have seen the greatest benefit produced by opening a vein in the arm; but I have only thought it necessary to try this in cases where the symptoms were violent, and the dis- ease of frequent recurrence, and in none of these instances has it ever return- ed. Besides fomentations, the application of leeches is serviceable, to be re- peated according to circumstances, and followed by a blister behind the ear if Decessary. It is also found advantageous, before dropping in laudanum and oil, to use an injection of milk and water, which will assist in softening and removing indurated wax, if any be collected. It is almost unnecessary to mention, that the regimen should be moderately, if not entirely antiphlogistic; and in severe cases, a brisk action is to be kept up on the bowels; I have 508 DISEASES OF seen good effects from the use of antimony, particularly in cases complicated with rheumatism, or produced by exposure to cold. As soon as an abscess is observed, it should be opened; if not opened early, or if it be situated too deep, considerable additional suffering may be expect- ed from the slowness with which the matter will form and escape, owing to its being situated in a hard and unyielding structure. If allowed to take its own course, a troublesome fungous ulceration sometimes follows, and a copious discharge of matter, which occasionally continues for years. Ottorrhcea.—A discharge of offensive matter from the ear is at all times very unpleasant, more particularly so when it ie habitual and in large quantity.— Sometimes the discharge consists of an increased quantity of the natural secre- tion in a very fluid state ; at other times, it is more or less mixed with pus. It may be the consequence of increased activity in the secreting vessels, but more frequently depends upon chronic inflammation of the lining membrane of the ear, and occasionally upon deep-seated inflammation, and caries of the bones. In treating cases of this description, attention should be paid to the above mentioned circumstances; and it should be also remembered, that after a dis- charge has existed for some time, it becomes, as it were, necessary to the con- stitution, and cannot be checked without creating some tumult in the system, which may terminate very unpleasantly. Therefore, certain preparatory measures should be taken before the suppression of the discharge is attempted. Perhaps the best method of doing this, is to apply repeated blisters behind the ear, to keep the bowels open by gentle laxative medicines, to use a light and a dry diet, avoiding slops, and a greater quantity of liquid than is sufficient to prevent thirst. After this system has been pursued for some time, then we may apply injections of an astringent nature; and, if necessary, exhibit acetate of lead internally. In some instances, it may be well to keep a small blister open or to apply tartar-emetic ointment to some other part of the body, to produce an external irritation. Should headache take place, or a tendency to lethargy, a few leeches ought to be applied behind the ear, or cupping glasses to the neck, followed by a blister, together with smart purgatives. In some instances in which it might be unsafe to interfere with the discharge, the disagreeable fetor may be very much diminished, by injecting a solution of the chloruret of lime or soda, properly diluted. PART VII. DISEASES OF THE SKIN. CHAP. I. GENERAL REMARKS ON DISEASES OF THE SKIN. The importance of a knowledge of this class of diseases is so great in a practical point of view, that I shall devote as large a space to their considera- tion as is consistent with the plan of this work. The study is important, from the .frequency of their occurrence, from the little which is yet known respecting them, and from the connexion, nay, I might have almost said the dependence, of cutaneous diseases upon the state of internal organs. These diseases have, for many years past, excited great attention ; and the late Dr. Willan has undoubtedly the credit of being the first to lead the way in the investigations which have taken place. On the Continent, Alibert and Rayer have followed his footsteps; but it is to be regretted that Alibert should have concealed that the spring which first set his mind in motion on this sub ject, was the knowledge of what had been previously done by Willan! Willan's great merit consists, not only of drawing the attention of medical men to a subject which was quite neglected, but in classifying the different diseases, and in examining the writings of the most ancient medical authori- ties. It is incumbent, however, upon me to state, that the errors of his system are numerous, from carrying his divisions and subdivisions too far, and in- creasing the number of names, thereby complicating the study without simplifying the practice. Practical physicians will, I feel persuaded, agree with me in this statement, and their opinion is of more value than that of scientific book-worms. Our sole object in classifying and investigating diseases, is to render the treatment more successful and certain, which a too minute division decidedly counteracts. The practitioners who, according to my ob- servation, are notoriously the most unsuccessful in the treatment of cutaneous affections, are those who, instead of taking a comprehensive view of the his- tory of the case, and attending to the state of the digestive and other organs, embarrass themselves by making minute distinctions, and by endeavouring to force every disease into some of Willan's classes and orders. Small-pox, measles, and other exanthemata, are included in almost all the popular works on cutaneous affections, and classed along with other dis- eases with which they have no connexion; as, for example, with purpura. I 512 GENERAL REMARKS ON have already treated of the exanthemata, in this work, as fevers attend- ed with eruptions;—my pathological opinions respecting these and simple cutaneous diseases, are in some respects very similar. In almost every instance of cutaneous affection which has fallen under my observation, whether it has been attended by fever or not, I find ample evi- dence in the history of the case, of functional derangement of some internal viscus; in some, the stomach and bowels are at fault, as in urticaria, erythema fugax, many cases of lepra, &c. while others are evidently connected with dis- ease of the liver, mucous membrane of the lungs, &c. Erysipelatous inflamma- tion is always the consequence of some internal disease, either functional or structural, sometimes of the stomach and bowels, at others of the lungs, and oc- casionally of the brain. This will be shewn when treating more particularly of erysipelas, which I have placed in this part of the work, and not among the exanthemata, because I do not consider it as a specific disease, having, like small-pox and measles, a definite course, progress, and termination. The principles which I shall now attempt to explain respecting cutaneous affections, are those which experience and observation have, from an early period of life, forced upon me, and which I have taught ever since I began to lecture, in the year 1823.* Practitioners pay little attention in general to the seat of the cutaneous disease, and they have either very complicated notions, or never think at all of the nature of the affection. It may be shortly mentioned, in this place, that its nature is generally inflammatory ; but that its seat is various, sometimes affecting the superficial vessels of the cutis which secrete the cuticle, as in recent cases of some of the squamous diseases; while at others, the sebaceous follicles are the seat of the inflammation, it being frequently produced by the mechanical irritation of the sebaceous matter which collects in too large a quantity, so as to over-distend the follicle and irritate its vessels,—as in acne, papulae, &c.—whereas in a third class of cutaneous affections, as erysipelas small-pox, &c. it is situated in the substance of the cutis vera itself, the inflammation and suppuration extending to the sub-cutaneous cellular mem- brane, and in some instances even deeper still, affecting the muscles and other tissues, as in bad cases of erysipelas and carbuncle. I shall avoid speaking of the rete mucosum, because its existence, even in the negro, has been denied by good anatomists, as well as of a minute glandular distribution, which some think they have seen by the help of the microscope, between the cutis and rete mucosum. Microscopic observations, like those performed by Mr. Che- valier, who describes the existence of these glands, are always liable to fallacy, and it is well to remind those who have much faith in them, of the dilemma in which the late Dr. Monro (usually called secundus) was placed, by an op- tical delusion, in the course of a very extensive set of experiments which he * It gives me great pleasure to notice the work on the diseases of the skin by Mr. Plumbe of London, and to recommend to my readers as the best pathological and prac- tical treatise on this class of diseases, which is to be found in any language. DISEASES OF THE SKIN. 513 I performed. He observed that all animal fibres were serpentine; he next proceeded with vegetable substances, and he also found that their fibres were serpentine. Astonished at these observations, he next proceeded to examine mineral substances, and he was astounded by observing, that whatever sub- stance he examined, it was composed of serpentine fibres. He either wrote, or was engaged in writing, a paper upon the subject, when he discovered, through a scientific friend, that the serpentine fibres were all produced by a slight defect in the glass of the microscope, which saved him further trouble at the time, as well as subsequent embarrassment and chagrin. It is to be feared that considerable errors have crept into medicine from the incorrect impressions conveyed by microscope apparatus. Some writers have described papilla over the whole surface of the body situated in the true skin, but I am inclined to agree with Mr. Plumbe, who states that he has never been able to discover any vestige of them ; and if they do not exist, the diseases ascribed to this tissue should be erased from medical writings. Mr. Plumbe has used a very strong argument against the existence of the diseases which have been ascribed to the papillae of the skin: " Every genus of this order ( papulae ) makes its appearance on all parts of the body at times, except where papillae are really and easily found." (p. 7. ) The skin performs several important functions:—1. The formation and re- pair of the cuticle, which is insensible like the nails, and forms an outer covering to the whole surface of the body. 2. The skin performs the office of separating a large quantity of a limpid fluid from the blood, which escapes from the body by what is called insensible perspiration ; and the proper per- formance of this duty must have very considerable influence upon the action of every other organ in the body. 3. It would appear that we are able to introduce many substances in the body by the process of absorption from the skin ; so much so, that even minute quantities of strychnia applied to a blis- tered surface have frequently produced violent constitutional effects. In this work I shall treat of cutaneous affections in the following order, without splitting the orders into so many different genera and species, as is usually done. 1. Erysipelas, or Rose. 2. Papular Diseases. 3. Pustular do. 4. Squamous do. 5. Vesicular do. 6. Purpura. 65 CHAP. II. ERYSIPELAS. Erysipelas appears to have been noticed by the earliest writers on medi- cine, who frequently, however, confounded it with other diseases under the general term of ignis sacer. This disease has been divided into several varieties, viz. idiopathic and symptomatic—erythematic—phlegmonous—erratic—bilious—local—malignant and putrid; and some of these have been again subdivided. All unnecessary divisions of diseases, as I have already observed, are use- less in theory, and injurious in practice. Mankind differ as much in consti- tution as they do in expression of countenance; and it is well known, that peculiarity of constitution gives rise to shades of difference in symptoms and appearances, which defy the ingenuity of the ablest nosologiste; but they nevertheless have exerted themselves in a wonderful manner to accomplish the task, retarding instead of advancing the study of true pathology. If all the time and talent which have been misused in devising nosological arrange- ments had been employed in discovering the nature and seats of diseases, our knowledge of pathology and of remedial agents would have been much fur- ther advanced than is at preset)::. I shall treat of all forms of the disease, under the simple term of erysipelas, while I shall take care to notice the peculiar, as well as the occasional symp- toms, appearances, and terminations which may seem to indicate correspond- ing alterations in the treatment. I am induced to follow this plan here, be- cause it has met with the approbation of practical men of considerable stand- ing in the profession, who have done me the honor to attend my lectures. Phenomena of erysipelas.—This disease takes place in people of all ages. I have seen it in new-born infants, as well as in extreme old age. It more particularly occurs in certain constitutions,—viz. in those who are liable to affections of the skin, to gout, and who are subject to disorder of the stomach and bowels. It is a disease which is met with in practice in every degree of severity, appearing under the form of the slightest erythematic blush con- fined to one spot, or under that of deep and intense inflammation of the skin, expending over the whole body. The inflammation may be severe, affecting riot only the skin and sub-cutaneous cellular tissue, but also involving the muscles, and terminating in extensive suppuration, ulceration, and mortifica- ERYSIPELAS. 515 tion. In some cases the disease spreads from the skin to deep-seated parts, while in others the inflammation extends from within outwards, sometimes from the periosteum, when it is primarily inflamed, but more frequently from the tendinous aponeuroses forming the strong fasciae which bind down the muscles. In such circumstances, the general phenomana of the disease and the local appearances differ considerably from those of simple erysipelatous inflammation. When the periosteum is primarily affected, severe gnawing pain, sleepless nights, &c. will be complained of for months, perhaps for years before the skin partakes of the inflammation. When the fasciae of muscles become inflamed, whether from a puncture or from the application of cold, deep-seated pain, tumefaction, tenderness to the touch, and severe con- stitutional symptoms, precede the redness of the skin. In contradistinction to erysipelas, these cases have been named by Dupuytren, and others, erysipiloid diseases, and appertain more to surgery than physic. The first local symptoms of erysipelatous inflammation are a tingling or pricking pain, with some degree of heat, swelling, tension and redness of the part. Soon a pungent burning pain is experienced, aggravated by motion or pressure: the swelling increases rapidly; the surface presents a shining ap- pearance ; on pressure, the redness disappears for a moment, but it immedi- ately returns; and, as the disease advances, the part assumes a purple colour. The constitutional disturbance manifests itself in the shape of febrile symp- toms and general functional disorder, varying according to a number of cir- cumstances, preceding the attack, of erysipelas,—such as the extent and severity of the disease, as well as its duration and situation. If the disease have come on after a long and debilitating illness, the symptoms will be dif- ferent from those produced in a person who had been previously in a good state of health. If the inflammation be superficial, the symptoms will be comparatively slight; if it be situated on the head and face, delirium and even coma may occur, which in all probability would not have happened if the disease had attacked an extremity, and were limited to the same extent of surface. The external characters of the disease vary much according to situation, severity, and duration;—affecting the head and face, the features swell much, as in small pox; the conjunctiva of the eye partakes of the inflammation, as well as the mucous membrane lining the nose, mouth, and ears; vesication takes place, even in slight cases, or the parts become exceedingly hard, more particularly the ears; and if the inflamation be superficial, desquamation of the cuticle, after diminution of the redness and pain, marks the decline of the disease. In cases where the inflammation has been more intense and deeper-seated, a doughiness or bogginess is left, which renders it probable that matter is effused. On some occasions, distinct fluctuation leaves no doubt of the existence of matter, which may be either circumscribed, as in phlegmonous erysipelas, or diffused, as in the diffuse inflammation of the 516 ERYSIPELAS. cellular tissue that occurs in patients who are of a bad habit of body, and which arises sometimes from a prick in dissection. The circumstances preceding an attack are also very various; erysipelas frequently comes on at the termination of fevers of long duration, as well as of inflammations of different organs, more particularly of the brain, lungs, and peritoneum; it also takes in individuals who have laboured for years under different chronic diseases, medical or surgical. Those who have long indulged in the abuse of strong potations, as well as gourmands, are also liable to it. At other times it appears to be the immediate effect of cold operating on the general system, or of some indigestible matter in the stomach and bowels Under whatever circumstances erysipelas may take place, the attack is gene- rally preceded by rigors or chilliness, alternating with flushes of heat, op- pression at the praecordia, difficulty of breathing, cough, expectoration, pain in the back and loins, general uneasiness, delirium, a sense of weight in the head, head-ache, lethargy, and sometimes a state bordering upon coma, with high or low toned febrile symptoms. These phenomena may exist with more or less severity for one day, or for twenty days before the inflammation appears in the skin ; there are no regular periods, as in measles, scarlatina, and small pox. Erysipelatous inflammation sometimes appears on a part for a few hours, and suddenly vanishes, shewing itself perhaps in another situa- tion ; or if it does not shew itself again on the surface, the constitutional symptoms become aggravated, coma,' or dispncea frequently follows, and some- times even death itself. Causes of erysipelas.—From the prevalence of erysipelas in particular years, a belief is pretty generally entertained of its being contagious, which has been much strengthed by the additional fact of the occurrence of a con- siderable number of cases at one time in particular hospitals. There is much stronger ground for believing that erysipelas is produced by epidemical influ- ence. But the occurrence of the disease can, in the majority of cases, be much better accounted for by sudden changes of atmospheric temperature, along with considerable moisture, together with the state of the bowels, and indulgence in particular articles of food. It is proper that I should here state, that I deny altogether the idiopathic nature of erysipelas, and that I believe it to be an occasional symptom of different diseases, which diseases may frequently occur, under atmosperical, epidemical, and contagious influences. In a great majority of instances, if the particulars of the cases be enquired into, it will be found that no communication, direct or indirect, had taken place with others labouring under erysipelas. Sometimes it attacks nurses and others who have had an anxious attendance upon the sick, labouring under various diseases, as peritonitis, pneumonia, different kinds of fevers, fractured limbs, and injuries of the head. Some may have been attacked, no doubt, with erysipelas, when attending patients labouring under that disease. But such an event does not take place more frequently than during an ERYSIPELAS. 517 attendance on patients affected with other disease. I have seen a great number of cases of erysipelas, and have been greatly interested, from the earliest period of my professional life, in the investigation of its nature and seat; but have never met with a nurse or attendant who was attacked with erysipelas when at- tending a patient laboring under that disease, although the confined, crowded, and extremely filthy state of the apartments on very many occasions, seemed but too well calculated to contaminate the atmosphere, and thereby to promote the generation and communication of contagion. If erysipelas were as con- tagious as it is represented to be, we ought certainly to see erysipelas produ- cing erysipelas in the same determinate manner that small pox and measles are known to produce these complaints; but I have never observed such a phenomenon. That erysipelas sometimes appears to exist as an epidemic, cannot be denied, and on many such occasions it is said to spread by contagion in hospitals; but if it were an idiopathic disease, and contagious, it ought to spare none, or at least few who have an ulcer, or any abrasion of the skin. It ought to spread more or less slowly from one to another, so as at last to affect almost every one who approached within the sphere of the contagion. We find, however, that it only attacks individuals here and there, frequently at a distance from each other, who have been in separate wards, and who have never come once in contact. This is very different from what occurs in small-pox, measles, and a few other diseases which are known to be contagious, and which are always marked by symptoms peculiar to themselves. In these there is an eruptive fever, which continues for a certain number of days before the erup- tion appears. This goes through a regular course of advancement and reces- sion, and all the other phenomena only vary in intensity. Each disease is recognized under every circumstance of age, sex, and constitution. Neither small-pox nor measles can be generated by any of what are called the common causes of diseases not contagious, such as exposure to cold, damp, and fatigue, affections of the mind, &c. Erysipelas sometimes does not appear in the course of fevers, inflammations, and other morbid conditions of the system, till perhaps the end of the third or fourth week; at othdr times it occurs on the second or third day, and at all intervening periods. This is certainly very unlike the acute eruptive diseases which are known to be contagious; besides, erysipelas has no regular and determinate course as the others, which attack the sam£ individual only once in a life-time, while erysipelas may affect a person twenty times. Let me ask if anyone has succeeded in producing erysipelas in a healthy person by intro- ducing matter taken from an erysipelatous surface ? This has been stated, but I believe it to be a mere assertion ; but even if this could be answered in the affirmative, it is no proof of the specific and contagious nature of erysipelas, because the same affection has followed scratches received during dissection. It has followed the application of leeches and blisters, as well as injuries pro- 618 ERYSIPELAS. duced by minute splinters of wood, and punctures made by perfectly clean sewing needles. In no point of view, then, can erysipelas be said to be a specific disease, or to resemble other diseases which are known to be contagious. When erysipelatous epidemics have prevailed, I have always remarked that they have occurred either under sudden vicissitudes, of weather, attended by considerable moisture, or during the autumn after a hot summer, when there was a great abundance of fruit. Under the first circumstances, fevers, and acute and sub-acute inflammations, also prevail, particularly bronchitis. Under the last, the functions of the stomach and bowels suffer, irritation of their mucous membrane ensues ; fevers and diarrhoeas also prevail; and the erysipe- las, in both cases, although a frequent occurrence, is a mere symptom. The reasons why erysipelas should be occasionally very prevalent in hospi- tals, and be attended with greater fatality than in private practice, can be easily explained. In this country, from the pride of being independent, it is only the most destitute of the poor,—servants at a distance from their friends,— or country people, who desire a consultation of doctors,—who can be prevail- ed upon to go into an hospital. In hospitals patients are generally too much crowded together ; there is great irregularity of temperature in the wards; and sufficient attention is not paid, except at the hour of visit, to ventilation. These circumstances, and many others which could be adduced, enable us to account in a more satisfactory manner for the prevalence of erysipelas in hos- pitals, than by supposing, as too many have done, that the disease lies in am- bush, embedded in the lime, mortar, and wood-work of the wards, watching favourable opportunities to seize on flesh and blood. Appearances on dissection in erysipelas.—The part which had been the seat of the inflammation, will be found after death to have lost much, if not the whole of its redness, but not its swelling. Upon making an incision, a bloody serum will be found infiltrated into the cellular substance. The skin will be often seen thick and hard, in the sar.ic state it is observed to be when a person has died twenty-four hours after a blister had fully risen ; or, if sup- puration have taken place, pus will be found infiltrated instead of serum, in some places distributed generally through the cellular tissue; in others, cir- cumscribed little abscesses exist. In the most sever"e degree of phlegmonous erysipelas, the parts will be very tender, easily torn, and a large collection of fetid pus will be found, with more or less of the cellular tissue detached, and perhaps mortified, tlfe disease even extending into the muscles. In the sub- cutaneous cellular inflammation, more extensive destruction will be discovered; small abscesses will be found, but pus and dark-coloured ichor will be seen generally and deeply diffused among the muscles, blood-vessels, &c.; partial mortification and sloughing will have taken place here and there; and in some dissections, the muscles will be seen tender, and altered in appearance, resembling, in many cases, the last stage of putrefaction. I have seen the blood-vessels also extensively diseased in the inner coats, and the lymphatics as well as veins containing a puriform fluid. ERYSIPELAS. 519 Besides the above appearances, of extensive disease in the membranes and substance of .the brain, pleura, pericardium, and peritoneum have been seen. But of all the tissues in the body, the mucous membranes are most frequently in a state of inflammation, and in many instances the fatal termination has been distinctly traced to bronchitic inflammation. Some years ago, I was requested to visit an infant three days old, who had shown symptoms of great suffering from the moment of its birth, which was attributed to colicky pains in the abdomen. On examining the abdomen the commencement of erysipelatous inflammation was discovered, which, by the following day, had extended nearly over the whole trunk and thighs. Soon afterwards it began to sink, and died in about forty-eight hours after the first appearance of the external inflammation. On dissection, the most extensive ravages of disease were discovered in the abdomen, the effects of peritoneal inflammation,—viz. considerable exudation, and the agglutination of the intestines to each other. My friend and pupil Dr. Yates, when attending my dispensary, was re- quested to see a child one month old, on a Saturday evening. He found the abdomen tumefied and tense; there was an erysipelatous spot about the size of a half-crown on the inner part of the right thigh near the groin ; the child appeared to him to be dangerously ill, but did not seem to be in much pain. Dr. Yates was informed that it had been taken ill on the preceeding Thursday morning, after having passed a bad night; that the bowels were confined; and that he cried violently at times, and gave evidence of the abdominal suffering. By the following afternoon the erysipelatous inflammation had extended over the whole abdomen, the child was in a moribund state, and died on the fol- lowing morning. Dissection.—The abdomen was considerably distended. The surface of the abdomen and thighs shewed the remains of the erysipelatous inflamma- tion, and there were, besides, much tumefaction and discolouration of the in- teguments at the lower part of the chest. On opening the abdomen, the intestines, which were moderately distended with flatus, appeared very vascu- lar, as well as the part of the peritoneum which lines the cavity. Flakes of coagu'able lymph of a yellow colour were spread over the intestines, and interposed between their convolutions, in some places forming slight adhesions. On displacing the intestines, a large quantity of this matter mixed with serum was found, a layer of yellow-coloured lymph covered the whole of the anterior and inferior surface of the left lobe of the liver, which adhered not only to the parieties of the abdomen, but was also glued to the stomach. The liver, when cut into, presented a very dark appearance, and the gall bladder was nearly empty. The omentum was also covered with the above-mentioned exudation. The stomach distended with air, was found to adhere to the diaphragm as well as to the liver. The colon was much con- tracted, and on being split open, its mucous membrane was found very vascu- lar, much elevated here and there, and coated with a dark, thick mucus. 520 ERYSIPELAS. The viscera of the pelvis were found slightly matted together by recent depositions of lymph. The ovaria were larger and softer than natural, and, with the uterus, were covered with coagulable lymph; the left broad liga- ment was attached to the peritoneum at the brim of the pelvis, by an inter- posed mass of lymph. In the thorax, the pleura costalis was very vascular on both sides, and slight recent adhesions were observed with the pleura pulmonalis, by means of large masses of lymph precisely similar to those met with in the abdomen and pelvis. The- following case by Dr. Gartshore is extracted from the 2d volume of the Medical Communications. "The child of-------Warwick, in June, 1773, was observed to be uneasy and hot, to vomit a yellow fluid frequently, and to have fewer stools than is usual for a child of that age. A gentle emetic was first given, after which manna was copiously poured down, and glysters frequently exhibited, notwithstanding which, his bowels were difficulty and scantily evacuated. Two days after, the abdomen was observed to be swelled, tense, painful to the touch, and had an inflamed appearance, which extended to the scrotum. Gentle aperients, glysters, fomentations, and the semi-cupium often repeated, were of no avail. He died on the twelfth day from his birth, and the fifth from the attack. Dissectim.—On opening the abdomen, we found the appearances very simi lar to what we had often observed in the true puerperal fever,—viz. a puru- lent exudation covering the surface of the peritoneum, and an adhesion of many of the viscera to this membrane and to one another from the diaphragm downward, with some extravasated fluid in the abdominal cavity. On laying open the scrotum, that also was swelled and inflamed, and we found purulent matter upon the surface of the epididymis and testis on each side; the testes themselves appearing inflammed. But though the chylopoietic and spermatic organs seemed to have undergone superficial inflammation, there was no ap- pearance of any tendency to mortification." Underwood, when noticing the appearances on dissection in the bodies of several children who had died of erysipelas, states that " the contents of the belly have frequently been found glued together, and their surface covered with inflammatory exudation, exactly similar to that found in women who have died of puerperal fever. In majes, the tunicae vaginales have been sometimes filled with matter, which has evidently made its way from the cavity of the abdomen, and accounts for the appearances of the organs just now described; in females the labia pudendi, are affected in like manner, the pus having forced a passage through the abdominal rings." (Diseases of Children, vol. I. p. 36.) Some years ago, I was asked to see a father and son labouring under erysi- pelas of the head and face, as pure examples of idiophatic erysipelas. In both cases I was able to satisfy the gentleman who had been previously at- tending, that there was a general affection of the mucous membranes,—that ERYSIPELAS. 521 of the lungs in one, announced by the dyspncea, cough and wheezing,__and that of the stomach and bowels in the other, announced by thirst, very red tongue, tenderness and tumefaction of the abdomen. Both cases presented most unpromising appearances; proper remedies were applied ; stimulants withdrawn; one recovered, but suffered during several years from the effects of chronic inflammation of the mucous membrane of the air-passages, and alimentary canal. On opening the body of the fatal case, traces of inflam- mation of the membranes of the brain were discovered, viz. vascularity and effusion; and on slicing the brain, it was found to contain a larger quantity of blood than usual. The pericardium was attached to the heart at every point. The mucous membrane of the trachea and bronchia was found dark coloured from vascularity, and the tubes were filled with tough exudation of a reddish colour. The mucous membrane of the stomach was red, vascular and soft, easily separated, and covered with a thick tenacious exudation; this was also the condition of the mucous membrane of the intestines, particularly of the ileum, where the vascularity was much greater than in the stomach, and appear- ances were discovered, which I now know to have been the commencement of ulceration. In the year 1823, I was requested to see a woman with erysipelas of the abdomen, which had commenced about a fortnight after abortion. The whole surface of the belly was affected, the inflammation was of a deep purple colour, with sloughing at the umbilicus. Although this woman possessed con- siderable property, she was living in a state of abject misery, neglected by a brutal, drunken husband, and had been long suffering in mind, as well as in body. A very imperfect account could be obtained, either of her previous or present symptoms. On the following day some of the mysteries of her case were removed by the separation of a slough at the umbilicus, and the dis- charge of a large quantity of urine. The woman soon sunk under her suf- ferings ; and on dissection, the peritoneal surface of the fundus of the blad- der was found strongly attached to the peritoneal lining of the abdomen cor- responding to the umbilicus; the bladder appeared to have been enormously distended and neglected, till at last the urine found an exit by this process of nature. The following abbreviated case of erysipelas is extracted from the patholo- gical work of Tacheron. A man was seized on 1st Feb. 1808, with anorexy, nausea, head-ache, severe pain of neck, and difficult deglutition. These symp- toms gradually increased for some days, the face becoming swollen, inflamed, and painful, with severe diarrhcea. He had cough and expectoration, which afterwards became bloody, and the patient died on the 19th. The following appearances were found on dissection: "In the head there was effusion of serum in considerable quantity (Jiss.) in the ventricles, between the mem- branes on the surface of the hemispheres, and also at the base of the brain. In the thorax several old adhesions were found, between the surfaces of the 66 522 ERYSIPELAS. pleurae on both sides. The middle lobe of the right lung was reddish, hard, and did not crepitate; in consistence it resembled liver, and adhered to the portion of the mediastinum next the heart. On cutting into this lobe, a thick greyish, puriform fluid oozed out; the rest of the lungs being healthy. The pericardium adhered in every part of the heart, but paricularly on its right side, where it could not be separated without tearing its substance. The heart was not much larger than natural; there was a well marked ossification of one of the mitral valves, which appeared almost entirely detached. At the base of the aortic valves, there "were also observed points of ossification, and cartilaginization. In the abdomen the intestines were found distended with gas; but, as well as the stomach, were in other respects healthy. The liver was larger than natural, and had contracted preternatural adhesions with the diaphragm; the convex surface of its left lobe was covered with lardaceous substance, which entered the substance of this vicus to the1 depth of two or three lines. The gall bladder contained polyhedrous concretions of the size of onion seeds, and of a dark-green colour; the cystic and choledic ducts were also filled with these substances. The spleen was three times its ordinary size, and so tender and soft, that the slightest pressure reduced it into a pulp. The kidneys were more vascular than natural." The following dissections of erysipelatous subjects, are extracted from Dr. Hastings' work on the Lungs:— "Dissection of case 5th, (page 228.)—The mucous membrane lining the bronchia and air-cells, was found very much inflamed. The tubes* were filled with frothy serum, which in some places was mixed with a substance very like pus. There were several small tubercles in the structure of the lungs, but none of them appeared inflamed. There were elongated adhesions between the pleura pulmonalis and costalis. Abdominal viscera healthy. " Dissection of case 6th.—A considerable quantity of fibrin was found in the cavity of the abdomen. The intestines were generally glued together, and the peritoneum was highly vascular. When the thorax was opened, the lungs did not collapse. The pleura was not inflamed. The mucous mem- brane lining the trachea, bronchia, and air-cells, was highly vascular, and the tubes were filled with a bloody serum. The right auricle and ventricle con- tained more blood than natural." Pathological remarks respecting erysipelas.—Doubts have been already stated as to the existence of idiophatic erysipelas, when it does not proceed from external injury; and I am inclined to believe, that when it does occur after external injury, it is even then, in most instances, only symptomatic of some internal affection, which may be a disorder of function, or one proceeding from structural lesion of some internal organ. Erysipelas appears to be an inflammation produced by one of those salutary efforts of the consti- tution, by which disease is sometimes removed or translated from one tissue to another. In this instance, from an internal organ, the functions of which are more immediately necessary to life, to the skin, which has a less important ERYSIPELAS. 523 part to act in the animal economy. In point of fact, erysipelas ought to be regarded very much in the light of a natural blister. But I shall now enume- rate the points on which these opinions rest, and afterwards proceed to adduce the evidence. 1. The constitutional disturbance, which exists in all cases before the ap- pearance of the erysipelatous inflammation of the skin, shews erysipelas to be merely an occasional symptom of some other diseased state of the system. 2. The mitigation of the internal disturbance which frequently follows the appearance of the cutaneous inflammation ; and the reproduction of perhaps worse symptoms than had previously existed upon the sudden recession of the erysipelas. 3. The appearances on dissection 4. The relief afforded by treatment founded on these opinions. 1. In proof of the first point, that constitutional disturbance exists in all cases prior to the appearance of the cutaneous inflammation, it may be men tioned, that I have never yet seen a case of erysipelas, however slight, which was not preceded by constitutional symptoms. Renauldin, in his short but able article on erysipelas, in the "Dictionnaire des Sciences Medicates," in giving an account of the symptoms and march of the disease, says: " It is rare that idiopathic erysipelas manifests itself, without having been preceded by some phenomena which denote an approaching alteration of health. But these precursory signs, being common to many diseases, do not announce an erysipelatous eruption, more than another of the exanthemata, or some other fever. It is thus that a person feels wandering pains in the limbs, spontane- ous lassitude, cold, shivering, agitation, anxieties, and is generally out of order ; he soon complains of disgust at food, nausea, and inclination to vomit, violent headache, want of sleep;—a burning heat succeeds to the cold, and spreads over the whole body," &c. In the previous page, in speaking of idiopathic erysipelas, he appears to entertain the same opinions that are here advocated, for in his division of erysipelas into different kinds, he states that the following division, which he has borrowed from Burserius, appears to him much more natural and useful than any other: " 1. Idiopathic erysipelas, primitive or essential, that is to say, that which takes place spontaneously, without having been preceded by any other malady, and which is produced by an internal cause, ( et qui nait dune cause interne.) 2. Symptomatic or secondary erysipelas, which depends upon another affection, and goes through its course with it; as phlegmon, cedema, every kind of continued fever, and different internal affections, sometimes of an acute, sometimes of a chronic nature. 3. Accidental erysipelas, which is occasioned fortuitiously by a manifest external cause, acting immediately upon the skin ; as the scorching rays of the sun, a superficial scald, the application of cantharides, or any other acrid and irritating substance, injuries, &c." Cullen has given the following history of the symptoms :—" Erysipelas oi the face comes on with a cold shivering, and other symptoms of pyrexia.— 524 ERYSIPELAS. The hot stage of this is frequently attended with a confusion of head, and some degree of delirium; and almost always wfth drowsiness, or perhaps coma. The pulse is always frequent, and commonly full and hard. When these symptoms have continued for one, two, or at most three days, there appears on some part of the face a redness," &c. ( Vol. 1. p. 255.) Although Cullen specifies " erysipelas of the face, " yet it is well known that this affec- tion, attacking any other part of the body, is preceded by the same train of symptoms. Sydenham, in his letter on the plague of 1665, and the following year, ob- serves, "that erysipelas began much in the same manner as the plague, viz. with a shivering followed by a feverish heat; so that those who never had the disease before, think it is the plague, till it fixes itself in the leg, or some other part." These paragraphs are purposely introduced, in order that I may not be suspected, by those who are yet inexperienced, of having dressed up a state- ment of the precursory symptoms to suit my own views. Cutaneous inflammation, produced by a blister, or a scald, will most un- doubtly excite general irritation, and mere or less fever. In this case we have occular proof to guide us, but in erysipelas, we have the general commotion of the constitution first, which I have known to continue for 10, or 12, or 30 days before the erysipelas appeared. Cullen himself does not seem to have been well satisfied with the prevail- ing doctrines respecting erysipelas. In describing the different species of this affection, at page 75, of his Nosology, after mentioning the erysipelas pesti- lens of Sydenham, he observes in a note: " This and the following species (erysipelas contagiosum) seem to be nothing but fevers with a symptomatic erythema;" and I find in the next page, that Cullen entertained doubts regarding the idiopathic nature of several other cutaneous affections. Treating of miliary fever, for instance, he says: "That it is never idiopathic, I dare not affirm, in opposition to the opinion of physicians from the middle of the 17th century to the present day, and contrary to the sentiments of some respectable modern physicians ; but as I know that experience, in this case is often fallacious, and that physicians, for the most part, are but a herd of imitators, I am forced to remain doubtful." No one can have been any length of time in practice, without having met ^with instances of erysipelas occurring in individuals whose constitutions were destroyed by long continued indulgence at table, and drunkenness,—in whose bodies there were abundant evidences of functional or structural disease of many important viscera : therefore it is unnecessary to quote cases in proof of this. That the disease frequently occurs during the progress of severe internal disorders, the records of medicine fully prove; several cases in my own practice have been already mentioned, when describing the appearances found on dissection, and similar cases have been quoted from Gartshore and ERYSIPELAS. 525 Underwood. In addition to these facts it may be mentioned, that the late Dr. Gordon of Aberdeen, in his able work on Puerperal Peritonitis, published in 1795, states, (atpage 75,) that "one of the most favorable symptoms is an erysipelas on the extremities, or abscesses on different parts of the body : for such are certain signs of a salutary crisis." And in a note, (at page 58) he observes: " This critical erysipelas most commonly fixed on the extremi- ties, but in a few instances, on the external surface of the abdomen, which happened in a case of puerperal fever, which I attended in the year 1788. The case alluded to, is the wife of William Walker at Newbridge, whom 1 attended at the same time with Thomas M'Roberts' wife, whose history is given in case VI. In both cases, the crisis was by an erysipelas, which, in the latter, fixed on one of the upper extremities, and in the former, on the integuments of the abdomen." Cullen in treating of phenomena, states, that "sometimes the disease dis- appears on the second or third day, while an erysipelas makes its appearance on some external part, and if this continue fixed, the pneumonic inflamma- tion does not recur." (Vol. I. page 149.) When treating of hepatitis, Cullen also observes, that " it would seem to be sometimes cured by an erysipelas appearing in some external part." (Vol. I 171.) From the repeated observation of such facts, I cannot avoid considering erysipelas in the light of a natural blister ; and it is very probable that the ancients were first led to apply external irritants, and the actual cautery, from observing the beneficial effects of erysipelatous inflammation occuring under severe internal disease. 2. The second point of evidence on which these opinions are founded, is the mitigation of the internal disturbance which frequently follows the ap- pearance of the cutaneous inflammation; and the reproduction of bad, nay perhaps of worse symptoms, than had previously existed, upon its sudden recession. These facts I have so often witnessed, that I feel obliged to receive them as a part of the medical evidence of the case. Sydenham's third reason for considering erysipelas to resemble the plague, is: " The expulsion of the malignant matter to the skin on the third or fourth day, with an abatement of the symptoms." Hoffman, in treating of erysipelas, observes, that " it sometimes exhibits a manifest mark of health ; other diseases, especially a convulsive asthma, and a convulsive colic, have been removed by an attack of erysipelas." In another passage he states: " But those who die of this disease, are carried off by a fever, which is mostly joined with a difficulty of breathing,—somtimes with a delirium,—sometimes with drowsiness, &c."—The same author again remarks, that "it is rendered very dangerSus by improper treat- ment. I have seen erysipelas strike in, after taking a vomit, and a strong purgative, when an inflammation of the stomach, and death, have followed. Bleeding also has struck it in, and rendered it wander- 526 ERYSIPELAS. ing with much greater inconvenience. I have also observed, that after being repelled in the leg, by an application formed of camphor, red lead, and boll, it has been followed by a high fever, and intolerable pain of stomach, a great difficulty of breathing, bilious vomiting, loss of strength and appetite. These symptoms have not gone off, till the erysipelas had been invited back to its former seat by a blister, and anti-spasmodics, and mild sudorifics,—and I certainly know, ( continues Hoffman,) that an erysipelas of the head, having been treated by repellent, cooling, binding, or too spirituous applications, and camphorated liniments, has brought on a vertigo, lethargic disorders, and quinsey, delirium, and palsy of the tongue; which evils have frequently proved fatal to persons in years, and scorbutic habits." " A gentleman, ( says Dr. Swan, the accomplished translator of Sydenham's works, ) who by the cold air, suddenly struck in the erysipelas of his face, had ail the symptoms of an inflammation of the brain, and was in the most imminent danger, appeared to be snatched from death by bleeding in the jugular vein, and besides that, applying two large blisters to both sides of his neck, bleeding him in the arm, and giving him a strong purge, all which was done in the space of an hour." Mr. Abernethy notices a case of this kind in his lectures: " A stout heal- thy young man had an attack of erysipelas on his hand ; he plunged it into cold water, and was soon seized with insensibility ; he fell down in a state of torpor, and soon died." This gentleman is also represented to have said in his lectures: " I'll be hanged if erysipelas is not always the result of a disordered state of the diges- tive organs. I never see it come on if the digestive organs be right, and it goes away as soon as they are put right. Now what is the medical practice I they powder the part a little, and they give bark, and so on!!" "It has been observed (says Wilson Philip, in his work on Simple and Eruptive Fevers, Vol. I. page 362,) that if the typhus has commenced before the appearance of this eruption (erysipelas), the symptoms of synocha are often recalled by it. They are not only recalled but maintained, for the typhus, which supervenes towards the end of an erysipelatous fever, is less conside- rable, in proportion to the preceding symptoms, than in other varieties of synochus." And at page 367, he observes: " Besides, the erysipelatous, like other eruptions which appear in continued fevers, has been known sud- denly to recede; an alarming train of symptoms, of which debility is the characteristic symptom, supervene." In another place, he also remarks: " This is also to be remembered, that when retrocession takes place, the patient is seldom out of danger till the eruption is recalled, which is done with greater difficulty the more he is debilitated." It may be said that the appearance of the erysipelatous inflammation does not always produce mitigation of the internal disease. The simple answer to be given to this objection is, neither does an artificial blister, applied for the express purpose of translating the diseased action to the surface, which I ERYSIPELAS. ' 527 maintain the erysipelas is intended by nature to effect. In severe inflamma- tion of an internal organ, a blister, however large, has but little effect, if applied before the disease is very much subdued by depletion. In like man- ner, I may be allowed to say respecting erysipelas, that if the internal disease exist in a greater ratio than the cutaneous inflammation, then little or no- con stitutional relief can be expected. At the period when the erysipelatous inflammation begins to decline, par- ticularly under improper treatment, it is frequently observed that the functions of the brain or lungs, or perhaps both, appear to become suddenly and serious- ly affected, accompanied by oppression at the praecordia, and other alarming symptoms. In such circumstances, it is said, in ordinary medical language, that the disease has spread, or extended itself from the skin to internal organs; others speak of it as a translation or metastatis. Cullen denied the doctrine of translation, and was rather inclined to adopt the idea of the extension of the inflammation. Thus, when the erysipelas attacks the head, and when the brain becomes affected, it is said to be in consequence of the extension of the inflammation, by continguity. I think there can be no doubt that a fair translation does occasionally take place in inflammatory complaints, particu- larly when connected with erysipelas; so much so, that we actually find a variety of erysipelas in books, termed " erraticum." In general, however, at- tentive observation has long convinced me, that in erysipelas, diseased action had existed in the internal organ before the external inflammation appeared, during what may be termed the eruptive fever, and that when the cutaneous inflammation occurred, acting the part of an effectual counter-irritant, it miti- gated, but did not altogether remove the original disease. In erysipelas, the attention of the patient and also of the practitioner is attracted by the burning heat and pain of the external inflammation; but the internal disease becomes again apparent when the effect of the external inflammation subsides. Here again we cannot fail to discover additional proof of the analogy between a na- tural and an artificial blister. Before quitting this part of the subject, a few remarks may be made re- garding the mitigation of symptoms upon the appearance of the erysipelas, although it is repeating nearly the same observations which were made in the first of this work, when treating of the general pathology of eruptive fevers. The relief will not strike the eye of a symptomatical physician, we cannot see the pathological mitigation of symptoms, because the patient, who may have been previously lethargic or comatose, now complains most vehemently. Form- erly there may have been little complaint, and little or no febrile movement; now, however, there are great anxiety, restlessness, pain, with febrile symptoms well developed, but upon minute examination of the particulars of a case of simple erysipelas, these will be found to depend principally, if not entirely, upon the external inflammation. Here again we observe the analogous ef- fects of a common blister, which very frequently aggravates the patient's suf- fering, while it is mitigating the disease. 528 ERYSIPELAS. 3. The third point on which these doctrines are founded, is the appearances found on dissection; and a triumphant appeal may be made to the dissections already recorded under the proper head, at page 522. I may here take an opportunity, however, of shortly stating the appearances found in the brain of a man affected with erysipelas. A respectable spirit-dealer was taken into the surgical hospital, affected with spontaneous erysipelas of the right arm; he had been several days ill. When Mr. Syme saw him, there was symptoms in- dicating violent inflammation of the brain. Immediately before my visit, the diseased part had been scarified, and twelve ounces of blood were ab- stracted. The inflammation on the fore-arm was severe, but above the elbow it was superficial, and did not extend quite to the axilla. He was continually talking, and could scarcely be restrained in bed, declaring he wanted to be up, for hir had no complaint whatever; his eye was bright and lively ; the ex- pression of countenance displayed no signs of sinking; tongue parched and furred towards the root; pulse 98, and soft; considerable rigidity of the flexor muscles of the right arm. We were of opinion, that the man was in great and immediate danger; but more from the inflammatory action in the brain, than from the erysipelas. The head was ordered to be shaved and, cold applied, Before this was done, he became more furious, and continued so till within an hour of his death, during which short period he was comatose; the rigidity was observed to take place in both arms, and to increase till the time of his death. After great difficulty the friends agreed to allow the head to be ex- amined, but the head only ; and, as had been predicted, great vascularity was discovered in the membranes of the brain, but particularly at its base ; the brain itself was generally soft, especially the middle lobes; and more particu- larly still, the corpora striata, and especially that on the left side, which was reduced to a state of complete ramollissement; the white substance of the brain was generally of a brownish hue,—an appearance which is known to be produced when its vessels contain much blood. A small cavity, containing a minute portion of blood, was found in the substance of the middle lobe on the left side. 4. I have now to bring forward a most important part of the evidence in proof of the views here advocated, viz. the relief afforded by proper practice. Treatment of erysipelas.—It is truly lamentable to reflect how fatal erysi- pelas has always been, and continues to be, not only in public hospitals, but in private practice. It is not my intention, and certainly it is not my interest, to give offence to any one, but I cannot resist expressing an honest opinion, that much of this great fatality has been and still is the result of bad practice, founded upon erroneous pathological notions, or, perhaps, if one may be al- lowed to judge from the vacillating measures too often employed, upon no fixed notions whatever. When engaged in lecturing or in writing, I think myself bound in duty, as well as in honour, to adopt the maxim of Aristotle, when he said, " Plato is my friend, but truth much more." However highly a medical man may be respected, and whatever friendship may be felt towards ERYSIPELAS. 529 him, such circumstances will, I trust, never prevent me from expressing an opinion respecting any particular view or mode of practice which he may pursue, particularly when it is destructive to human life. Many of my medical acquaintances are as much afraid of erysipelas as they would be of the plague; others, from the dread of typhoid symptoms, and of mortification and putridity, aggravated the disease by improper remedies. The symptoms which are called typhoid, are often the consequence of the the intensity and depth of the external inflammation, running into extensive destruction of parts, by diffuse suppuration and mortification. This cannot be denied, and when the case arrives at these stages, patients have but little chance of recovery under any plan of treatment; but the question comes to be: How are these bad consequences to be prevented in subsequent cases? The answer is easy, and the practice simple, provided medical men would use the common sense with which they are endowed, and glue up a prejudice that has been inculcated on their minds from the earliest period of their lives by forgetting that there is anything mysterious in erysipelas,—and learning to treat each case that comes before them upon its own individual merits. Some take large quantities of blood indiscriminately from every patientf because they have seen the practice successful in one or two instances; others give the most powerful stimulants and tonics in every case, because they have seen that plan succeed in a few instances; a third set depend upon opiates, or some other one particular remedy; a fourth class will be found to draw blood, but not in sufficient quantity, or they repeat the operation in small quantities without mitigating the disease, while they do great harm by debilitating the patient; and in order to counteract this, they give stimulants too soon. Some timid practitioners will be found to do nothing, but to keep open the bowels, and sprinkle the diseased part with flour; and often have I had occasion to commiserate wretched patients, who, with dry, parched tongues, were doomed to swallow beef steaks,—as well as others, consumed by burning thirst, com- pelled to take wine, and even brandy. Some practitioners make incisions into erysipelatous parts under all circumstances, while others decry the prac- tice, except when matter is formed, as in phlegmonous erysipelas. Typhoid symptoms, besides being produced by mortification, and extensive destruction of the affected parts, are frequently occasioned by the continuance or concentration of acute or chronic diseased action in a vital organ, as seen in cases already recorded under the head " Appearances on Dissection." The next question comes to be, after this information is obtained: How can these results of diseased action be prevented in subsequent cases ? The answer is neither so easy, nor the practice so simple, as in the case of the external in- flammation, where that alone has to be subdued; because it is now fully es- tablished that erysipelas occurs complicated, with a great many diseases of internal organs, and that inflammation of these (even of the brain itself,) may go on, and be beyond the reach of art without exciting such violent symp- 530 ERYSIPELAS. toms as to make the patient or his friends, nay, even some medical men aware, that his life is in the least danger. I cannot but agree with my late lamented friend Dr. Armstrong, when he stated that " "pure surgery is like a vam- pire, whose daily food is human blood," and depricate the conduct of those pure surgeons who boast of enjoying immense wealth from medical, as well as surgical practice, and at the same time do not blush to confess their igno- rance of what may be called medical pathology ; nay, who even decry every part of the profession, but the practice of pure surgery. With regard to the great doctors of London, Air. Abernethy used to tell his pupils what they do and say about erysipelas. " I will tell you (said he) what the doctors say about that; they say you had better not meddle with it at all. You may- powder it a little if you please, but do not attempt to repel it, for if you do, you will have it affect some other part, perhaps some affection of a vital organ may take place. Now this is true enough, (continued he,) for if you try to drive it away, if you put on your cold washes, or play any of your surgical tricks, why, you have a metastasis at they call it, and the man dies!'" General bleeding was practised in erysipelas by Sydenham, and has since been followed by many practioners; but either they have not been able to support the practice by sound reasoning, or bleeding has been injudiciously employed, and has therefore frequently fallen into disrepute. Bateman says in his synopsis, page 131: "Blood-letting, which has been recommended as the principal remedy for the acute erysipelas, is seldom requisite ; and unless there is considerable tendency to delirium or coma, cannot be repeated with advantage, at least in London and other large towns." " Venaesection (says Mason Good) was formerly recommended, and has been so of late by a few writers, but upon mistaken principles. I can conceive few cases in which it can be serviceable, and the application of leeches always exasperate the efflorescence." I know no remedy so decidedly and immediately efficacious as general bleeding, if it be performed sufficiently early in the attack, and in constitu- tions not much debilitated by previous disease or bad habits : Whereas noth- ing but bad consequences can be expected to result from general bleeding in erysipelas, when the disease, having passed its first stage, is about to termi- nate in extensive suppuration, or in gangrene; or when it has taken place towards the termination of an acute or chronic inflammation of a vital organ, or at the termination of fevers. General bleeding may be attended also with bad conseqences when employed under the following circumstances: 1. When the bleeding is not carried far enough to arrest the disease, at the same time that it destroys much strength. 2. When not followed up at a sufficiently short interval by a second general bleeding,—a local abstraction of blood,—or by purgatives, contra-stimulants, &c. In the year 1824, I was requested to see a young man, residing near Leith Fort, who had part of the leg and the whole of the thigh affected with ery- sipelatous inflammation, the disease rapidly extending over the abdomen. ERYSIPELAS. 531 The part affected was very red, painful and tumefied. The constitutional symptoms were severe. The disease was attributed to his having knocked his knee against the edge of a grate; no contusion was to be perceived, but he stated, that for some time he had been unwell, feeling drowsy through the day, and restless at night, being often chilly, with want of appetite, and other symptoms of impaired health. He had been thus affected for perhaps ten days or a fortnight before the slight accident. A vein was immediately opened, and about twenty ounces of blood ab- stracted, when a tendency to syncope took place, and the arm was tied up. Upon looking at the inflamed part immediately after the bleeding, no trace of redness could be observed, except in a circle of about two inches round the part on which the blow had been received. Dr. T. P. Lucas, now in the Royal Artillery, who was present at the time, cannot forget the impression this case made upon his mind. The treatment was followed up by antimony, laxatives, and the antiphlogistic regimen. A small abscess was opened in the course of two days after the bleeding, and the patient made a rapid recovery. A hard-working woman, aged 70, frequently much exposed during labori- ous occupation as a water-carrier,* was seized, in December 1823, with what she called a severe cold. Her voice was altered ; she had a cough ; severe headache, sickness, and oppression at the praecordia, together with constant chilliness. These symptoms existed for some days, attended by loss of appe- tite, and want of sleep ; but she thought they would wear away. At length she felt heat and acute pain in the integuments of the upper part of the face and head; general swelling soon followed, severely affecting the ears, which were quite hard to the touch. Even those symptoms were allowed to continue for three days, before she applied to my dispensary for advice, when at length the symptoms became alarming, and the night previous to my seeing her she was delirious. I found her labouring under great headache, general oppres- sion, and fever. The skin was hot and dry; tongue loaded; thirst; pulse quick, and hard; together with considerable prostration of strength. One of my pupils (Dr. Henry Lucas,) was requested to bleed her to the near approach of syncope ; but not having succeeded in making a large orifice, and being perhaps rather afraid to take away much blood from a woman of her advanced age, he did not bleed her so as to make any impression upon the disease, or upon the constitution; but he came immediately to inform me of his proceedings. Another gentleman, who was further advanced in the pro- fession, ( Mr. Munro, ) returned with Dr. Lucas, and bled the patient till syncope took place. The swelling and redness of the parts immediately disappeared; the thickening of the ear being only left, which also went off in the course of a day or two. The general oppression, fever, &c were also immediately subdued—passage was obtained from her bowels before bed-time, when she got a large opiate, and passed a good night. A solution of tartrate of antimony was given to act as a contra-stimulant, but of this she only took * The last of her class—the old " water cadies " of Edinburgh. 532 ERYSIPELAS. two doses. In four days she was convalescent, walking about the house, made an excellent recovery, and still enjoys good health. Several such cases could be quoted shewing similar results, even in some instances where fears were entertained that the disease had advanced too far, from the appearances of debility under which the patients laboured. I have never experienced bad effects from opening a vein ; but care has always been taken to restrict the employment of this remedy according to the circumstan- ces already noticed. The application of leeches upon the inflamed part stands next in import- ance to general bleeding. Their number is to be regulated by the age and constitution of the patient, and also by the intensity, extent, and duration of the disease :—to an adult with ordinary strength, I would scarcely think of applying fewer than twelve or eighteen. This practice I have been in the habit of adopting ever since the year 1811, and with uniform success. But I apply them only when the disease is in its first stage, and, contrary to the predictions of many individuals, neither ulceration nor mortification have ever ensued. Medical gentlemen have seen the patients twenty-four hours after the application of leeches, when they could scarcely see the marks of the bites. Previously they did not believe that any, except bad consequences, could ensue from such practice. The application of leeches possesses advantages over scarifications in the first stage of erysipelas, and before either hardness of the skin or suppuration has taken place. More blood can be evacuated by the leeches, unless the incisions be made very deep, and patients will be more easily persuaded to allow the application of the leeches, than to have scarifications made. But under the other circumstances already mentioned,, viz. the hardness of the part, or the existence of matter, the knife is to be used in preference. Should suppuration have taken place beneath a fascia, the incisions ought to be extensive, in order to give it free vent; but I must mention that I have seen profuse hemorrage on two occasions from punctures which could not be restrain- ed. Both patients would, I believe, have died under any circumstances; but they began to sink immediately, and never recovered the loss of blood. In one of these patients, the part was carefully examined by the late Dr. Dease, Sur- geon to the Forces, and Mr. Marshall, now Assistant Surgeon in the 87th Regiment, and I believe my learned and facetious friend, Surgeon Martindale of the 17th foot, with a view to discover if any large vessel had been wounded, but none could be found. Indeed we thought it would be so, and that the dark-coloured blood which flowed in a large stream from the wound, had been previously effused into the cellular tissue. It is necessary to obtain free motions from the bowels, at first, by purgative medicines, and this may be subsequently effected by the use of antimony,which cannot be too highly extolled from the effects it produces as a contra-stimulant in this disease. It is a remedy which may be frequently trusted to exclusive- ly in very slight cases of erysipelas, where there is no headache, delirium, ERYSIPELAS 533 difficulty of breathing, or oppression at the praecordia, uo pain on pressure in the abdomen, and no diarrhcea. The reader will therefore perceive that 1 neither think it necessary to bleed, nor to apply leeches, unless compelled by the constitutional symptoms, or the severe pain in the inflamed part. I may here mention, that in many cases which come under my notice, where an internal organ is suffering from diseased action, I trust to the leeches without having recourse to general bleeding, particularly when afraid that the disease may be too far advanced for the lancet. Opiates are often of considerable benefit in erysipelas, although they have aggravated the external irritation in several instances in which they have been prescribed, and particularly in one case where the disease affected the whole body. The use of opiates appears to be most advantageous in cases which have passed into suppuration or mortification, but in which there is no ten- dency to coma. Some practitioners have great faith in emetics; but they seem to be serviceable in very recent cases only, where the disease depends upon some acrid or indigestible substance taken in the stomach ; and by the speedy evacuation of which, the progress of the erysipelas will in many instances be checked. Blisters applied to the part affected have, I understand, been much used in France, where they are highly extolled; but as I cannot speak from my own experience, I shall merely mention the practice. With respect to tonics and stimulants, there can be no doubt of the great advantages occasionally derived from their employment in certain cases, where the disease is so far advanced before medical aid is obtained, that the strength and vital powers have begun to sink—where suppuration has taken place, and the matter has been evacuated—or where dead parts are undergo- ing the process of separation from the living. The best local applications are warm fomentations in the first instance, and should the part shew a tendency to suppurate, light poultices may be applied alternately with fomentations. Cold astringent applications and evaporating lotions will sometimes be found to soothe the patient's sufferings, by removing the pungent heat for the time. I would recommend, however, that they should not be used until the bowels have been well opened, or till bleeding, and other antiphlogistic means have been employed. Speaking of cold ap- plications, Renauldin (Die. des Sc. Med. p. 266,) declares they ought to be entirely proscribed, and that he could cite many examples of their baneful effects; and he actually quotes such instances on the authority of Hagen- dorn, Hoffman, and Fabricius ab Aquapendente. In truth, it will be seen from the preceding statements, that erysipelas must be treated upon very dif- ferent pathological principles from those stated in the London Medical and Physical Journal, by Mr. Earle, who considers erysipelas to be " essentially an affection of the skin." CHAP. III. PAPULAR DISEASES. Under this head I shall speak of the diseases which Willan has termed Strofulus, Lichen, and Prurigo, without splitting them into the same number of varieties. Willan has divided Strofulus into five species, viz. S. intertinctus, S. albi- dus, S. confertus, S. volaticus, S. candidus; but I shall not treat of them separately, because they are not, even according to Bateman, "very impor- tant objects of medical practice." With respect to the second class, Lichen, I shall speak of it also under one head, as Bateman himself admits, that "there is scarcely any limit to the varieties of these papular affections." Were I to follow Willan's classifica- tion, I should have to treat of Lichen simplex, L. pilaris, L. circumscriptus, L. agrius, L. lividus, L. tropicus, L. Urticatus. As to the third class of this order, I shall describe only one variety, Prurigo, instead of four or five, as the same treatment is to be followed in all, whether it occur in youth or old age, upon the neck or pudenda muliebris. By the term papular eruption, a number of small elevations under the cuticle is meant, generally having an inflamed base, sometimes, although sel- dom, containing a fluid, or suppurating, and commonly terminating in des- quamation of the cuticle. STROFULUS. Strofulus is a papular affection of the skin, to which infants and children are liable, and in common language, is known by the term " gum;"—if it is reddish, it is called "the red gum," if whitish, "the white gum," and so on It is a form of eruption depending either upon irritation in the primae viae, or upon teething, and is most commonly met with in those infants who are fed with the spoon too early. Treatment of Strofulus.—I have always observed that those children thrive best, and have fewest complaints, who get least physic, and who are brought i up at the breast; I would therefore strongly recommend, that in general, spoon- meat should not be given to children for the first three months, and physic as rarely as possible. Should this eruption appear, care must be taken not to expose the patient to cold or damp air, and ablutions with tepid water are PAPULAR DISEASES. 535 to be had recourse to twice a day. When the child is asleep, it should not be covered with too many bed-clothes; and should it appear during the period of dentition, the gums must be scarified occasionally. If fever take place, the usual remedies should be exhibited, and the diet regulated. LICHEN. This disease is to be regarded as strofulus occuring in adults. Dr. Willan has defined it, " an extensive eruption of papulae affecting adults, connected with internal disorder, usually terminating in scurf; recurrent, not conta- gious." I have no doubt that the different varieties of lichen depend partly upon gastro-intestinal irritation, and partly upon determination of blood to the surface, as occurs during warm weather, and when the body is over heated, either by too much clothing or violent exercise. The great characteristic of the disease, is tingling or itching, aggravated upon going to bed ; and the purest example of it is to be found in that variety which is called " prickly heat." It sometimes occurs in old age, when it is attributed to debility of constitution, which, I am convinced from experience, is not so frequently the cause as indigestible food. Treatment of lichen.—Regular attention to the bowels, avoiding every acrid and indigestible kind of food, and violent exercise, together with the use of the tepid bath, and the local application of common vinegar, or the juice of limes, constitute the treatment. PRURIGO. This is a disease resembling lichen, excepting that the papulae possess more of a chronic than an acute character, and that the itching is more violent and intolerable; indeed, I have considerable doubts whether it ought not to be considered as an aggravated form of lichen. The chief form under which we see the complaint, is in females in and about the labia pudendi; the desire to relieve the sensation by scratching is very difficult to suppress, and it is in- creased by exposure to heat, the action of walking, &c. It may be produced in this region of the body by the causes already mentioned when treating of lichen, as also ascarides in the rectum, and the acrid nature of discharges from the vagina. Treatment of prurigo.—The general principles of treatment must be the same as those described under the last head, with the following additions, when it attacks the parts of generation,—viz. frequent ablutions, sometimes using astringent washes, and occasionally throwing them into the vagina; and if there be much irritation and swelling, the recumbent posture is very necessary. In such cases, particularly when the inflammation of the part runs high, I have seen the best effects from from one general bleeding. If ascarides be suspected to exist in the rectum, enemeta with turpentine should be employed. In extreme cases, when the parts are very tender, considerable benefit has been derived from the application of a solution of the nitrate of silver to the part, of the strength of six grains to the ounce. An alterative 536 PAPULAR DISEASES. course of mercury, either in the form of blue-pill, or that which goes under the denomination of Plumber's, is sometimes found of benefit, as is also the Harrogate water. A minute examination should be made to ascertain if any pediculi exist, which often create intolerable itching, and red papular eleva- tions. The best method of destroying these is by applying a little calomel, mixed with hogs-lard, or the precipitate produced by throwing calomel into lime water. CHAP. IV. PUSTULAR DISEASES. In this class I shall treat of impetigo, porrigo, scabies, ecthyma, rupia, acne, and sycosis. The last two have been included by Willan in his seventh order Tubercula; and I have excluded one disease which he has comprehended in his order Pustulae, viz. variola, because it ought to be classed among the fe- vers with eruptions, where I have placed it in the first of this work. A pustule is known by an elevation of the cuticle, with an inflamed base, containing pus, which is formed sooner or later, if the disease be not cut short. IMPETIGO. Impetigo may be regarded as a pustular eruption, the pustules being small, irregularly circumscribed, with but a slight elevation of the cuticle, and termi- nating in scabs. It is produced and accompanied by active inflammation and considerable irritation of the parts affected, which terminate in a chronic ac- tion of the vessels engaged in the disease. In the first stage, the eruption is ve- sicular, but like small-pox, and other similar diseases, it becomes pustular, and terminates either in the formation of scales, presenting an appearance like lepra vulgaris, and psoriasis, or when there is a number of pustules accumu- lated in one part; the matter is discharged, and dries, forming extensive scabs, which irritate the surrounding parts, particularly if removed incautiously. Willan and Bateman describe five varieties, viz. Impetigo Figurata—I. Spar- sa—I. Erysipelatodes—I.Scabida—I. Rodens; four of which differ from each other only in the intensity and extent of the diseased action, and the shape and distribution of the pustules; and they seem to have confounded this dis- ease with scabies. Their fifth variety, the " impetigo rodens," Bateman ad- mits he has never seen, but describes it to be a cancerous ulceration extend- ing deeply and extensively, and which is said to commence with a cluster of pustules. Impetiginous disorders are not necessarily accompanied by fever, neither are they contagious, nor, it is said, communicable by inoculation. Causes of Impetigo.—Dr. Willan believes, that this disease is frequently preceded by constitutional disorder, such as pains in the head and stomach; but Mr. Plumbe is of opinion, that when these exist, they are owing to acci- 68 538 PUSTULAR DISEASES. dental circumstances; and that the disease is always occasioned by local irritation, such as the application of alkali to the skin, &c. My experience leads me rather to agree with Dr. Willan, admitting at the same time, that the exciting cause may be, in many cases, fairly attributed to the local application of substances which irritate the skin, as sugar, lime, pepper, &c, but which would produce no local effects, were the constitution not strongly predisposed to cuticular inflammation. The predisposition is in general to be sought for in the condition of the mucous membranes, and sometimes in the functions of the liver, kidneys, &c. Treatment of Impetigo.—Fomentations, when there is much inflammation, together with the tepid bath, gentle laxatives repeated daily, attention to the diet, and avoiding irritating the part by scratching, and the rough or incau- tious removal of the scabs, are all points of importance. At the same time, care should be taken to avoid even a chance of the reapplicaton of the irrita- ting cause. In the acute stage, I have often seen it serviceable to take- a littl*1 blood from the part, either by means of a fine pointed lancet, or a sharp needle ; and if pus be formed, it may be evacuated by the same means with benefit. When the inflammation becomes chronic, stimulating and astringent washes may be used, such as lime juice, common vinegar, solutions of the sulphates of zinc, alumina, or copper, or even, what is still better if there be much pain and irritation, of the nitrate of silver. Cases may occur in which certain well-known ointments, as those of the acetate of lead, nitrate of mer- cury, &lc. may be found useful; but I have generally observed that greasy applications rather retard the cure. porrigo. Porrigo is a contagious pustular disease which principally affect the young, and may be divided into two kinds, one of which is mild, depending upon some constitutional irritation, and affecting the head and face of children, who are generally of a full habit of body. The other variety affects the scalp, often extensively, and is in particular constitutions, and in circumstances of neglect, very intractable. I shall first treat of all the mild varieties, under the term porrigo larvalis, ( commonly called crusta lactea,) for notwithstanding what has been stated by authors, the affections called porrigo larvalis, eaidporrigo favosa differ so very little, either in their causes or in their appearance, that I consider it unneces- sary to give a separate description of each. I shall afterwards notice the true ring-worm of the scalp, which is termed by some authors simply Porrigo, by others P. furfurans, P. lupinosa, P. scutulata. " The porrigo (says Bateman) is a contagious disease, principally charac- terized by an eruption of the pustules, denominated favi and achores, unac- companied with fever. The several appearances which the disorder assumes, ate reducible to five or six specific forms. PUSTULAR DISEASES. 539 " 1. The porrigo larvalis, or crusta lactea of authors, is almost exclusively a disease of infancy. It commonly appears first on the forehead and cheeks, in an eruption of numerous minute and whitish achores, which are crowded together upon a red surface. These pustules soon break, and discharge a viscid fluid, which concretes into thin yellowish scabs. As the pustular patch- es spread, the discharge is renewed, and continues also from beneath the scabs, increasing their thickness and extent, until the forehead, cheeks and even the whole face, become enveloped, as by a mask, (whence the epithet larvalis ) the eye-lids and nose alone remaining exempt from the incrustation. The eruption is liable, however, to considerable variation in its course ; the discharge being sometimes profuse, and the surface red and excoriated,—and at other times scarcely perceptible, so that the surface remains covered with a dry and brown scab. When the scab ultimately falls off, and ceases to be re- newed, a red, elevated, and tender cuticle, marked with deep lines, and exfo- liating several times, is left behind ; differing from that which succeeds to impetigo, inasmuch as it does not crack and form deep fissures. " Smaller patches of the disease not unfrequently appear about the neck and breast, and sometimes on the extremities; and the ears and scalp are usually affected in the course of its progress. In general, the health of the child is not materially affected, especially when the eruption does not appear in the early period of lactation ; but it is always accompanied with conside- rable itching and irritation, which in young infants, often greatly diminish the natural sleep, and disturb the digestion. Whence much debility some- times ensues; the eyes and eye-lids become inflamed, and purulent discharges take place from them, and from the ears; the parotid, and subsequently the mesenteric glands, become inflamed; and marasmus, with diarrhcea and hectic, cut off the patient. " Most commonly, however, the disease terminates favourably, though its duration is often long and uncertain. It sometimes puts on a healing appear- ance for a time, and then returns with severity. Sometimes it disappears spontaneously soon after weaning, or after the cutting of the first teeth; and sometimes it will continue from two or three months, to a year and a half, or even longer. It is remarkable, however, that whatever excoriation may be produced, no permanent deformity ensues." (Bateman on Cutaneous Dis- eases, p. 158.) The only additional observation I shall make respecting the porrigo favosa, isj that it occurs in adults, particularly in females, and affects principally the scalp, the hair falling off, and becoming of a lighter colour. In both affec- tions, small glands in the neck and behind the ears enlarge, and sometimes suppurate. The worst cases of the disease called porrigo furfurans occur after fevers, particularly the eruptive, and also when a scurfy state of the scalp has existed for a considerable time previous to the attack. Treatment of the milder forms of porrigo.—As these diseases occur under some constitutional irritation, local applications are not beneficial, till the 540 PUSTULAR DISEASES. original causes are removed. If they depend on teething, great attention should be paid to relieve the irritation of the gums, by dividing them freely as the teeth advance; and also to the diet, that it be light and easy of diges- tion; as well as to keep the bowels in a proper state. Every care must be taken to keep the parts clean, and to avoid the application of all oint- ments, at least in the first stages, when there is acute inflammation. When the inflammation runs high, immediate advantage may be derived from leeches; and I have had no hesitation in applying them to the face. When the inflammation is considerable, but does not run so high as to require leech- ing, benefit is obtained by bathing the parts with warm saturnine lotions. Should the scabs, from neglect or other causes, become extensive or hard, they should be carefully removed by means of tepid fomentations or poultices. Under the best treatment, the disease will return with each pair of teeth; and not only does it trouble children when getting their milk teeth, but also occasionally when cutting the permanent ones. In many of the cases which occur after eruptive and other fevers, the state of the tongue, the thirst, the appearance of the secretions, and the tumefaction and tenderness of the abdo- men, evince that there is considerable irritation or inflammation of the mu- cous membrane of the stomach and bowels. In such circumstances the patient may be placfrd under the following treatment: Gentle aromatic laxa- tives, repeated according to the state of the bowels; a diet consisting of bread and milk, arrow root, sago, whey, &,c.; the application of leeches to the abdomon; the tepid bath ; and sometimes an eruption of pustules maybe produced upon the belly by means of the antimony ointment. Mr. Plumbe states, at page 121, of his excellent work on " Diseases of the Skin," that, in much neglected cases, a perfect cure has seldom been pro- duced, except when "the operation of plucking the hair from the diseased part has been diligently followed up, and every other possible means taken to check inflammatory action." I must confess that such cases are very rare in this country, so much so, that in my Dispensary practice for the last seven years, the patients averaging about four thousand annually, no such intracta- ble instances have occurred, notwithstanding the reputation for dirtiness which the Scotch have acquired in the minds of their English neighbours! Appearances of the most severe forms of porrigo.—The following descrip- tion of the disease is complied from the work of Mr. Plumbe, who has de- voted much time and attention to affections of the skin, and more particularly to this disease. "Thedegree of obstinacy evinced by a larger portion of cases of this dis- ease, the interruption it frequently occasions to the education of children, (its known infectious nature preventing their admission into schools,) com- bine with other circumstances to give it a peculiar interest." Mr. Plumbe thinks that there are two particular forms of the disease which produce all the varieties mentioned by authors, and that both occasionally arise spontaneous- Jv or are the result of infection, and that the one may produce the other. PUSTULAR DISEASES 541 In the first form the hair falls off, leaving sometimes, but not always, circu- lar patches, the margin being clearly defined, and exhibiting a line of scurf considerably thicker than that in the centre. In the centre of the spots, the skin is scurfy, and the hair thinned, and easily extracted by the finger and thumb. What remains of it, is unhealthy in appearance, some hairs being thin and delicate, others being the remains or stumps of those which have been broken, or dropped off. There is a downy substance just rising above, and mixing with the scurf, evidently formed by feeble attempts at the production of new hair. The spots vary in number and in dimensions, and on the hair being removed, exhibit a red and slightly inflamed appearance. Here and there this form of the disease will be observed in an incipient state, and is known by small discolorations of a yellowish red colour before the hair begins to drop off. The spots shew no pustular appearance at the margins, and en- large slowly in diameter till they unite; but if stimuli, in the form of oint- ments, have been applied a more active condition often take place, and minute achors form not only on the margins, but on other parts, accompanied by ir- ritation, heat, and itching. The pustules discharge their contents, and form scabs of a light stiaw colour, under which extensive abrasions of the cutis are sometimes found. Spots of the same nature may be seen on different parts of the body at the commencement of the affection of the scalp, and for some time after, but they generally disappear before its termination. This is the usual appearance of the disease in children, whose general health is unimparied, and skin not particularly irritable; but in opposite conditions, small pustules, instead of vesicles, are perceived, which dry, and form a cir- cular scab. The ring of pustules enlarging in the same manner as that of the vesicles, and their contents drying, and adhering to the margin of the scab already formed, increase its bulk and diameter. The scab becomes a source of increased irritation, and the pustules, under its margin are enlarged and more elevated, raising its edges, and giving the appearance of the P. lupinosa The other variety of porrigo never assumes the circular, circumscribed form of the one just described; but is diffused over a considerable space, and is pustular from the beginning on the scalp. It can, like the other, be iden- tified with an affection of the skin of other parts, which is partly vesicular and partly consists of papulae of different sizes. The pustules are thickly dispersed over the head, and a hair occupies the centre of each, the skin in the interstices being red and inflamed. This form of the disease is accompanied by fever and irritation; and derangement of the digestive organs will be found to have existed, generally, for a long time pre^- vious. The absorbent glands at the back of the head and those of the neck inflame, and sometimes, though rarely, suppurate. Inflammation of the cel- lular membrane, under the scalp, takes place here and there, forming abscesses which burst, and soon heal, but leave the parts which they occupied bald ever after. 542 PUSTULAR DISEASES. As the pustules are ruptured, and their contents distributed over the adja- cent parts of the scalp, these parts become inoculated, the disease spreads, and yellowish scabs are formed of an unpleasant odour and aspect, which, unless frequent ablution be had recourse to, rapidly accumulate. These descriptions, according to Mr. Plumbe, comprehend every thing essential to the history of porrigo (except as regards the P. favosa, and P. larvalis,) as it occurs in the better classes of society, where cleanliness is par- ticularly attended to, the general health not materially injured, and where the disease is not aggravated, and its character changed, by the improper use of stimulant applications; and, under these circumstances, both will frequently disappear spontaneously by the continued employment of ablution. But, wnder other circumstances, both forms may terminate in that most obstinate and intractable one—the P. furfurans of Bateman, which seems to be the result of long continued irritation. Its principal distinguishing feature is the copious production and rapid exfoliation of morbid cuticle, which from its, branny form, is readily entangled by the adhesive matter of the pustules forming a sort of cement. The union of the morbid cuticle, which is secreted in great quantities, with the matter of the pustules, increases the mischief by matting the hair together, and preventing the application of remedies. Upon examination in this state, after cleaning the scalp by the long continued use of warm water, the interstices of the hair exhibit an erythematous redness, and appear altogether deprived of cuticle; the passages by which the hairs arrive at the surface are enlarged, the covering which they receive from the cuticle is destroyed, and its place occupied by a glutinous fluid, which may be seen exuding, and surrounding each individual hair. % The quantity of this secretion varies at different times, and the proportion which it bears to that of the exfoliations of the cuticle, determines the consistence and adhesiveness of the diseased part; and hence, when small in quantity, the latter is more dry, harsh and shining. In this state of the disease, and also under circumstances, when the accu- mulated secretions are considerable in quantity, the term " scalded head " is generally applied. Treatment of the most severe forms of porrigo.—Cleanliness, and prevent- ing the formation of hard scabs, are of still more importance in the cases now under consideration than in those of a milder character; and when scales have formed, they are to be softened by means of fomentations and a poultice of lint-seed meal. Gentle mercurial laxatives are also serviceable, assisted by the daily use of Harrogate water. The diet must depend entirely upon the state of the constitution, as to whether it ought to be very nourishing and somewhat stimulating, or the reverse ; but in all cases the stomach must not be overloaded, and the diet should be dry. The use of the tepid bath will be found very advantageous. It would be impossible to give an account of all the local remedies which have been used for the cur? of porrigo ; therefore I shall merely enumerate PUSTULAR DISEASES. 543 some of them. Coarse soft soap, sulphur ointment, or both conjoined ; oint- ment of the coculus indicus—of the oxide of zinc—of calomel—of the red oxide of mercury—of nitrate of mercury—of tar—of nitrous acid—muriate of ammonia—of acetate of lead and opium—hellebore—turpentine__mustard__ stavesacre—dulcamara—black pepper—cayenne pepper—galls—savine, &c. Lotions of acetate of lead, sulphates of zinc and copper, infusion of tobacco and tar-water; equal parts of the spirits of wine and oil, and also the same proportions of vinegar and oil; muriate of mercury, in alcohol, in water, and lime water; the black wash, a solution of nitrate of silver, and tincture of the muriate of iron; blisters. Some recommend the part to be powdered with sulphur; the direct application of a stick of lunar caustic ; adhesive plaster ; the oil-silk cap, and pitch cap. In addition to the constitutional remedies for the cure of the true vesicular circumscribed ring-worm of the scalp, I find few cases resist the nitrate of sil- ver, applied by rubbing it carefully over all the diseased parts, and re-applied as soon as the dark-coloured exfoliation separates. In the other form of the disease, the formation of scabs will be prevented, at least in a considerable degree, by wearing a wax-cloth cap ; when this is done, however, the patient should have two or three changes of caps for the sake of cleanliness, and to avoid an almost insufferable smell. Mr. Plumbe has been very successful, by removing the roots of the hair with a pair of pincers, which is a merciful alternative for the old pitch cap; and should any local inflammation be excited, he recommends the use of a cooling lotion. SCABIES OR ITCH. This disease, as Bateman admits, almost bids defiance to any attempt to re- duce it to an artificial classification, as it appears sometimes in the form of pustules, vesicles, and papulae, the one variety often running into the other. In all of these forms it is accompanied by a constant and almost irresistable itching. It is contagious, but is not attended with fever; all parts of the body are liable to it, except perhaps the head, particularly the wrists, between the fingers, the flexions of the joints, &c. Causes of scabies.—It has been universally attributed to contagion, but it appears to me that this cause has its limits, and that it depends as much, if not more, upon a state of the constitution and consequence of diet. It seems to be almost endemic in some remote districts of this country, in Ireland, and in France, where sulphur, the sovereign remedy, has no effect in extermi- nating it, because it is an eruption produced by unwholesome food. In the army it is rare to see an old soldier affected with itch, the subjects mostly af- fected are recruits, recently joined, who had either brought the disease into His Majesty's service with them, or had caught it from other recruits, they themselves being predisposed to it by a change of diet and habits. Treatment of scabies.—This is so well known, that medical men are rarely applied to. The specific powers of sulphur, applied externally in the form 544 PUSTULAR DISEASES. of ointment, and taken internally in half-dram doses with an equal weight of cream of tartar, soon cure' the affection. Three or four days generally are suf- ficient. Other remedies have also been extolled, as the root of white hellebore, diluted sulphuric acid, and the muriate of mercury, all of which have been used with benefit. In obstinate cases, Dr. Robertson has seen much benefit arise from mixing half an ounce of powder of white hellebore with four ounces of sulphur ointment. ECTHYMA AND RUriA. Perfectly agreeing with Mr. Plumbe, that these are merely varieties of the same disease, I have thought it right to consider them together, particu- larly as they occur under the same states of constitution, and are to be treated in the same manner. Indeed, Bateman observes, when treating of rupia, (at p. 237.) " For practical purposes it might have been included with the ecthymata, as it occurs under similar circumstances with the ecthyma luri- dum ; but the different form of the eruption, for the sake of consistency of language, rendered the separation necessary." According to Bateman, we have five species of ecthyma, and three of rupia, the one differing from the other only as to the age of the patient, and the colour and form which the eruption takes. Ecthyma and rupia may be defined to consist of an eruption of inflamed pustules, commonly of a large size, raised on a hard circular base, of a vivid red colour, and succeeded by a thick, hard, dark-coloured scab, usually distinct, and arising at a distance from each other. This kind of erup- tion is indicative of some state of distress under which the constitution la- bours, and though it is not attended with actual fever, yet a degree of general irritation or erythism is often present with it. Occasionally the eruption is confined to the trunk, but sometimes spreads to the other parts, seldom, how- ever, being seen on the face or hands. Causes of ecthyma and rupia.—According to Mr. Plumbe, " anxiety of mind, accompanied by great bodily exertion, fatigue, low living, the debilitat- ing effects of previous fever; in short, any thing reducing the energies of the constitution beyond a certain extent, is capable of producing it. Almost the whole of the cases which I have had an opportunity of observing have oc- curred in young people; the majority in young men, who, with constitutions originally not of the strongest class, had imprudently indulged in excesses and irregularities to a great extent, accompanied by privation of rest and other depressing circumstances. Very frequently, in such cases, it is mistaken for a venereal eruption, and the patient himself is readily made to believe in an opinion which his habits have made so probable. If mercury be had recourse to under these circumstances, the disease is much aggravated," &c.—p. 439. Pathology.—From a careful consideration of all the cases of this kind of disease which have fallen under my notice, as well as from what I have read, I cannot help regarding the pustules above described as effects of nature to translate disease to the surface ; that they depend upon irritation, and the re- mains of inflammation in the mucous membranes generally , and that they are not produced by mere debility of constitution, as is generally supposed. PUSTULAR DISEASES. 545 Treatment of echtymia and rupia.—According to the above views, the treat- ment is simple, and consists in the daily use of the tepid bath; mild laxa- tives, occasionally combined with a mercurial preparation ; light nourishing diet, avoiding beef tea, and all other forms of animal food, till the tongue im- proves in appearance, and the stools look more natural. In the course of some days, the sulphate of quinine will be found very serviceable; but it is not to be employed until the tongue becomes quite clean. On some occasions I have seen benefit derived from a blister applied on the lower part of the chest, more particularly when the sound of respiration announced the pres- ence of a bronchitic affection. ACNE. Bateman has divided this simple disease into four varieties, viz. acne sim- plex, punctata, indurata, and rosacea, thus creating distinctions without dif- ferences, the only effect of which is to embarrass students. This affection has also obtained the name of slow suppurating tubercles; and appears to me, that the reason why it is called a tubercle, and classed as such in all the books on cutaneous diseases, except Mr. Plumbe's, is that a hard painful, circum- scribed body is felt under the skin, which is perceived for a considera- ble period, now and then becoming painful, and continuing in this state for many months, and at last suppurating, perhaps, only from having been fre- quently irritated. There cannot be the least doubt, that the pathological views of Mr. Plumbe concerning acne are quite correct. They accord with the opinions upon which I have acted for a number of years, viz. that acne is a diseased condi- tion of the sebacous follicles. In the slighter cases, the sebaceous matter con- cretes, distends the follicle, irritates it, and produces inflammation; slight suppuration takes place, a pimple is formed, and sebaceous matter is dis- charged, with or without a small quantity of pus. In the severer cases a higher degree of inflammation is produced, involving the surrounding cutis ; the suppuration is more extensive, and slower in its progress, and per- haps the part suppurates again and again until the follicle is emptied, or its structure is completely destroyed. The parts chiefly affected are the forehead, the sides of the nose and the shoulders. The age at which acne most frequently occurs is that of puberty, alike affecting males and females. Causes oj acne.—Although acne be not preceded by fever, and notwith- standing that it seems to be produced by the sebacious matter, yet it is not difficult to shew, that it is connected with the state of the constitution, not only from the age at which it occurs, and the bad habits of drinking and gor- mandizing which frequently induces it, but also from the state of the tongue and the digestive organs. It occurs likewise under diseased states of menstrua- tion, and under sedentary habits. 69 546 PUSTULAR DISEASES. Treatment of acne.—This may be divided, as in other cases of skin dis- eases, into constitutional and local. The first consists in attention to the bow- els and diet, and taking all the ordinary means to improve the powers of di- gestion, including the warm bath. The local treatment consists in avoiding stimulating applications during the inflammatory stage, and puncturing the point of the pimple, to prevent suppuration, and allow a free passage to the sebacious matter, without destroying the follicular structure. This has also the effect of preventing any permanent hardness, which so frequently hap- pens when the process of suppuration is very slow, or when it does not take place at all. If matter have formed, the lancet should be used to allow it to escape, and gentle presure applied at the same time to force out the hard sebacious matter. I know many females in whom marks were left by the disease, before the plan of early puncturing the pimples was adopted. Indi- viduals liable to this affection, should pay scrupulous attention to their diet, and to the state of bowels ; they should also use frictions with a flesh-brush, a piece of flannel, or a soft towel. SYCOSIS. This affection scarcely deserves a separate consideration from acne; I agree with Mr. Plumbe, that it is produced by follicular obstruction, and consequent inflammation occurring in parts covered with hair; and its principal seats are the chin in men, and the head in both sexes, particularly the margin of the hairy scalp, in the occiput, around the forehead and temples, and near the external ear, which is also liable to be included in the disease. Sycosis is more troublesome than acne, as all eruptive diseases situated on parts covered with hair are observed to be. Treatment of sycosis.—The constitutional and local treatment recommended in acne must be followed up, with this addition in severe cases, that not only is the point of the lancet necessary, but the foreceps also, to extract any hair which may appear to be a source of irritation; and it is particularly necessa- ry on the chin, where on many occasions the root of the hair itself will be found in a diseased thickened state. The extraction is seldom attended with any pain. CHAP. V. SQUAMOUS DISEASES. Under this designation I shall consider the following diseases,—Lepra, Psoriasis, and Ptyriasis, which latter I might perhaps without any disadvan- tage, altogether pass over, because I consider it as the mildest form of lepra. I have not included ichthyosis, or fish-skin disease, because it is exceedingly rare ; it has the same pathology with lepra, and similar treatment is applica- ble to this affection. One form of it, ichthyosis cornea, is a surgical disease. lepra. By this term is designated a disease exhibiting red, inflammed, elevated spots and patches, in many cases not larger than a split pea, which yield al- most daily crops of scales or scurf, and is rarely, if ever, accompanied by a vesicular or pustular appearance, unless such formation be accidentally pro- duced by roughly tearing out hairs. After seeing the disease once, the scales can never be mistaken for scabs formed by the drying of pustules or vesicles, unless the affection have run into the state called psoriasis, which falls next to be described. Willan and Bateman have divided the disease into three species, viz. lepra vulgaris—alphoides—and nigricans. The first two ought to be regarded as different degrees, or perhaps rather stages of the same affec- tion : while the last species, nigricans, differs in the colour and state of the constitution at the time; and I heartily agree in the following remarks of Mr. Plumbe: "That they may therefore be dispensed with with advantage, is obvious, inasmuch as they have had their share in creating the confusion elsewhere alluded to, and discouraging the student in the prosecution of his inquiries. It is to little purpose that preceding authors have expended so much time in investigating the confused records of ancient times, to determine what was meant by the term, and to ascertain the correct history of the dis- ease, if new difficulties in its study are to be invented by encumbering it with useless and multiplied names," (page 128.) On looking minutely at the part affected, it is observed to have a shining hard surface, owing to a somewhat transparent, smooth, polished scale, which separates in a day or two, and to be encircled by a dry, red, and slightly elevated border. When the scales are removed, the skin underneath appears smooth, red, and shining, and ge- 548 SQUAMOUS DISEASES. nerally free from cuticular lines. As the diseased spots extend, fresh scales are produced, having a somewhat different appearance from those formed at the beginning of the disease, and they do not extend uniformly over the diseased surface in one continued scale, but separate more like scurf. The disease very generally commences on the extremities at parts where the bones lie nearest the surface, but I have often observed the eruption appear first on the surface of the abdomen, breast, and shoulders. The head, face, and hands, often become involved in the disease, and in very severe cases the nails of the fingers and toes are much thickened, incurvated at the extremities, and some- times fall off. When the disease covers a considerable portion of the body, a large quantity of scurf is found in the bed in the morning, which is rapid- ly reproduced. More or less of an itching or a tingling sensation is experienced by the patient when heated by exercise, and after getting warm in bed ; but when the disease becomes extensive, and attended by considerable inflammation, extreme soreness, stiffness, and sometimes severe pain are produced, more par- ticularly at the flexures of the joints, where the skin often cracks, discharges serum, and in fact runs into the state termed psoriasis. The parts likewise swell so much under these circumstances, that I have seen a limb fully more than a third above its natural circumference. It is surprising to find Bateman stating, at page 28, that in the worst of these circumstances " there is no constitutional disturbance." If by this expression he means to say that there is no fever, the statement is correct, but there is frequently considerable and severe constitutional disturbance without the existence of febrile symptoms; and when speaking of the causes of this disease, I shall endeavour to describe the actual constitutional derangements upon which the disease appears to depend. Causes of lepra.—Leprous disorders are very often met with among the poor in all countries, but they are more frequent and severe in warm climates, and in countries where the poor are most destitute. I do not believe that they originate from want of cleanliness, but certainly when once produced, this circumstance renders them more intractable. All causes which have a ten- dency to produce functional diseases of the chylopoietic viscera may be rank- ed as causes of lepra in particular constitutions. Sometimes, and most fre- quently, it is produced by unwholesome and indigestible food, particularly such articles as yield little nourishment. Affections of the mind, &C. may likewise give rise to it. The rich are not exempt from this disease, and it frequently attacks those with gouty constitutions. For many years past, I have paid considerable attention to disorders of the skin, and a great many cases of lepra and psoriasis have fallen under my observation: and gastro- intestinal irritation has been discovered in all the cases but one : and in that one, there were great mental anxiety and despondency, with hepatic derange- ment. There can be no doubt that the disease, in the first instance, is seated in the vessels of the cutis which are employed in producing the cuticle, and that its nature is inflammatory. SQUAMOUS DISEASES. 549 Treatment of Lepra.—In detailing the treatment, I shall describe the differ- ent plans which experience and pathological considerations have led me to follow with very great success, and I shall notice these under different heads. 1. In all cases, it is necessary to attend to the bowels by very gentle, but frequently repeated laxatives, occasionally combined with calomel, and assist- ed also by the daily use of Harrogate water. The diet must likewise, in all cases, be attended to; and it will be found that the disease often depends upon one particular article of diet, varying in different constitutions, as dried fish, shell-fish, salted meats, new bread, coarse and unwholesome bread, potatoes, onions, garlic salads, cheese, oat-meal, sweet-meats, bitter almonds, nuts, vari- ous kinds of fruits, particularly if the skins or husks be swallowed, broths and soups, different kinds of malt liquors, cyder, wine, spirits, &c. Indeed the diet is of such vital consequence, that I find it necessary in many obstinate cases to make my patient write down a daily list of every article which he has put into his stomach, so that by comparing his condition with the food he has been using, we are between us able at last to detect those articles which disagree. It is also necessary to take care, that while the patient has suffi- cient clothing, his skin is not kept too hot; and I have sometimes found it of service to cause linen to be worn next the skin instead of flannel. When it can be managed, the inner garments should be changed daily, particularly in severe cases, and this is still more necessary when the disease takes on the appearance which constitutes psoriasis. When the patient goes to bed, care should be taken that his feet be warm, and that he be not over-heated by too many bed-clothes. The tepid bath should be used daily, or when that is inconvenient, the whole body should be sponged twice a-day with soap and warm water, or vinegar and water. 2. If the inflammation of the skin be very severe and extensive, I com- mence by taking blood from a vein in such quantity as may be necessary, at- tending to the state of constitution as well as the extent of the inflammation, and afterwards proceed with the plan above described; and there are few cases which resists these means. 3. In old or very intractable cases, where these remedial means have been tried without success, recourse ought to be had to sulphurous baths and fumi- gations, which can scarcely be praised too highly ; but they must not be used when the inflammation is acute. When these cannot be obtained, some benefit may be derived from the external application of Harrogate water, se- veral times a-day. 4. In still more intractable cases, where the above remedies have failed, or where sulphur baths cannot be obtained, considerable benefit will be derived from the use of lime-juice, externally as well as internally ; but I place more dependence on the employment of an alcoholic solution of the oxymuriate of mercury in the proportion of four grains to the ounce, beginning with ten drops twice or thrice a-day, and increasing each dose to twenty, thirty, or forty drops, of course attending at the same time to the diet, bowels, cloth- ing, &c. • 550 SQUAMOUS DISEASES. 5. Should these plans fail, recourse is to be had to the use of arsenic, which is placed last in the list of remedies, because its use is frequently attended by more constitutional disturbance. And I have frequently seen it fail in cases where the other plans have succeeded. For some years past I have only had occasion to employ it twice, but on both occasions without success; in one instance it was perserved in till the patient was nearly poisoned. Mad- dar or madaar, an Indian remedy, was also tried in this case, but only with temporary benefit. Various ointments, such as that of tar, nirate of mercury, and carron oil, have frequently been employed, but according to my experi- ence, not with much success. A most injurious plan is followed by some, of putting all patients affected with lepra, and other skin diseases, on farinaceous food, with which they stuff themselves in such a manner as to increase the functional derangement of the stomach and bowels, thereby producing an inveterate affection. Many in- stances of this kind of mal-treatment fall annually under my care, in which a change of diet has generally affected a benefical change in the character of the disease; an interesting case of this nature I shall notice, when treating of psoriasis. In addition to what has been said already respecting diet, it may be shortly remarked, that in cases where the inflammation of the skin runs high, an abstemious diet should be recommended, but, generally speaking, a moderate quantity of animal food is necessary. In no case should the patient be allowed to load the stomach with any article, and he should be cautioned particularly against taking above a small tea-cup full of soup of any descrip- tion ; he must likewise altogether avoid taking that " animo-vegetable decoc- tion," called Scotch broth. The tongue should be frequently examined as well as the stools, as from both of these we may draw conclusions respecting the effects of diet and medicines. Tonics are often serviceable, as well as a moderate allowance of such stimuli as are found to agree best with the patient, and which he can afford. PSORIASIS. According to Bateman, " Psoriasis, or scaly tetter, occurs under a considera- cle variety of forms, exhibiting, in common with lepra, more or less rough- ness and scaliness of the cuticle, with redness underneath. It differs, how- ever, from lepra in several respects. Sometimes the eruption is diffuse and continuous, and sometimes in separate patches of various sizes; but these are of an irregular figure, without the elevated border, the inflamed margin, and the oval or circular outline of the leprous patches; the surface under the scales is likewise much more tender and irritable in general, than in lepra; and the skin is often divided by rhagades,or deep fisures." And he might have added, that when the inflammation runs high, and extends deep into the substance of the cutis, there is often a very considerable discharge from these fisures, and even from the general surface, forming extensive scabs; but this;'f«r the most part, never takes place except in mismanaged cases. It is SQUAMOUS DISEASES. 551 to be regarded in every respect, pathologically speaking, as a similar disease to lepra. I have seen the eruption leprous in one part of the limb, and psoriatic in another, particularly between the fingers, and at the flexures of the joints. Lepra may be converted into psoriasis by bad management, and particularly by the application of irritating substances to the diseased parts. Psoriasis may be converted into lepra by a general bleeding, thereby mitigat- ing the local inflammation. From all the facts which experience has enabled me to collect, I cannot but regard psoriasis as an aggravated form of lepra, and by treating it upon corresponding principles, I have been very successful in curing the affection. Willan and Bateman have divided psoriasis into four varieties—viz. the guttata—diffusa—gyrata, and inveterata; but I shall avoid such distinctions, as no good practical results can be expected from them. This disease like lepra, may be very partial, but I have seen several cases where the whole of the extremities were covered with psoriasis, while the trunk of the body, the face, and the head, were affected with lepra. I shall now relate the case which was formerly alluded to, (p. 550.) A gentleman of a healthy, strong constitution, accustomed to good living, and engaged in an extensive speculation, experienced a great and unexpected reverse of for- tune. Possessed of highly honorable feelings, he was determined to pay off every shilling of debt, by reducing his establishment, and altering his style of living, and, it is to be regretted, by denying himself many of the common necessaries of life. For upwards of two years he lived almost entirely upon fish and potatoes, and he employed himself so assiduously at his business, that he never went out to take exercise except when obliged. In the course of time, a leprous eruption appeared upon his arms and legs, but it gave him little trouble, and he did not apply for medical advice; by and by it appeared here and there upon the trunk of the body, still it attracted little of his atten- tion. One day he slipped his foot and sprained his ancle, which swelled much and was attended with pain. He sent for a doctor, who confined him to bed, leeched the part affected, put him upon the strictest antiphlogistic regi- men, and prescribed a dose of salts daily. Under this treatment the leprous eruption extended rapidly ; his appetite became bad, the tongue foul and load- ed. At the end of a month the surface of both extremities was inflamed, and the disease was now converted into psoriasis, with excessive discharge, swelling, and itching. All kinds of local applications were tried without benefit; and when I was consulted, the gentleman was in the following con- dition. His legs and arms were very much swollen, painful, and so itchy that he was deprived of rest; they were covered with scabs, which were pro- duced by the partial drying of a profuse discharge of fetid serous fluid, which seemed to ooze from every pore of an intensely red, shining, and highly in- flamed cutis. So profuse was the discharge, that it soiled the bedding, and notwithstanding every precaution, no means could be devised to prevent the linen from sticking to the affected parts, the separation of which produced 552 SQUAMOUS DISEASES. great pain, aggravated the local inflammation, and frequently caused bleeding from the parts. The trunk of the body, the face and scalp, were also affect- ed with that form of lepra termed vulgaris. His strength was destroyed, partly by the remedies and the diet, and partly by the constitutional irritation, and want of sleep, but principally by the constantly profuse discharge. He had now been confined for the most part to bed for about 140 days. The pulse was quick and weak; he had constant singing in his ears, giddiness upon raising his head from the pillow; and for some days had always fainted upon getting up for necessary purposes. Notwithstanding the quantity of salts and other purgatives he had taken, his bowels were in bad order, the stools were scanty, very dark in colour, and fetid; the tongue was swollen, rough, fissured, and covered with a thick crust. The following treatment was adopted. The carron oil was changed for a warm solution of sugar-of- lead to the parts affected, which was applied by means of bandages kept wet with it; a few doses of calomel were exhibited ; and he was allowed some wine and water. From this time he enjoyed good rest; the tongue improved so much in two or three days, that he was allowed a small quantity of animal food; the heat, inflammation, and discharge, were so much diminished in the course of three or four days, that the saturnine lotion was discontinued, and the limbs were enveloped in fine oiled silk. He made such a rapid recovery, by the assistance of small doses of blue-pill and Harrogate water, that he con- sidered himself quite well in the course of three weeks; and although he has since had several slight relapses, they were attributed to errors of diet, and inattention to the bowels. Exactly a year afterwards, the disease returned in a severer form on the extremities, but was speedily cured by general bleeding and the employment of the local remedies. This last paragraph was written more than two years subsequent to the first illness, and the gentleman is now in excellent health. Treatment of psoriasis.—The above cases shews the treatment that I would recommend; and the only circumstances which ought to be mentioned in addition to what has been stated respecting lepra, are the greater necessity for cleanliness, and the application of oiled silk to the affected part. pityriasis. This is a very superficial affection, consisting of irregular patches of slen- der scales, which repeatedly exfoliate and recur but which neither form crusts, nor are accompanied by fluid excretion, or excoriations; and it is stat- ed not to be contagious. The most frequent situation of pityriasis is the scalp; and when it attacks infants, it is commonly called " dandriff;" Willan and Bateman have given it the term pityriasis capitis. It is now and then observed in adults, particularly those of dark complexion. Cleanliness in this instance, prevents the disease from being troublesome; and it may be easily removed, even when the scurf is pretty thick, by washing the part with soap and water, and a soft brush daily, or using a solution of the carb. sodae. When neglected, howevers it runs into a state much resembling the worst forms of of porrigo. SQUAMOUS DISEASES. 553 Pityriasis in a severe form now and then occurs in adults, producing consi- derable discomfort to the individual. According to Mr. Plumbe, different parts of the body become the seats of much itching and tenderness; and when friction is employed, scabs of considerable thickness fall off, the parte below exhibiting a red, shining, glossy, and sometimes slightly moist surface. The skin of the chest and back are the common seats of this form of the affection; but the hairy scalp and its margin also partake of it. The colour of the parts, when covered with the diseased cuticle, is of a lightish yellow, or copper hue; when the cuticle is removed, it approaches more to red; but the cutis at no time appears of the colour consequent on common abrasion. The figure of the patches is very various, "here and there are spots of from half an inch or less, to two or three inches in diameter, approaching perhaps to a circular form. These will perhaps be found around the margin of a lar- ger patch, the outlines of which are as irregular as the outlines of a map of an island. The colour of these larger patches also varies from time to time in different parts from a light straw to a reddish colour; hence the terms pityri- asis versicolor, p. rubra, which Willan and Bateman have formed into varieties. Causes and treatment, of pityriasis.—I have seen only two cases of this disease which required any treatmeut; and therefore I shall make free with the pathological and practical remarks of Mr. Plumbe. He says the disease as occurring in adults, pretty uniformly attacks individuals of delicate health; and diminished energy of circulation. In such states of the system, the cuta- neous vessels partake of the general debility, and have the disadvantages of their locality, as furthest from the centre of circulation : and being exposed at the same time to vicissitudes of temperature, they are incapable of the forma- tion of sound cuticle, and produce instead of the delicate and ill-formed sub- stance described. " The state of the circulation and system, in all cases which come under our notice, proves this view of the case to be correct. I have never seen a single case, (says he,) where want of energy was not apparent, and very few where the supply of this was not followed by speedy recovery. Violent and distressing impressions on the mind, original debility of constitu- tion, the depressing effects of long continued illness in warm climates, &c. are found very commonly to have been co-er "stent with the first appearance of the disease." The constitutional treatment which wijl be found most successful, is that which is in strict accordance with the above principles. Measures which tend to invigorate the system, will be always proper, if not forbidden by or- ganic disease. Bark, steel, sea-bathing, gentle exercise in the open air, ease of mind, nourishing food, and plenty of rest, constitute what is usually re- quisite on such occasions. Now and then the sulphur vapour bath has been rendered necessary, the cutaneous vessels having failed to recover their tone, though the general health had been much improved. When the scalp is much affected, and the scurf forms in considerable quantities, the free use of a solution of acetate of zinc, in equal parts of rose water and proof spirits, 70 554 SQUAMOUS DISEASES. constitutes an agreeable and useful application. In addition to these remarks, it may be mentioned, that in the few cases which have fallen under my notice, the internal and external use of fresh lime juice has been found beneficial, or common vinegar applied externally. CHAP. VI. VESICULAR DISEASES. The following is Bateman's definition of vesicle: " A small orbicular ele- vation of the cuticle, containing lymph, which is sometimes clear and colour- less, but often opaque, and whitish, or pearl-coloured. It is succeeded either by scurf, or by a laminated scab." This author has divided his order vesiculse into seven genera, viz. varicella, vaccinea, herpes, rupia, miliaria, eczema, aptha. Each of these he has subdivided into several varieties. Some of his orders, as varicella, vaccinea, miliaria, and aptha, are misplaced ; I shall include all that I have to say on vesicular diseases under the term herpes. herpes. Willan and Bateman have subdivided herpes into six species, viz. herpes phlyctaenodes, h. zoster, h. circinatus, h. labialis, h praeputialis, h. iris. Ac- cording to the latter of these authors, this appellation is "limited to a vesicular disease, which, in most of its forms, passes through a regular course of increase, maturation, and decline, and terminates in about ten, twelve, or fourteen days. The vesicles arise in distinct but irregular clusters which commonly appear in quick succession : and they are set near together, upon an inflamed base, which extends a little way beyond the margin of each cluster. The eruption is preceded when it is extensive, by considerable constitutional disorder, and is accompanied by a sensation of heat and tingling, sometimes by severe deep- seated pain in the parts affected. The lymph of the vesicles, which is at first clear and colourless, becomes gradually milky and opake, and ultimately con- cretes into scabs ; but, in some cases, a copious discharge of it takes place, and tedious ulcerations ensue. The disorder is not contagious in any of its forms." Herpetic eruptions occur in various parts of the body. When on the lips and angles of the mouth, the disease is called herpes labialis,—when in the form of a belt across the shoulder, or round the Waist, like a sash, it is termed herpes zoster, and in common language " shingles." When it has no certain seat, but sometimes appears on one part of the body, sometimes on another, with the exception of the situations already mentioned, the disease is termed herpes phlyctaenodes; but surely difference of locality is no reason why dif- ferent appellations should be applied. 556 VESICULAR DISEASES. This class of disorders is for the most part, if not always, accompanied by constitutional disorder sufficiently marked to attract attention, such as that produced by sub-acute inflammation of the bronchial membrane. Hence we find it taking place towards the termination of what are called catarrhal fevers, producing immediate constitutional relief, which the strongest remedial agents had perhaps failed to accomplish. I have also often seen the other forms of the affection, particularly that described as herpes zoster, occur in the course of bronchial inflammation; but more particularly when there were strong marks indicating a disordered state of the stomach and bowels. Females appear to be more subject to this disease than males, and people who are delicate, more than the strong and athletic. Causes of herpes.—Besides occurring under the forms of internal disease already mentioned, it has been referred to the suppression of hemorrhal or menstrual discharge, sudden change of habits as to diet, but more particularly from an active to a sedentary life; and particular articles of food may cer- tainly produce it. With respect to the pathology of the herpetic eruption, its seat is in the superficial vessels of the skin, and its nature is inflammatory, the effect of which is the effusion of serum, separating the cuticle by mechanical disten- sion ; we see similar effects produced by blisters, and some other external irritants. Treatment of herpes.—This is very simple, and consists in relieving internal disorder, and by subduing any constitutional disturbances that may exist. The lancet is not often required; but I have seen it sometimes necessary, and very beneficial; in general, however low diet, consisting of arrow-root, and the like; gentle laxatives, repeated twice or thrice in the twenty-four hows, the warm bath, and confinement to the house, will be adviseable. The best local treatment is to open each vesicle early, and occasionally to apply fomentations ; but in the most severe form of the complaint, viz. the herpes zoster, where the pain is very severe, and when consulted early, the best effects will be produced by applying a dozen of leeches on the inflamed part; if done before many vesicles have appeared, the further progress of the dis- ease will be stopped; and I observe that Mr. Plumbe has, in two or three instances, applied small blisters to the uninflamed skin in the neighbourhood of the vesicles, not only with the effect of checking their extension, but pro- ducing a shrivelling of those already formed. If it be not found necessary either to apply leeches, or a blister, the best application after opening the vesicles, is a poultice of lint-seed meal; and I can see no objections to the occasional application of a cooling wash, composed of a solution of acetate of lead. When treating of syphilis, I shall speak of an herpetic eruption affecting the prepuce, which is consequently termed herpes praputialis. VESICULAR DISEASES. 557 pemphigus and pompholyx. There can be no doubt but that the diseases described under these two names, have in all ages been confounded with each other, The terms denote the ex- istence of large vesicles, which are termed "bullae," and in common language "blebs." The affection is called pemphigus, when the blebs are preceded or accompanied by fever, and pompholyx when without fever, and when the eruption is without an inflammatory base. The existence of pemphigus as a distinct disease, was denied by Cullen and others, but it has been de- scribed by many authors. I have frequently seen large bulla!! take place in the course of slight, as well as severe fevers; but instead of considering them thereby entitled to any specific character, I have always looked upon their occurrence as an accidental circumstance, and have made no difference in the treatment of the original disease. With respect to local treatment, I have only to observe that the bullae are not to be interfered with, unless there are considerable local irritation and pain, when a small puncture is to be made with the point of the lancet, and perhaps a light poultice of lint-seed meal applied; but it is rarely necessary to interfere with them, unless from the rest- lessness of the patient they are ruptured, when the same application may be made to them. Pompholyx.—As far as I understand, this disease, as defined by Willan and Bateman, is of very rare occurrence; one case only has been seen in this city. It is in the person of a poor man who appears to have no constitutional distressj and who is able to work hard for his daily support. CHAP. VII. PURPURA. I purpose to treat in this chapter of that kind of purpura, which is com- monly known by the term purpura hamorrhagica. A number of diseases which appear on the surface of the body have been already described. Some of them terminate by suppuration, others by a se- cretion of serum; a third class by the formation of scales, &c.; and now we have to consider an affection where blood is poured out under the cuticle, forming appearances which are termed petechia, and upon the surface of all the cavities lined by mucous and serous membranes, forming dark-coloured spots, resembling in every respect those found on the cutis. Purpura is a dis- ease which is accompanied by such threatening symptoms, that it has riveted the attention of almost every medical man who has seen it; but we are still in total ignorance of the pathology of the disease. The following description of purpura haemorrhagicais taken from Bateman:—" The petechiae are often of a large size, and are interspersed with vibices ecchymoses, or livid stripes and patches, resembling the marks left by the strokes of a whip, or by violent bruises. They commonly appear first on the legs, and at uncertain periods afterwards, on the thighs, arms, and trunk of the body ; the hands being more rarely spotted with them, and the face generally free. They are usually of a bright red colour when they first appear, but soon become purple or livid ; and when about to disappear, they change to a brown or yellowish hue; so that, as new eruptions, arise, and the absorption of the old ones slowly proceeds, this variety of colours is commonly seen in the different spots at the same time. The cuticle over them appears smooth and shining, but it is not sensibly elevated ; in a few cases, however, the cuticle has been seen raised into a sort of vesicles, containing black blood. This more frequently hap- pens in the spots which appear in the tongue, gums, palate, and inside of the cheeks and lips, when the cuticle is extremely thin, and breaks from the slightest force, discharging the effused blood. The gentlest pressure on the skin, even such as is applied in feeling the pulse, will often produce a purple blotch, like that which is left after a severe bruise. " The same state of the habit which gives rise to these effusions under the cuticle, produces likewise copious discharges of blood, especially from the in- PURPURA. 559 ternal parts, which are defended by more delicate coverings. These haemorr- hages are often very profuse, and not easily restrained, and therefore some- times prove suddenly fatal. But in other cases they are less copious; some- times returning every day at stated periods, and sometimes less frequently, and at irregular intervals; and sometimes there is a slow and almost incessant oozing of blood. The bleeding occurs from the gums, nostrils, throat, inside of the cheeks, tongue, and lips, and sometimes from the lining membrane of the eye-lids, the urethra, and the external ear; and also from the internal cavi- ties of the lungs, stomach, bowels, uterus, kidneys, and bladder. There is the utmost variety, however, in different instances, as to the period of the disease, in which the haemorrhages commence and cease, and as to the pro- portion which they bear to the cutaneous efflorescence. " This singular disease is often preceded for some weeks by great lassitude, faintness, and pains in the limbs, which render the patients incapable of any exertion; but, not unfrequently, it appears suddenly, in the midst of appa- rent good health. It is always accompanied by extreme debility and depres- sion of spirits; the pulse is commonly feeble, and sometimes quickened; and heat, flushing, perspiration, and other symptoms of slight febrile irritation, recurring like the paroxysms of hectic, occasionally attend. In some patients, deep-seated pains have been felt about the praecordia, and in the chest, loins, and abdomen; and in others, a considerable cough has accompanied the com- plaint, or a tumour and tension of the epigastrium and hypochondria, with tenderness on pressure, and a constipated or irregular state of bowels. But in many cases, no febrile appearances have been noticed; and the functions of the intestines are often natural. In a few instances, frequent syncope has occurred. When the disease has continued for some time, the patient be- comes sallow, or of a dirty complexion, and much emaciated; and some degree of oedema appears in the lower extremities, which afterwards extends to other parts. " The disease is extremely uncertain in its duration; in some instances it has terminated in a few days, while in others, it has continued not only for many months, but even for years. Dr. Duncan related a case to me, when I was preparing my thesis on this subject, which occurred in a boy, who was employed for several years by the players at golf to carry their sticks, and whose skin was constantly crowded with petechiae, and exhibited vibices and purple blotches, whenever he received the slightest blow. Yet he was, in other respects, in good health. At length a profuse haemorrhage took place from his lungs, which occasioned his death. When the disease terminates fatally, it is commonly from the copious discharge of blood, either suddenly effused from some important organ, or more slowly from several parts at the same time. A young medical friend of mine was instantaneously destroyed by pulmonary haemorrhage, while affected with purpura, in his convalesence from a fever, after he had gone into Lincolnshire to expedite his recovery ; and I have seen three instances of the latter mode of termination, in all oi 560 PURPURA. which there was a constant oozing of blood from the mouth and nostrils, and at the same time considerable discharges of it from the bowels, and from the lungs by coughing ; and in one it was likewise ejected from the stomach by vomiting for three or four days previous to death. On the other hand, 1 lately saw a case of purpura simplex, in which the petechiae were confined to the leg, in a feeble woman about forty years of age, who was suddenly relieved from the eruption, and attendant debility, after a severe catamenial flooding." (P. 104.) The result of the following highly interesting cases of purpura hemorrhagica, shews in a marked manner the benefit of venaesection, conjoined with purg- ing. It is extracted from the first vol. of the Trans, of Med. Chirurg. So- ciety of Edingburgh :—A boy aged 6, of a weak and strumous constitution, with swelling of the glands of the neck, and a slight inflammatory affection of the eyes, was observed to be particularly unwell on the 24th April 1823, and the two following days. He was dull, thirsty, with flushed face, and manifested an inclination to sit near the fire. On 27th, spots like flea- bites appeared on a great part of his skin, and soon increased considerably j some were small and red, and others large, and of a purple colour. On 28th, blood oozed from the mouth, with occasional bloody sputa. On the 29th, the urine became turbid, and of a reddish colour ; he moved about occasionally, unwilling to remain in bed; and even, on the forenoon of this day, walked a dLstance of at least a mile and a half for medical aid. Dr. Ebenezer Gairdner first visited this little patient on the afternoon of the 1st May, and saw at once that it was a distinctly marked case of the purpura haemorrhagica of Willan. The whole body, the anterior part of both thighs, the conjunctiva of the right eye, the tongue, the Schneiderian membrane, were all affected with pur- ple spots. Blood oozed from the gums, which were neither soft nor swollen; breath extremely fetid; and Dr. Gairdner was told that he occasionally vomited blood. There were fulness, with pain on pressure in both hypochondria, particularly in the left; the abdomen was rather tumid, and affected with ob- scure pain; belly costive; urine free, and in appearance the same as before described. Pulse quick and sharp ; slight heat of skin. He seemed little op- pressed, was attentive and acute, and expressed curiosity to know what were the marks on his skin. A saline cathartic immediately. Fifteen drops of dil. sulph. acid thrice a-day. To be bathed in tepid water morning and evening. May 2d\ Passed a bad night. There were now considerable oppression, and hurried respiration. The haemorrhagic symptoms had increased, with more petechia? and vibices; pulse 110, wiry ; skin hot and dry. Blood was immediately drawn to the extent of about 10 ounces, when the boy became suddenly sick, and vomited. Considerable difficulty was experienced in sup- pressing the flow of blood from the wound, and during the remainder of the day he lost some quantity, which could not, however, be estimated, notwith- standing which the pulse at 4 o'clock P. M. was 124 and wiry, the skin was also hot. He was afterwards drowsy, and slept quietly for three hours and PURPURA. 561 a half. The tepid bath and acid drops to be continued, and a powder con- taining three grains of calomel and the same quantity of jallap, the next morning, and repeated every three hours, until the full effect was produced. 3d. Blood still oozing from the orifice in the vein ; there were less oppres- sion and dyspncea; the pulse, though quick and sharp, was less so than yes- terday ; tongue improved; little thirst; urinary and alvine discharges nearly as before. The acid drops, laxative powders, and the tepid bath, to be con- tinued. 4th. Pain under the os frontis; ecchymosis of the eye greater; the pain in both hypochondria increased with considerable tension; pulse 124, firmer. Another bleeding was determined upon; and when the bandage was loosened, the wound was still found opened, the part corresponding to the compress had become ecchymosed, but without swelling. At first the blood oozed out, and soon flowed, but not very freely ; the patient became faint, so that only two or three ounces were obtained. At evening visit, it was found that there had been some draining of blood from the orifice; but the patient was then in a quiet, sound sleep; pulse the same as in the morning; skin rather soft, and not very hot; a&l it was stated, that he had been asking for food in the course of the day. 5th. Passed since yesterday a good deal of urine, which was now pale and limpid; pulse 102 ; heat moderate ; tongue clean and moist; gums still tender; and during the night there had been some oozing of blood from them. Has taken a little light nourishment with some relish. Bowels opened by the powders; the stools were excessively offensive, and very black coloured; some increase of pain, with tension of the abdomen, and in both hypochondria. Fomentations, and small doses of castor oil. In the afternoon, the pain had increased, and he moaned much; during the day several copious and grumous stools were passed ; and at 4 P. M. he seemed much distressed. A mixture with an ounce of bark infused in a pound of port wine, with an equal quanti- ty of water; was then ordered to be exhibited in small doses; castor oil to be continued. In the evening he passed more black feces; he was relieved from pain, and had some sleep. 6th. Passed a good night; little or none of the bark infusion had been taken; he also refused the oil, therefore a laxative powder was ordered. The same dark-coloured feces were passed from the bowels with less pain; no oqzing of blood from the gums, nor in the sputa; pulse 98; temperature oi the skin natural. 7th. Symptoms favourable. Much.black feces discharged. 8th. Stools of a natural appearance ; petechia; began to fade; pulse 96, not weak; appetite improving. From this time he recovered rapidly. On the 14th he was out taking an airing ; and on the 16th was running about, and his parents thought him to be in better health than he had been before the accession of the present com- plaint. 71 562 PURPURA. The blood first drawn congulated very slowly, without separating any serum; on the following day it looked like a tremulous jelly, the top being of a greenish buff colour, interspersed with brownish spots. That which was afterwards discharged had, as it came from the arm, more the appearance and consistence of turbid lymph, or fluid in which some reddish colouring matter was in suspension, and the cloths which were soiled did not present the usual stains of blood, but something like those of dirty water, interspersed with large stains of a reddish brown colour. The reader is referred to the volume of the " Transactions," for an inter- esting account of the analysis of the urine. In the same volume of the " Transactions" will be found another interest- ing case of purpura, with an account of the traces of disease discovered on dissection. A girl aged twelve, of the scrofulus constitution, although other- wise in good health and spirits, with the exception of a chronic disease in her left wrist, was first observed on the 21st June 1823, to have a dark spot on her under lip, as if she had been putting a pen in her mouth. Next morning similar spots were observed thickly studded over her legs, and also a conside- rable number on her arms, but she made no complaint, and was amused at being thought sick, when she felt in perfect health. She walked about a mile and returned with perfect ease. A laxative prescribed. Next day she was sitting up, unconscious of ailment; external appearance much the same as yesterday ; pulse good; no heat of skin. Salts. About 10 on the evening of the 22d she asked for supper, and was allowed some bread and milk.— During the night she had two stools; she felt faint and giddy with the last, and required assistance on returning to bed ; she was now seized with vomit- ing, and with a very severe pain in the right temple ; the sickness was most distressing, and when raised up, vomiting supervened; the matter vomited was tinged with blood; and it was also observed, that the gums were readily excited to bleed. This was followed by great langour and exhaustion, and excited alarm of her immediate dissolution. Subsequently symptoms of oppressed brain came on, and she died at 3 P. M. of the 23d. Dissection.—The appearance of the surface of the body remained unchang- ed. The pericranium was covered with petechial spots, as was the dura mater; on removing the membrane, the effects of a large effusion of blood were exhibited. In the right temporal region, a firm coagulum floating in bloody serum had forced its way through the broken down brain into the ventricle. The pleura and the peritoneum were found, like the dura mater, studded throughout with the dark livid spots. This case requires no comment. The patient had the able advice of Mr William Wood of Edinburgh, a gentleman of great practical acumen, and large experience. It is evident, however, from the history of the case, that the bad symptoms came on suddenly about twelve hours before the death of the patient, in consequence of the effusion of blood which was afterwards found in the brain, and when no human means could have averted the fatal PURPURA. 563 termination. How far a previous bleeding might have operated in prevent- ing the cerebral effusion, it is difficult to determine; but I must own, that were such a case to occur in my practice, now that I have had the advantage of reading the result of that related above, I should feel little hesitation in opening a vein. Another case of purpura haemorrhagica was communicated by Dr. Fair- bairn to the Medico-Chirurgical Society of Edinburgh, in the second volume of whose " Transactions" it will be found recorded, and from which the fol- lowing brief extracts are made. The subject of this case was J. Henderson, aged 24, of robust constitution and regular habits. On the 18th November, 1823, Dr. Fairbairn found him complaining of deep-seated pain in the left breast, aggravated by frequent fits of coughing, and by a full inspiration; breathing hurried and laborious, with a distressing sensation of suffocation in the horizontal posture; counte- nance flushed and anxious. A copious discharge of dark venous blood oozed from the mucous membrane of the mouth, and a portion was also apparently expectorated from the lungs. Numerous petechiae and vibices were observ- ed upon the arms, neck and trunk, but they were in greater number on the legs, varying in magnitude from a mere point to the size of a sixpence. There were also a few spots upon the forehead; some of the spots were of a bright red colour, others were purple or livid, and a few of a dirty yellow. In the mouth, similar spots occupied the gums, cheeks, tongue, and fauces; the tongue itself was covered with a dark fur; urine presented a grumous appearance; pulse 110, firm and sharp; increased heat; belly loose from a powder composed of jahip, which he had taken early in the morning. The patient stated, that he had for several weeks previous to the attack experienced considerable depression of spirits, general lassitude and pains in his limbs, which were stiff and swollen at night. He also felt pains occa- sionally darting across his head and chest; had a tickling cough, irregular shivering, followed by flushes of heat and partial perspirations. About the 12th Nov. six days before Dr. F. saw him, he first observed his sputa tinged with blood, which afterwards gradually increased. On the 16th the disco- loration of the skin made its appearance first on the legs, afterwards on his arms and trunk; it was only in the morning on which Dr. F. saw him that the dyspnoea, and other symptoms above described, came on. Bled to 26oz. from the arm, which occasioned threatening syncope, with alleviation of the breathing, oppression, and pain. No buffy coat on the blood, which, how- ever, presented a colour resembling arterial, and coagulated slowly without separating any serum, the coagulum being somewhat soft and tremulous Frequent doses of 15 drops of dil. sulph. acid, to be given in cold water. 19th. Passed a restless night with fearful dreams and startings; pectoral symptoms somewhat alleviated, though he still complained of a corded sen- sation across the lower part of his chest. Considerable oozing of blood from the mouth ; urine grumous, and rather scanty; no stool; pulse 112, and sharp; 564 PURPURA. skin hot; tongue furred, and streaked with blood. Eighteen ounces of blood were taken from the same wound in the arm, which nearly produced syncope, the blood exhibiting the same appearance as formerly. An ounce of Epsom salts immediately. At 8 P. M. Dr. Fairbairn found that his patient had had three hours of refreshing sleep in the course of the afternoon, but there was no mitigation of the pain, dyspnoea, and corded sensation in the chest. One loose fetid stool from the salts; oozing of blood from the mouth diminished; urine grumous, but the quantity is increased; pulse from 115 to 120, sharp and wiry; tongue dry and furred; skin rather moist. An ounce of castor-oil. 20th. Had some intervals of sleep during the night, but awoke in great alarm; experienced darting pains in the head occasionally, with slight deli- rium ; frequent hiccup; pectoral symptoms the same; very little discharge of blood from the mouth ; petechiae more numerous, especially on the inferior extremities; had two stools resembling pitch ; urine scanty and grumous; tongue dry and furred. Blood to the amount of £xx. was drawn, which pro- duced syncope; buffy coat now apparent. A little wine and water, and beef-tea occasionally till the state of collapse be removed, and subsequently decoct, cinchon. to be given in repeated doses. 4 P. M. Had some intervals of sleep since the bleeding; is perfectly sen- sible, though he cannot articulate distinctly; pulse small and irregular; skin covered with a cold sweat. The decoction had not been given as directed. Wine and beef-tea to be continued. At midnight Dr. Fairbairn found him in a comatose state, insensible to sur- rounding objects; the breathing laborious, with frequent heavy moaning, and he expired on the morning of the 21st, being the sixth day from the appear- ance of the petechiae. The appearances on dissection in this case will be found at page 566. The following is extracted from Dr. J. S. Combe's case of purpura haemorr- hagica, detailed in the 17th vol. of the Edingburgh Medical and Surgical Journal, (page 83.) 19th Sept. 1820. Edward Canny, JEt. 10. Skin universally covered with petechiae of a dark brown, almost black colour, varying in size from that of a pin-head to one-third of an inch in diameter, of form nearly circular, but, on the lower extremities, less distinctly circumscribed, and pale. The tongue, gums, and fauces, as far as can be seen, are studded with spots, but not so thickly as on the outer surface. There is a constant and pretty copious discharge of thin pale blood from the mouth and nostrils. The petechiae on the tongue bleed freely when touched. Pulse 116, small, and rather sharp; skin hot; tongue white; breathing hurried, but he is able to draw a full in- spiration. Appetite not affected; very thirsty; has severe pains in head and legs; very weak. The spots were first observed two days ago in the morning, and on the even- ing of the same day blood began to issue from his mouth; he passed a stool, in which bloody dots were perceived—ordered a brisk purgative, and 10 drops of acid, sulph. dil. aromat. thrice a-day. PURPURA. 565 20th. Petechiae present various shades of colour; blood oozing freely; pulse 120, small; had one stool, very fetid; skin hot; appetite good; urine scanty, very thick.—Rep. pulv. purg. et cont. acid, sulph. dil. 22d. A number of the spots have run into large vibices; discharge of blood equally copious, and much attenuated; pulse 120, fuller. Vomited a little blood twice; complains of sickness on raising his head ; severe pain in the head; bowels freely open; stools dark-coloured, fetid; urine said to be high- coloured and sparing in quantity.—Habt. iterum pulv. purg. et sumat, pulv. chinch, gra. x. cum acid, sulph dil. gtt. viij. quarta quaque hora. Let him have an ounce of port wine every five hours. 23d. Slept ill; pain in forehead; nausea, and occasional retching; great debility. Pulse 110, small; petechiae and haemorrhage as before; bowels freely opened; urine scanty, turbid, and depositing a copious sediment; body emits a most offensive fetor.—Cont. omnia. 24th. He is in an alarming state; oppressed with nausea; vomits on the ex- ertion. Has not taken his medicines; blood flowing more copiously from mouth ; petechiae have gone into large clusters on forehead, arms, and legs. Pulse 120, hard; violent pain in the head; skin hot in the trunk, but cold on the extremities. Eight ounces of blood abstracted from external jugular vein. He became faint, and vomited, and the pulse softer and fuller. The blood flowed in a small stream, and was of a very pale colour liker the washings of flesh than common blood; coagulated slowly, without any separation of serum, and shewed no buffy coat.—Ordered a purgative,—discontinue the other me- dicines. On visiting him eight hours after, he was rather better; sickness much abated, and no vomiting. Pulse 110, soft; head-ache easier ; bowels opened three times; stools more natural in appearance. There has been a copious flow of pale, limpid urine; the wound in the vein had not closed, from which he lost about fiss more of blood. 25th. 8 A. M. Dr. Combe was called in great haste to stop the bleeding from the jugular. The patient's clothes and bed clothes were quite soaked with blood; it was paler and even more attenuated. Caustic applied to the wound. In other respects decidedly better; voice stronger; countenance more animated; head-ache relieved; no nausea or vomiting; urine very turbid. Or- dered to be kept quiet, and to have any diet he chose, but no spirits. In the evening no blood had been discharged for the last two hours, either from wound or mouth. Habt. tinct. opii gtt. xx. h. s. et pulv. jalap, gr. xii. eras mane. 26th. Lost about Ii of blood from the wound during the night. Slept well; headache very slight; pulse 120, soft. No discharge of blood from nose or mouth; petchiae fainter and more diffused. Bowels freely opened ; stools natural; urine clear, and of a pale yellow colour. 27th. Convalescent. From this time he went on doing well, and the spots having altogether disappeared, he was discharged on the 7th October." Causes of purpura.—According to Bateman, " the causes of this disease are by no means clearly ascertained; nor its pathology well understood." Seven 566 PURPURA. teen years have now elapsed since this statement was printed, and although many cases have since occurred, and several have been minutely recorded with the appearances found on dissection, we are still perfectly ignorant both as to its causes and pathology. It has taken place in individuals who were strong, enjoying good health, breathing a pure country air, with all the ne- cessaries and comforts of life around them; and it has likewise attacked those of delicate habit, living in crowded situations, on poor diet, and subject to distress of mind ; and it has also occurred in others who were left in a state ol debility by previous diseases, some of an acute, others of a chronic nature. In most of the cases which have been recorded, there has been severe pain or oppression in the chest, and in some, in the head. In two cases, mention- ed by Dr. Parry in 5th vol. Ed. Med. and Surg. Journal, the blood was very much buffed, the proportion of crassamentum to that of serum was uncom- monly great. In Dr. Fairbairn's case, three bleedings were had recourse to the first to twenty-six ounces, the second to eighteen, and the third to twen- ty ; there was no buff on the two first, the blood was red like arterial, coagu- lated slowly, and separated no serum; but on the third bleeding, the blood showed a buffy coat. In Dr. Johnson's case, only a part of the blood drawn at the second bleeding exhibited a buffy surface. In different cases the pulse has been variously described—as full;—70, full but not hard;—100, full and intermitting ;—quick, soft, and small;—very quick and weak;—100 and small;—110, firm and sharp;—very hard and strong;—120 full. In almost all the cases the stools have been dark-coloured and fetid; some describe them as being of a dark-green colour; and others, as black as pitch. Appearances on dissection.—Petechial marks have been discovered on the surface of all internal organs; vascular turgescence, sanguineous and serous effusions, have been observed in the head. The lungs have always been found diseased—congested in their substance, the air passages filled with bloody effusion, and the mucous membrane lining the tubes of a dark colour. In the abdomen the mucous surface of the stomach and intestines has been found vascular, and spotted with petechiae; the liver tender and more or less gorged. In one case mentioned by Dr. Bateman, the spleen was found enormously en- larged ; and in another instance there was a large morbid growth, consisting of a fleshy tumour with a hard cartilaginous nucleus, weighing about half a pound, found in the situation of the thymus gland, firmly attached to the sternum, clavicle, pericardium, and surrounding parts. The following appearances were found in the case recorded by Dr. Fair- bairn, thirty hours after after death:— " The petechial spots over the body exhibited nearly the same appearances as before death. The sides of the neck, and upper parts of the chest, were swollen and livid, and there was a feeling of crepitus, with considerable oedema over the trunk. On removing the integuments from the fore and la- teral parts of the chest, the cellular and muscular textures were in some places injected with blood, and emphysematous. PURPURA. 567 " The thorax contained about a pound of a fluid resembling blood, of a very dark colour and viscid consistence. " The lungs were somewhat collapsed, of a dark livid appearance, and con- tained a bloody serous fluid, which occupied all parts equally; there was much less of feeling of crepitous throughout their substance, and the spongy texture was less observable than natural. The bronchial tubes and trachea were filled with a similar fluid; and beneath the internal coat of the latter, there was a slight effusion of dark venous blood, which tinged the membrane of a deep purple shade. Between the folds of the anterior mediastinum, and of the pericardium, there was effused into the cellular tex- ture a considerable quantity of very dark blood, mostly in a clotted state, amounting to several ounces by computation. The pericardium contained the usual quantity of lubricating fluid; the inner surface presented its natural smooth, glossy texture, but it had assumed anteriorly a deep or brownish red colour, from the effused blood between its layers shining through it. The heart appeared pale and flaccid; there was no blood in any of its cavities. Under its internal membrane, particularly towards the valves of both sides, but more copious in the left, there was a similar effusion as in the trachea, giving a deep livid colour to the surface of the heart, and tinging its sub- stance to the depth of half a line or a line. " The inside of the aorta presented an increased tint of redness, apparently from the same circumstances, without evident thickening, or change of tex- ture. " In the cavity of the abdomen, the floating viscera were of a dark leaden colour, and less vascular than natural. " There were a few petechiae on the intestines. In the ileum there was slight inflammation, extending for a couple of inches, where one portion of the bowel had passed within another. " In the stomach, towards the pyloric extremity, its inner membrane was thickly studded with petechiae ; whereas that portion surrounding the cardia, for about three inches, was distinctly emphysematous. " The liver was paler than usual, and somewhat softened, its peritoneal proper coat was very easily peeled off; from its internal surface a bloody serous fluid could be squeezed out. The spleen was of full size, and softer than usual; and when torn, effused a quantity of dark-coloured matter, of a semi-fluid consistency. "The right kidney seemed softer than natural; there was an effusion of blood under the internal membrane lining its pelvis, similar to that on the inside of the heart. The left appeared peculiarly blanched, and was also soft; but there was here no effusion. " The bladder was pale and contracted, containing a few ounces of the same turbid coloured urine as he had been lately passing. " On removing the scalp there were two large ecchymoses, two on each side, over the superior attachments of the temporal muscles. The brain with 568 PURPURA. its membranes, appeared quite healthy; there might be about an ounce or so of clear serum in the ventricles, and at the base of the brain. " In the course of dissection it was remarked, that there was a full propor- tion of adipose substance in every part of the body." Pathology of purpura.—After relating two cases of purpura in the 5th vol. of the Ed. Med. Journal, the one occurring in a lady about 50, the other in a colonel of the army, who had been rather a free liver, Dr. Parry observes: " These cases strengthen an opinion which I more than twenty years ago maintained, and which a large subsequent experience has tended to confirm,— that in various diseases, among which may be reckoned inflammations, pro- fluvia, haemorrhages, dropsies, exanthemata, and other cutaneous epruptions, and even the generality of nervous affections, there is one circumstance in common which is an over-distension of certain blood-vessels, arising probably from their relative want of tone, or the due contraction of their muscular fibres." Dr. Duncan Jun. in ihe 72d Number of the Edinburgh Journal, conceives that this disease may probably arise from the following circumstances: " 1st. Increased tenuity of blood, allowing it to escape from the superficial extremities of the minute arteries. " 2d. Dilatation of the mouths of those arteries allowing natural blood to escape. " 3d. Tenderness of the coats of the minute vessels which give way from the ordinary impetus of the blood. " 4th. Increased impetus of the blood rupturing healthy vessels. " 5th. Obstructions in the vessels causing rupture, with natural impetus, and without increased tenderness. " 6th. Two or more of these causes may act simultaneously or successive- ly." Mr. Plumbe thinks that Dr. Duncan's third conjecture is unquestionably correct as regards the formation of cutaneous spots of purpura. " That this tenderness is the result of deficient nourishment in the superficial vessels is perhaps equally clear; and it may fairly be suspected that such deficiency is consequent on the congestion in the hepatic and gastric circulation. My own experience in this disease has been very limited, but after a careful review of the whole subject, I cannot subscribe to Mr. Plumbe's opinion, for the two following reasons.—1. If the disease had any thing to do with tender ness of the vessels, the consequence of deficient nourishment, it would be of far more frequent occurrence, whereas it is avowedly rare. 2. It is my impression that the state of the lungs in all stages of the disease, and more particularly in the early stages, has been hitherto quite overlooked. In one rapidly acute case which I was called to see, and which terminated fatally, the rale crepitant was heard in some parts of the chest, and the rale muceux in others. Although I have not been able to determine the true pathology of the disease, I think it possible that it may be owing to general functional derangement of many PURPURA. 569 organs, which at last produces a great change upon the blood; and that it may be owing probably to disease primarily seated in the lungs. It is pretty generally admitted, that there is considerable analogy between the purpurous spots and the petechial which sometimes take place in fevers in which there are also occasional discharges of blood from various organs and I can state with the utmost confidence, that since my attention became di- rected to the investigation of the probable causes of petechiae, I have not in one instance failed in detecting disease of the lungs, and particularly of the the mucous membrane, by ausculation, and that the observations so made have been confirmed upon examination after death. Treatment of purpura.—Under the mystery which at present involves the nature and seat of the purpura haemorrhagica, it is impossible to enter upon this part of the subject without a feeling of embarrassment. Dr. Parry and others have, from certain notions, strongly supported venaesection, while it has been condemned by some practitioners, whose opinions are entitled to at least equal respect. Dr. Willan is one of those who recommended " a gene- rous diet, the use of wine, Peruvian bark, and acids." There is one point, however, on which almost all practitioners agree, viz. the advantage of keep- ing up a free discharge from the bowels. It is strongly impressed upon my mind, from a review of the cases, that there are some instances, like those recorded by Dr. Parry, Dr. E. Gairdner, and Dr. Combe, in which the patient's only hope of safety depends upon ve- naesection ; and that there are other instances, as those probably from which Dr. Willan drew his practical conclusions, which require an opposite mode of treatment. Daily experience also convinces me, that there is a third set of cases, in this as in almost all diseases, which requires a combination of bleeding and stimulants, and that it is not inconsistent with sound notions of pathology to bleed first, in order that we may be able to stimulate, and to stimulate for the purpose of enabling us to draw blood. Bleeding is always a dangerous remedy when employed late in severe diseases; and I fear con- siderable errors have happened, from drawing blood too late in purpura. It is only a year since I directed a vein to be opened in the arm of a girl affect- ed with purpura ; she died the same night; and in Dr. Fairbairn's case, the man, although previously strong, never recovered from the loss of blood, and died in a few hours afterwards. The particulars of the case which I attended, should have been detailed, but I was not allowed an opportunity of examin- ing the body of the patient after] death, although every exertion was made to obtain it. The case was so similar to others already published, that it is of no value without a minute dissection-report. When the operation of bleeding is performed, a larger orifice should not be made than is actually necessary, and the patient ought to he visited at short intervals, as subsequent haemorrhage frequently occurs from the vein, and a good deal of difficulty is sometimes experienced in suppressing it. The 72 570 PURPURA. jugular ought not to be opened, unless in a case similar to Dr. Combe's, where no vein was found in the arm. Acids, particularly the mineral, have been highly recommended; but I am disposed to place more confidence in the vegetable, and especially fresh lime- juice, not only taken internally, but applied externally. Turpentine has also been found useful by Dr. Nicholl, vide 17th vol. Edinburgh Medical and Sur- gical Journal. From the beneficial effects produced by the acetate of lead in other dis- charges, I am induced to believe that it will be found serviceable in purpura haemorrhagica. Since writing the above, I was called to see a child, between two and three years of age, who lived in the same room with two other children affected with genuine small-pox. I found it feverish and lethargic, with con- stant vomiting; it had several petechial spots, and although it had gone through the process of vaccination when a few months old, I was apprehen- sive of small-pox. Laxative medicines were ordered. Next day the child was found in the same state. The petechial spots had increased in number and size, and had spread over the trunk and extremities; the skin was hot, and the pulse quick and strong; nothing could be retained on the stomach; several attempts were made to give laxatives, but even small quantities of calomel were immediately vomited. Four leeches were applied to the instep. On the third day the child was found convalescent; the leeches bled pro- fusely ; and although a tight bandage had been applied as directed, still the greatest difficulty was experienced in restraining the haemorrhage. No pe- techial spots were now to be seen, but the foot was ecchymosed from the pressure of the bandage, on the removal of which blood again began to ooze from the leech-bites, which made it necessary to re-apply it. There had been no stool for three days, but as the irritability of the stomach had now subsided, laxative medicines were given, the bowels were moved before night, and so little debility was produced, that the child was walking about the room on the third day. At the very moment I was engaged in completing this article, I was favour- ed with a letter from Dr. J. S. Combe, in answer to a communication from me on this subject, from which the following cases are extracted. They are very interesting, as in both instances the disease occurred in connection with general acute rheumatism:— " A remarkable case of purpura was pointed out to me (says Dr. Combe) by the late Dr. Kellie. The subject was a brewer's servant, big and pletho- ric^ who, on the fourth day of an attack of acute and general rheumatism, was found covered with bright petechial spots; he also discharged some blood from the bowels. Active depletion was had recourse to, and he made a quick recovery." Dr. Combe further states that he " lately saw a robust girl aged 5, who had been attacked with a violent convulsive fit, and on recovery com- PURPURA. 571 plained of severe pain of head. In the course of a few hours I saw her, and as small-pox prevailed in the neighbourhood, her friiends considered it as such, and pointed out some spots on the skin; they were undoubtedly pete- chial, and covered nearly the whole body, with smart fever and vomiting On the 3d day the extensor muscles of the head were so painful that she could not bend it forward without much suffering; in a few hours this was fol- lowed by acute pain of all the larger joints. The spots on the 5th day were fainter in colour, and disappeared in a few days after; but eight days more elapsed before the rheumatic affection had subsided. She was treated active- ly by venaesection and purgatives." EXUDATION OF BLOOD FROM THE SURFACE, WITHOUT ABRASION OF THE CUTICLE, COMMONLY CALLED BLOODY SWEAT. Perhaps nearly allied to purpura, is the transudation of blood from some parts of the surface of the body, which in all the cases I have heard of, has attacked females. It is a rare disease, and having a case under treatment at the time these pages are passing through the press, I shall state the appear- ances which presented themselves to my notice. It has been observed to be for the most part vicarious with the menstrual discharge, but it is not always so:— Elizabeth H-------, aged 19, employed as a house servant, stout, thick set, clumsy shaped, with large mammae, short neck, and thick lips, plethoric constitution, presenting no external appearance of bad health, having an an- imated eye, and a good complexion, states, that she menstruated at 11 years of age without any difficulty, or constitutional distress, and continued always healthy till the month of September, 1829, exactly 11 months before I was consulted. At that time she became obstructed, and has since never felt well To the best of her recollection, about three weeks after she should have seen a certain appearance, an oozing of blood took place from her cheeks, eye-lids, and eyes; it coagulated and hardened upon the surface, but was easily wiped off, leaving no unnatural appearance on the skin. Blood has since oozed not only from these parts, but also from the right breast, both fore-arms, and both ancles. When the discharge takes place from the ancles, it has never at the same time oozed from any other part of the body; and only twice has it been discharged from the cheeks, eyes, right breast, and fore-arms simultaneously,— generally it comes from one place only. Once the discharge flowed from the right ear, to the amount of about two table-spoons full, which is the quantity for the most part discharged at each attack ; it has never exceeded that, but sometimes it only amounts to about a tea-spoon full. She sometimes passes a day without any discharge, but never two, since it first appeared last year, and she has generally three attacks during the twenty-four hours; they occur when she is working or moving about, but have never taken place when quiet in bed. She is aware when the oozing is about to occur, by a feeling of weakness and faintness, but never experiences shivering at such times. 5?2 PURPURA. As soon as the discharge commences, she is affected with giddiness, and, if walking, reels about like a person intoxicated; she is equally affected how- ever small in quantity the discharge may be. Hitherto it has always ceased spontaneously, when she becomes for the most part very faint and drowsy. Two or three days before I was consulted, she was bled to the amount of 25 ounces; the bandage subsequently became loose, and she lost 3 ounces more; she had also taken several doses of" powerful laxatives, but, as she thinks, without benefit. She was brought to my own house for the first time 'in the afternoon of the 6th August 1830, and was desired to return during the period of an attack, which happened in about an hour afterwards; and I had an opportunity of seeing her during a slight discharge from the left cheek. She was exceedingly giddy and faint, and staggered very much in her gait; she felt so ill on the road, as to be compelled to solicit assistance from a person who was passing, who brought her to my door. The pulse was strong and full, beating 82; heat natural; the exudation from the cheek ueemed to take place from every pore; as it oozed out, it collected into drops and ran down; was of a red colour, looked like thin blood, and immediately hardened upon the surface; upon a white handkerchief it left a stain much winter than pure blood, and perhaps more like what would have been caused by bloody serum; and she stated, that when the discharge drops upon the floor, it leaves a mark like blood, unless immediately wiped off. In a quarter of an hour, the giddiness went off, but left a degree of faintness, readily re- lieved by a glass of sherry, which did not produce any return of the exudation. She was now observed to be drowsy; the pulse had lost much of its fullness> but was still far from being weak, and it beat 80 in the minute. In about 5 minutes the drowsiness went off, and in a short time she felt so well as to be able to return home, and made a promise to collect some of the discharge in a tea-cup for examination. She further stated, that there is acute pain in the part from which the blood oozes, and when the discharge takes place from Hhe fjye-lids, a severe pain is experienced in the eye, increased on pressure. The breasts are tender to the touch, particularly the right breast. In a few days afterwards, about 2 ounces of a sanguineous-looking fluid, which had been discharged from her left cheek and eye, were brought to me; it resembled blood mixed with serum. PART VIII. DISEASES 0JP THE URINARY AND GENITAL ORGANS CHAP. I. INFLAMMATION OF THE URETHRA, BLADDER AND KIDNEYS. INFLAMMATION OF THE URETHRA. Under this head I snail treat of gonorrhoea, for although inflammation of the mucous membrane of the urethra may be produced by external injuries and other causes, yet this is rare in comparison to the disease produced by impure contact. Gonorrhoea, (known also by the term blenorrhcea,) is an inflammatory affec- tion of the mucous membrane of the urethra, the consequence of impure coition, and of which there are a great many varieties. The symptoms vary according to the extent and intensity of the inflammation, the constitution of the patient, and perhaps also the condition of the matter applied. A disease resembling gonorrhoea, may, it is said, be produced by inflammatory action extending from the kidneys and bladder—by calculi, highly acrid urine, ex- cessive indulgence in sexual intercourse, long continued abuse of spirituous liquors, the action of cantharides on the system, and the incautious introduc- tion of instruments. Symptoms and course of gonorrhoea.—A short time after impure connection, a sense of titillation is experienced in the urethra, which soon amounts to itching, and is attended with frequent desire to make water. There is a feel- ing as if some urine were still left, in the urethra, and a consequent effort is made to discharge it; the orifice is now observed to be red and swollen, and perhaps a small quantity of discharge is seen. By and by the desire to make water is more frequently renewed, and on each occasion the passage of the urine becomes more and more painful, sometimes almost intolerable, while the stream becomes smaller, notwithstanding the increased impulse given by the patient in bearing down. A pretty copious discharge of matter soon takes place from the urethra, which augments for some days, becomes thicker, pu- riform in appearance, and yellowish in colour; but when the inflammation is intense, it is greenish, and sometimes tinged with blood. It is denied that the matter is pus; we shall, however, commit no error if we consider it as a 576 INFLAMMATION OF THE URETHRA, puriform fluid, analagous to that which is discharged from the inflamed surface of other mucous membranes. The glans and prepuce frequently become swollen, and although the swelling of the prepuce is generally owing to oedema, yet it is sometimes occasioned by the extension of inflammation from the glans. Often during the course of this disease there are excessively pain- ful erections, particularly during the night, the penis being sometimes bent one way, sometimes another, which condition is termed chordee. This dis- ease generally goes on increasing in violence to the seventh, and sometimes even to the fourteenth day, and I have known the acute stage to continue even to the thirtieth. The decline of the acute stage is marked by the dimi- nution of the ardor urina, and the inflammation at the meatus; still, how- ever, the discharge of puriform fluid may continue considerable under the chronic form of inflammation. Every act of sexual indulgence, the use of ardent spirits, errors of diet, the application of cold, and inattention to the bowels, frequently reproduce acute inflammatory action, by which means the disease may be prolonged for a considerable length of time. This is a description of the disease as it usually occurs. Sometimes, how- ever, it is seen in a much milder form, so much so as to give the patient little trouble, and occasionally appears to undergo a spontaneous cure; but there is a far more severe form of this affection, in which the pain, and probably the inflammation, extend throughout the whole of the urethra, affecting in some cases even the bladder, and occasioning pain in the loins ; the calibre of the canal is very much diminished in consequence of the swollen state of its mu- cous membrane, and notwithstanding all the efforts which the patient can exert, the urine flows drop by drop, accompanied by most excruciating pain, and chordee is frequent and distressing. In the worst cases Cowper's glands and the prostate partake of the inflammation, when a sense of heat, weight, and fullness are felt in the perinaeum, generally accompanied by dysuria and tenesmus, which more frequently, however, occur when the disease spreads to the neck of the bladder. This state ends sometimes in abscesses, fistulas, and permanent disease of the prostate. But a more frequent termination of go- norrhoea's stricture of the urethra, produced by a permanent thickening of the mucous membrane, or by an extension of the inflammation to the cellular tissue surrounding that part of the urethra most intensely affected. During the course of gonorrhoea, even when very slight, inflammation of the testes occasionally takes place, and also of the glands in the groin; and sometimes an herpetic eruption is produced upon the glans or prepuce, probably from the acrid nature of the matter. The term gleet is used to express the existence of a discharge from the urethra, the consequence of a diseased condition in which the mucous mem brane is left after acute inflammation. This discharge is attributed to chronic inflammatory action; it comes and goes, varies in appearance between serum and pus, but for the most part is muco-purulent. The least error in diet, the use of spirits, wines, acids, and peppers, is followed by frequent desire to BLADDER, AND KIDNEYS. 577 make water, some ardor urinae, and increased discharge of matter; sometimes these symptoms exist to such a degree as to make the patient himself believe that it is a fresh attack. This state increases year after year, till at last a per- manent stricture is formed. Loss of health is often the consequence of dis- turbed nights, produced by pains in the lower extremities, and by the patient being obliged to rise many times out of bed to empty the bladder, perhaps to void only an ounce of urine.. Thickening of the bladder follows, with disease of the prostate, and perhaps also of the kidneys. Symptoms of gonorrhoea in females.—The chief differences produced by this disease in the male and female are the following. In the latter, the in- flammatory action sometimes affects the mucous membrane of the vagina; and I have seen several cases where there was reason to believe that the lining membrane of the uterus also became involved, giving rise to leucorrhaa and menorrhagia in their worst forms. From the small extent of the urethra in the female, which does not exceed an inch and a half in length, and the sim- plicity of its structure, the symptoms upon the whole are not so distressing at the time as in the male, but the disease often leaves a severe form of prurigo, affecting the labia, the nymphae, and the clitoris. I shall not stop to enquire whether this disease is, or is not connected with syphilis, or whether it ever had a syphilitic origin. Appearances of the urethra when affected with gonorrhoea.—Few opportuni- ties of examining the state of the urethra in this disease present themselves. Sir Astley Cooper, however, had once such an opportunity in a criminal who had gonorrhoea at the time of his execution. "The inflammation had ex- tended down to the bulb of the urethra; for an inch or an inch and a half down the urethra was exceedingly red, and there was some effusion of matter on the internal surface; the urethra was also red at the bulb, but not of so deep a colour. The inflammation therefore, (says he,) is not always confined to an inch, or an inch and a half down the urethra, but often extends over the bulb, and in this way produces strictures." In the case above alluded to, the gonorrhoeal inflammation had extended seven inches down the urethra; Sir Astley Cooper thinks the inflammation to be of the erysipelatous kind, and that ulceration does occasionally take place in the mucous follicles, but never in the urethra itself; if that were the case, the mucous membrane would more frequently give way. (Vide Lectures, p. 462.) Treatment of gonorrhoea.—This is in many cases, a very intractable disease, and there is no telling where it will end. I have more frequently been an- noyed and disgusted in conducting the treatment of gonorrhoea than of any other affection. We are often not consulted till the disease is far advanced, and great difficulty is experienced in keeping this class of patients under a proper degree of restraint. There are two methods of treatment strongly recommended. The one is to endeavor to alter the action of the part immediately, even during the acute stage, by means of stimulating injections, or the action of cubebs, a remedy 578 INFLAMMATION OF THE URETHRA, which was introduced into this country a few years ago from the island of Java. There can be no doubt that cubebs is a very powerful, and in many instances an excellent remedy; but bad consequences, it cannot be denied, are often produced both by it and the stimulating injection when indiscrimi- nately used. There appears to be a time at the very commencement of the first stage of the inflammation, when either remedy may prove beneficial, but this must be during the first hours, before the inflammation has extended, and previous to the formation of matter ; but we seldom have such an oppor- tunity. Were a medical man himself the patient, he might indeed apply these remedies at once, and successfully, particularly if his habit of body were in a good state at the time. Cures appear to have been effected when the first stage had been further advanced, but perhaps for one such event, there have been fifty failures, out of which several cases might.be produced, where more violent inflammation and suppuration of the parts an4 even inflam- mation of the testes succeeded. Therefore, generally speaking, it is not in the first stage that these remedies are found to be so advantageous as in the chronic. The other plan I shall give in the words represented to have been used by Sir Astley Cooper in his Lectures:—" When the patient applies to you for his first clap, there will be generally a great deal of inflammation, and I advise you to give the sulphate of magnesia, with the infusion of senna. An ounce of the sulphate of magnesia may be mixed with six ounces of the infusion of senna, and three table-spoonsful given two or three times a-day, so as to purge the patient very actively. You may afterwards give the submu- rias hydrargyri with extract of colocynth, but merely as a purge; for if it were to act as a mercurial, I would not give it at all. There is no necessity for giving calomel, unless you wish it to act on the liver, as well as on the in- testinal canal. Having purged the patient pretty freely, you will direct him to take diluting drinks of which he can hardly take too much. Two drachms of the carbonate of potash, or the sub-carbonate of soda, should be taken in a quart of some diluting drink in the course of a day : capillaire, or tea, will answer this purpose very well: some advise the gum of acacia, but whether it does any good or not, I do not know. I have found the liquor calcis a very excellent diluent in this disease. Soda water is often useful, but it must be ascertained whether it produces irritability of the bladder; for, in some persons, it increases irritability. If it increases very much the in- clination to make water, it should not be persisted in; if it does not produce this effect, it is a very excellent diluent. The penis should be suffered to hang for a considerable time in warm water, which will relieve the inflam- mation, and produce nearly all the good of a warm bath. When the ardor urinae and pain from chordee are very severe, twenty drops of the liquor po- tossae with from three to five grains of the extract of conium, in the mistura camphorata, may be given with considerable advantage. This is the plan which you should pursue during the first week. You may then apply lint, dipped in the liquor plumbi subacetatis dilutus, to the part. Do not use an BLADDER AND KIDNEYS. 579 injection in the first instance, but pursue the plan I have pointed out to you during the first ten days." Having frequently tried this plan of treatment without success, I had re- course to that which shall now be described, and I can recommend it strongly from its superior success. 1st stage.—If the inflammation be severe and extensive, with much ardor urina, swelling of the penis, and chordee, I open a vein, particularly if the pa- tient be young and robust, and if the pulse be full or hard, and in this manner make a speedy impression upon the inflammation. The bleeding is to be fol- lowed by the use of saline purgatives, given after the exhibition of a moderate dose of calomel combined with any other laxative in common use; the antiphlo- gistic regimen; and perhaps also a solution of tartar-emetic. By these means, the severity of the inflammation will in general be quickly subdued, and the first stage shortened. After this I have often seen the greatest advantage from the immediate employment of cubebs, the balsam of copaiva, as well as from astringent injections thrown into the urethra. In some cases where bleeding is inadmissible, and where the inflammation produces pain in the perinaeum, much benefit may be derived from the repeated application of a dozen or two of leeches. Ardor urina, dysuria, and chordee, are most effectu- ally mitigated, in cases not requiring the active treatment above recommend- ed, by lint-seed tea containing a small proportion of the nitrate of potass, as also by anodyne injections thrown into the rectum. A very useful remedy is to be found in pills composed of equal parts of camphor and hyosciamus, of / which two may be taken every second, third, or fourth hour. 1 The tinctures of muriate of iron and iodine have been much praised. / 2d stage.—It frequently happens, however, that we are not consulted {fill the second or chronic stage has taken place. Even then, I have seey 'con- siderable advantage from the application of leeches to the perinaeu/m, more particularly in old subjects, and when the inflammation had extended far down the urethra. It is in this stage that the effects of cubebs, baHsam of copaiva, and astringent injections are so beneficial, provided there be )no ten- dency to stricture, to ascertain which, a bougie is to be introduced i and if one should be discovered, it will be in vain to use any remedy, till itf be re- moved. The usual injections employed, are those composed of the acetate of lead, or sulphate of zinc, at first in about the proportion of a grain'-to the ounce of water. Sometimes these substances are united, forming a sortition of the acetate of zinc, the sulphate of lead being precipitated; the solution should be carefully strained before it is used. An infusion of green tes^, is also often serviceable. In treating the disease in females, the same principles are applicable; and when injections are ordered care should be taken that they be not thrown into the vagina only, which generally happens unless instructions are given where to find the urethra. It has been mentioned already, that a troublesome pru- rigo sometimes affects the labia, nymphae, and clitoris, for the cure of which, 580 INFLAMMATION OF THE URETHRA, it is necessary to pay great attention to the bowels, to use ablutions of the parts every second or third hour, with astringent washes; and in obstinate cases, the application of a solution of the nitrate of silver is necessary. Con- finement to the horizontal posture, and even general bleeding, are called for, particularly when the parts are inflamed and much swollen. INFLAMMATION OF THE MUCOUS MEMBRANE OF THE BLADDER. This disease most frequently affects the neck of the bladder, and is gene- rally recognized by pain and swelling in the hypogastric region, the pain being increased by pressure, with a sense of internal heat and tension, fre- quent desire to make water, and extreme difficulty in passing a few drops, notwithstanding violent bearing down efforts; occasionally indeed there is complete retention. There are also considerable pain and burning heat in the urethra, sometimes, however, only at its orifice, with a sense of itching in its course. The bladder sometimes greatly becomes distended, and indeed, it may be mentioned, that the distention is sometimes the cause of the inflammatory action. If the disease is not soon mitigated, tenesmus, tympanitic distension of the abdomen, pains in the loins, and febrile symptoms take place. Causes of inflammation of the bladder.—Individuals subject to gouty and cutaneous diseases, as well as those affected with dyspepsia, are liable to this complaint. The application of cold; the use and particularly the abuse of ardent spirits; the external or internal use of cantharides, and small doses of \turpentine, together with acrid urine, are also occasional causes of this dis- ease, particularly in individuals who are afflicted with strictures in the urethra. There is also a chronic form of inflammation of the bladder, which occurs in^ld people, and is often occasioned by stone, which terminates in thicken- ing, •■ and even ulceration of the mucous membrane, with very considerable hypertrophy of the muscular structure of the organ: and it is in these cases that the d^ischarge of a large qtiantity of mucous takes place. This disease terminates by what is called resolution, and by becoming chronic, when pus is sometimes discharged. Gangrene is exceedingly rare; peritonitis is a more frequent occurrence, owing more to distension of the bladder, than to the extension of the inflammation from one tissue to the other. Treatment of inflammation of the bladder.—Bleeding, general and local; the hip-bath, gentle laxativtes frequently repeated, emollient and mucilaginous diluents, and opiates, particularly per anum, ought to be had recourse to, ac- cording to the severity of the disease and sufferings of the patient, but the introduction of the catheter into the bladder must be regarded as a principal remedy,*and ought to be had recourse to as soon as possible. This is not only serviceable by drawing off perhaps a large collection of water, thereby re- lieving the distension, but sometimes by removing a small quantity of acrid, high-coloured urine, which mitigates the patient's sufferings immediately. In this case also, the employment of camphor and hyosciamus will be benefi- BLADDER, AND KIDNEYS. 581 cial • and when the disease becomes chronic, I have seen cubebs and copaiva useful. In instances where we have good evidence that acrid urine is the cause of the disease, it will be found serviceable to inject tepid water into the bladder, provided it is not allowed to be retained ; this means is also recom- mended when the inflammation becomes chronic. Rubefacients are servicea- ble both in acute and chronic inflammations of the bladder. Tincture of cantharides given internally, and small doses of turpentine, are beneficial in some cases, but are only to be used in chronic forms of the complaint of long standing, when we want to rouse a little action. It need scarcely be stated, that after there is evidence of stone in the bladder, the first opportunity should be seized, which the local and general symptoms will admit, to extract it by the usual surgical operation. INFLAMMATION OF THE KIDNEYS. The term nephritis has been applied to this disease, the causes of which are much the same as those of inflammation of the badder. Gouty subjects, and others who are frequently troubled with rheumatism and lumbago, and also with eruptions, are often affected with nephritic complaints, as well as those who are subject to dyspepsia. The abuse of spirituous liquors, the too frequent use of diuretics, the employment of cantharides, sudden changes of temperature, the suppression of habitual discharges, and the recession of erup- tions, retention of urine, external injuries, irritation produced by the presence of a calculus in the kidney, and inflammation of the urethra and bladder, extend- ing to the kidneys by continuity of surface, are all exciting causes of the disease. Symptoms of inflammation of the kidneys.—This disease generally com- mences, like other inflammations, with rigors, followed by pain and fever, which vary in intensity. The pain is generally severe and lancinating, but sometimes is obtuse, with a sense of increased weight, which is felt in one or both lumbar regions; it often extends to the bladder, the penis, the groins, and scrotum, and sometimes even to the thighs; and is increased by pressure and motion, as well as by taking in a full breath, and efforts made at stool. In slighter cases, the patient complains only of a sensation of heat and weight, sometimes of gnawing constrictions in the loins. The urine is scanty, and passed drop by drop, of a red colour, and sometimes is entirely suppressed. Besides these symptoms, there are often a feeling of faintness, nausea, and bili- ous vomiting, borborygmus, oppression at the praecordia, hiccup, tympantic distension of the abdomen; occasionally there is diarrhcea with tenesmus; at other times the bowels are constipated, and numbness and retraction of the testicle on the affected side are complained of,—if both kidneys be affected, there is retraction on both sides. There is likewise fever, and the pulse is generally hard. Sometimes the skin is covered with perspiration having a urinous smell; at other times it is dry and hot. These symptoms are often variously combined, and are sometimes modified by the occurrence of great restlessness, headache, and the passage of bloody 682 INFLAMMATION OF THE URETHRA, urine, which, however, on some occasions, is clear and limpid, although it may subsequently deposite a white sediment. This disease is rarely fatal, although the bodily pain is perhaps fully as h> tense as in any other malady which is the product of inflammation, and ac- companied by fever. It rarely terminates in extensive suppuration in the substance of the kidney, but I have sometimes seen small abscesses in indi- viduals who died of the ordinary fevers of this country, which were treated as typhus fevers, and where on suspicion was entertained during life that any local disease existed. Sometimes the matter escapes and finds its way into the pelvis of the kidney, and from thence into the bladder; on other occa- sions, the inflammation seems to be confined to the lining membrane of the pelvis, which is found greatly enlarged and distended with pus, instances of which have fallen under my observation within the last few years; these were also treated as idiopathic fevers of the typhoid type. Cases are on re- cord, where the suppuration has been so extensive, that the substance of the kidney has been entirely destroyed. It is rare for the pus to escape into the cavity of the abdomen, and equally rare for the abscess to point externally, but instances have been known where the matter has found its way into the colon, one case of which I have seen. It is said that gangrene occasionally ensues, but such a termination must be extremely rare; I have seen the natural pro- gress towards decay mistaken for gangrene. When suppuration does take place, the more violent symptoms subside; a throbbing sensation, and a sense of weight, are said to occur, with alternate chills, slight flushes of heat, and profuse sweating. In chronic inflammation, induration of the kidney is produced, and some- times it is completely disorganized. This diseased condition of the kidneys shall be fully illustrated in a subsequent part of this work, in the chapter on dropsy. Treatment of inflammation of the kidneys.—Antiphlogistic means, such as are recommended for the cure of other inflammations, are to be had recourse to. Copious venaesection, repeated according to circumstances, and local bleeding, which is better effected in this particular disease by cupping the loins, than by applying leeches, are highly necessary. Fomentations, applied as hot as they can be borne to the loins, are peculiarly soothing, fully more so than the general warm bath, which, however, is not to be neglected ; gen- tle laxatives, particularly of the saline kind, are to be frequently repeated; lint-seed tea, or any other mucilaginous drink containing small proportions of the nitrate of potash, is to be taken, but diuretics are not to be exhibited un- til the acute stage is subdued. Large injections of tepid water per anum are often found to produce temporary relief,and should therefore be frequently used, but it will be well to employ Read's syringe, by which a larger quantity can be more conveniently introduced into the bowel, than by any other means. Rubefacients, particularly mustard plasters, applied to the lumbar region, are found beneficial, but are by no means to be used till towards the end of the acute stage. CHAP. II. CALCULUS IN THE KIDNEYS, —BLADDER, —AND OTHER PARTS OF THE URINARY PASSAGES. The urine is one of the most complicated fluids secreted by animals ; it is composed of acids, alkalies, calcareous earth, and other substances hereafter to be noticed. The substances hitherto discovered in uninary calculi are lithic, sometimes called uric acid—phosphate of lime—ammoniaco-magnesian phosphate—ox- alate of lime,—cystic oxide, with a variable proportion of animal matter ce- menting their ingredients. According to the best authorities, it would appear that these substances seldom exist singly, yet some of them generally prevail in a sufficient degree to impart to each stone a peculiar character. Dr. Mar- cet has given the following classification: 1. Lithic calculus ;—2. bone-earth calculus, principally consisting of phos- pnate of lime ;—3. the ammoniaco-magnesian phosphate;—4. the fusible calculus, consisting of a mixture of the two former;—5. the mulberry calcu- lus, or oxalate of lime;—6. the cystic calculus, consisting of the substance called by Dr. Wollaston cystic oxide;—7. the alternating calculus, or concre- tion, consisting of two or more different species, arranged ih alternate layers; v 8. the compound calculus, the ingredients of which are so intimately mixed, • as not to be separable without chemical analysis;—9. calculus of the prostate gland. f 1. Lithic calculus.—So called from the preponderance of lithic ac/d, which substance was first discovered by Scheele. This is a hard inodojfous concretion of a brownish or fawn colour, sparingly soluble in water, but ^asily dissolved by solutions of either of the fixed alkalies. It is also soljuble in nitric acid. When exposed to the action of the blow-pipe, it blackens, emits a peculiar animal smell, and gradually evaporates, leaving a little whf te alka- line ash. 2. The bone-earth calculus, principally consisting of phosphate of lime.— The existence of a urinary concretion, consisting entirely of phosphate of •'-■ Kme, was first pointed out by Dr. Wollaston, who gave the following de- 11 scription of its appearance: " Its surface is generally of a pale brown, and ' so smooth as to appear polished; when sawed through, it is found very regu- 584 CALCULUS IN larly laminated, and the laminae in general adhere so slightly to each other, as to separate with ease into concentric crusts." When powdered, this cal- culus is very soluble either in the muriatic or nitric acids. Under the ac- tion of the blowpipe it first blackens, but soon becomes perfectly white. Dr. Marcet thinks that calculi entirely composed of pure phosphate of lime are very rare. 3. The triple calculus, or ammoniaco-magnesian phosphate.—Dr. Wollaston also discovered this triple salt as a constituent of urinary concretions, although calculous masses consisting solely of this substance are perhaps never met with. Calculi in which the ammoniaco-magnesian phosphate prevails, are generally whiter and less compact than those of the former class. An ammo- niacal smell is emitted under the blow-pipe, the fragment diminishes in size, and if the heat be strongly urged, an imperfect fusion takes place, leaving a phosphate of magnesia. 4. The fusible calculus.—With the exception of the lithic, this kind of calculus occurs more frequently than any of the others. It is also in general whiter, and more friable, sometimes resembling a mass of chalk. It likewise appears in the form of a spongy and very friable whitish mass, without a laminated structure. 5. The mulberry calculus, or oxalate of lime.—It was Dr. Wollaston who first discovered this substance in urinary calculi. Although named mulberry from its external resemblance to that fruit, yet we are assured by Dr. Mar- cet, that a number of calculi of this class occur, which, far from having the mulberry appearance, are remarkably smooth, and pale coloured; and it is conjectured, that the dark colour of the tuberculated calculi may arise from blood having been imbibed by them. 6. The cystic oxide calculus.—This calculus was first discovered by Dr. Wollaston, and resembles more nearly that of the triple phosphate of mag- nesia, than any other sort; but is more compact, has no distinct laminae, and appears as one mass confusedly crystallized; it has a yellowish semi-transpa- rency, and a peculiar glistening lustre, like that of a body having a high re- fractive density. The solvents of the cystic oxide are too numerous to be ^particularized here; but it may be mentioned that it is not soluble in water, alcohol, acetic, tartaric and citric acids, or saturated carbonate of ammonia. 17- The compound calculus in distinct layers.—Calculi of this description are frequently seen in practice, and shew lithic strata alternating with layen of oxalate of lime, or with its phosphate. Dr. Marcet has given a represen- tation;, of a calculus, in which lithic acid forms the nucleus, pure phosphate of lime being next to this, and so on, the fusible crust at last enveloping the whohe concretion. 8. ^Compound calculus, with the ingredients intimately mixed.'—This kind is comparatively rare; but Dr. Marcet states, it may be sometimes recognized by it$ more or less irregular figure, and less determined colour, by being leu distinctly, if at all stratified,—and by often possessing a considerable hard- stitoc KIDNEYS AND BLADDER. 585 ness. When exposed to analytical processes, confused results are obtained, which soon proclaim its compound nature. 9. Calculus formed in the prostate gland.—Calculi formed in this situation often give rise to symptoms which are mistaken for the effects of stone in the bladder. According to Dr. Wollaston, they all consist of phosphate of lime, not distinctly stratified, and are tinged with the secretion of the prostate gland, the salt is in the neutral state, without a redundance of calcareous earth as in bones. Their external appearance is similar to that of the lithic calculi; but Dr. Marcet has shewn, of how much consequence it is in a prac- tical point of view, to be able to detect the difference. For full information upon these points, and upon all others connected with the formation of uri- nary calculi, I must refer the reader to Dr. Marcet's excellent work on calcu- lous disorders, published in 1819. Besides these, Dr. Marcet describes two other kinds of calculi, the names of which I shall only mention:—1st, The Xanthic oxide, which makes an _ approach to the cystic calculus, but gives a bright lemon residuum on evapo- rating its nitric solution, which is not yielded by the cystic calculus. 2c. until I come to treat of the particular forms of dropsy. The general symptoms are, a sallow complexion; dry skin; costive bowels; urine in small quantity, and of a high colour, in some cases coagulable by heat, and of low specific gravity; muscular emaciation; general debility; febrile symptoms, particularly towards night; want of appetite and indiges- tion, and sometimes nausea, vomiting, and diarrhoea. In some cases, there are cough, difficulty of breathing, particularly in the horizontal posture, and occasionally expectoration. Sometimes there are a sense of suffocation, vio- lent palpitation, and startings during sleep. The pulse is sometimes slow, at others quick, often irregular and intermitting; the tongue is sometimes furred and moist, at others parched and red, and sometimes it is preternaturally clean and florid. Occasionally, erysipelatous inflammation takes place, or the skin cracks, allowing a watery fluid to ooze out. The duration of dropsy is very various, and depends almost entirely upon the nature of the disease, by which the effusion is caused. General remarks on the treatment of dropsy.—Among the remedies em- ployed in dropsy, the consideration of blood-letting is the most important; because it is indispensably necessary in some cases, while its employment is doubtful in others, and would be decidedly injurious in many. In the treatment of dropsy, many insurmountable obstacles are experienced in investigating and deciding what organ or organs are affected; besides which, sudden changes take place from the occurrence of inflammatory action in other parts, so that it requires no ordinary share of pathological and practical DROPSY. 725 knowledge to act decisively, and yet cautiously. Dr. Cullen gives three general indications of cure :— 1. The removing of the remote causes of the disease. 2. The evacuation of the serous fluid already collected in the cellular texture. 3. The restoring of the tone of the system, the loss of which may be considered in many cases as the proximate cause of the disease. The endeavour to fulfil these indications, has, I apprehend, been the cause of much embarrassment to practitioners, and increased distress to patients.— ' With respect to the first, practitioners will in many instances be found contending with mere shadows, and wasting much valuable time, because disease may exist after riie removal of its cause, or be even incurable, and the patient may yet be enabled to live a considerable number of years with tolerable comfort, following his business, provided the attention of the practitioner be directed to certain consequences, the occurrence of which is constantly to be dreaded. According to Dr. Bright, " the two great sources of casual danger will be found in inflammatory affections, more particularly of the serous, sometimes of the mucous membranes, and in the effusion of blood or serum into the brain, and the consequent occurrence of the apoplexy. Of these secondary or casual dangers, we have illustrative examples in many of the cases which have been stated above. Out of the seventeen dissections, we have found ten or eleven betraying inflammation of the pleura, generally old, but sometimes of recent date. We have found three instances in which the patients had suffered decided attacks of inflammation in the pericardium shortly before death, and in two of these cases, we had proof of some previous affection of the same kind. In one only were the signs of inflam- mation in the peritoneum well marked. Five out of the seventeen had altogether escaped inflammatory affections of the serous membranes, and one of these died with inflammation of the epiglottis. With regard to the cere- bral affections coming on in the progress of these dieases, we find, in the cases above related, both apoplexy and epilepsy to have occurred ; and a very well- marked instance of the former was witnessed in a patient in the clinical ward in 1825." . The second indication, "evacuating the serous fluid," may be fulfilled in two ways. 1. By evacuating, by means of a surgical operation, the effused fluid 2 By exciting the action of the absorbents, and producing an increased discharge from some of the excretory organs. These are no doubt great objects, if they could be attained; but we must always recollect that the dropsy is a mere symptom or consequence of functional or organic disease in some other organ, and unless that be cured, much mischief may be done not only by wasting precious time, but by exhibiting medicines which are sometimes manifestly injurious to the patient. Against the third indications-" restoring the tone of the system, the loss of which may be considered in many cases as the proximate cause of the 726 DROPSY. disease,"—I have to enter a strong protest, from the injurious consequences which I have seen result from attending to it in practice. It accords, however, with Dr. Cullen's notion, that the disease is owing to a general debility, producing a laxity or want of tone in the exhalents. There is a time that we may stimulate and give tonics with advantage, when we have conquered the cause of the disease perhaps by debilitating remedies, and when the strength must be supported. It will be sufficient for me again to refer to the cases and dissections of Dr. Bright, to show the dangers which must often arise from following such treatment, except under the above restrictions. In Edinburgh I have met with several medical men in extensive practice, whose invariable method of treating dropsy, is by giving digitalis, and large quantities of strong gin-toddy, containing an English pint, and sometimes even two of the spirit, in the course of twenty- four hours; and I have reason to believe, that the same means are used elsewhere. I would implore these individuals to peruse with care the works of Drs. Blackall and Bright, who have given us additional guides in the treatment of dropsy, by showing the inflammatory diathesis which generally prevails, and by directing our attention to the coagulability of the urine, as indicating an affection of the kidneys, which affection almost always terminates in inflammatory action, to the destruction of the organ. It is believed by many, and it certainly appears probable, that bleeding and the antiphlogistic regimen, within certain limits, act upon the absorbent system, by creating greater activity. Blood-letting, therefore, as already ob- served, stands the foremost remedy; but in using it, we must be guided by the age, strength, habits, and peculiarity of constitution of the individual,—the duration of the disease,—and also by the state of the pulse. Should the condition of the pulse and other circumstances contra-indicate venaesection, local bleedings may be had recourse to, either by means of cupping-glasses or leeches, and are peculiarly serviceable when applied to the loins in cases of diseased liver and kidneys. The propriety of repeating the abstraction of blood, may be discovered from the state of the blood itself, the strength of the pulse, and the relief afforded. The rash conduct of some practi- tioners in taking away large quantities of blood in all cases, is to be deprecated, because, although it may be successful in some instances of dropsy, it will be found to be very injurious and even fatal in a majority; and it is greatly to be feared that the indiscriminate employment of general bleeding in this disease has too frequently led to the adoption of the opposite mode of practice already noticed. I have seen several cases where chronic bronchitis existed with dropsy, whether as cause or effect I could not in some instances discover; but in all, great and permanent advantage was obtained from venaesection. Purgatives stand next in importance to blood-letting. In all case&, it is necessary to keep the howels open ; and, in many, we are obliged to depend upon the use of free purgation, when the constitution is not sufficiently DROPSY. 727 strong to stand the effects of venaesection; consequently, we find that powerful doses of jalap, gamboge, scammony, and elaterium, have been highly recommended by different authors. I have heard many practitioners declare that they have never failed in curing dropsy by elaterium ; but individuals who made such assertions, must either have been singularly fortunate in meeting with slight cases only, not produced or accompanied by organic disease, or they must have been short-sighted or forgetful. In. using this class of remedies, practitioners should recollect, that violent and long continued purging is fully as debilitating as vensesection ; and, in point of fact, I have seen several individuals die under the action of purgatives, to all appearance from syncope. In the case of Evans, who recovered, Dr. Bright gave first half a grain of the extract of elaterium every six hours, and afterwards one grain twice a day, and with considerable benefit; but he was subsequently bled, and took several doses of opium. Dr. Bright seems to prefer, however, the saline laxatives, which unite a certain degree of diuretic power, and amongst these, he found the super-tartrate of potash the most efficacious ; indeed, it will be seen, on perusing the cases, that in several he trusted almost entirely to this remedy. Diuretics have been long used in all cases of dropsical effusion, apparent- ly with the simple intention of " pumping the water out of the system ;" but I am convinced, that the active and indiscriminate use of these, as well as of drastic purgatives, will become less general as our pathological information increases. It appears to me that little benefit wilt be derived in many cases from the use of diuretics, even should the effused fluid be absorbed, if the original disease, whether it be of the heart and large blood-vessels, the liver or the kidneys, remains; and, indeed, in several lingering instances, which I have treated by these means, so far successfully as to get rid of the dropsical effusion; the disease afterwards became more urgent and active. The principal diuretics employed are squills; foxglove; acetate of potash ; super-tartrate of potash ; infusion of fresh broom; cantharides; oil of turpen- tine ; and balsam of copaiva. Of these, the squills and balsam of copaiva I believe to be the best; Dr. Bright prefers the former, which he finds to act best in combination with hyosciamus, or when a grain of opium has been at the same time taken once or twice a-day ; indeed, he says that he considers these two substances to form an important part of the treatment, by diminish- ing the irritation of the kidneys, as well as by allaying the general disturbance. The propriety of tapping is very questionable, unless we are convinced there is no incurable organic disease; but I shall return to the consideration of this point, when treating of hydrothorax and ascites. Scarifications are frequently practised in anasarca, and occasionally with ad- vantage ; but I believe it will in general be only temporary; and in many constitutions, inflammation, ulceration of a bad character, and even mortifica- tion, sometimes ensue. 728 DROPSY. Emetics were formerly in great repute in the treatment of dropsies, owing to the high encomiums passed upon them by the illustrious Sydenham, who says that antimonial emetics do not seem merely to evacuate the stomach, but open some passages from the cavity of the abdomen into the intestinal canal. Whatever may be the cause I cannot tell, but they seem now to be very much laid aside; there can be no doubt., however, that emetics, either of antimony or copper, do promote absorption in a wonderful manner, in induration of the testicle; and although these good effects have been much overrated by Syden- ham, still perhaps they have been abandoned by practitioners of the present day without sufficient examination. Mercury has been often used in dropsy; and there can be no doubt that it has been frequently serviceable. It would be a matter, however, of the first practical importance, if we could determine precisely the cases in which it is to prove beneficial, in order to prevent much valuable time from being lost. We now, by means of auscultation and percussion, possess advantages which those who lived before us did not enjoy, and almost any ear will be able to de- tect disease of the heart or chronic bronchitis—very frequent causes of dropsy, —in which the action of mercury will certainly not be so serviceable as if the liver were diseased. Dr. Bright has shown that dropsies frequently depend upon disease of the kidney, in many cases of which mercury may prove de- cidedly injurious, unless preceded or accompanied by general or local bleeding. In many instances, it will be found serviceable after bleeding, to prescribe a combination of calomel, squills, and digitalis, in the form of pill, to be repeat- ed in proper doses three or four times a-day. But Dr. Bright assures us, that the cases which have proved most successful in his own practice, have gene- rally been those in which the use of mercury has been rigidly abstained from; and he further states, that in some cases he has seen the good effects of other remedies entirely interrupted by the mercurial action ; and he has likewise seen several instances, in which the cure, when mercurials have formed part of the plan, has been protracted to a great length. (Page 73.) Poultices made of the male fern applied to the abdomen, have been used in several cases of dropsy by Dr. Shortt, in the Infirmary of Edinburgh, with a view of promoting an increased flow of urine, and, it is stated, with remarka- bly good effects. I have tried this remedy in two cases, but without success, although every care was taken to procure the plant fresh. Blisters, and counter-irritation produced by other means, have been occa- sionally found of great service in dropsies, produced by whatever cause. They merely act by translating inflammatory action from an internal organ to the skin, and not, as was formerly imagined, even by Dr. Blackall, by evacuating the dropsical fluid. I have often seen the best effects from their judicious employment, and they appear to be more particularly useful when applied to the loins after topical bleeding in cases of diseased kidney. Formerly when used for the purpose of drawing off the dropsical fluid, they were applied to the extremities, and frequently caused sloughing ulcers. DROPSY. 729 Great difference of opinion exists as to the quantity of fluid which ought to be allowed to a patient labouring under dropsy ; some allow as much drink as the patient feels inclined to take—others none at all; but I believe that a medium plan is the best to follow. If a patient be thirsty, and is interdicted from taking a drink, additional suffering, and many a sleepless night, is the consequence; whereas, if he be encouraged to drink, he may subsequently experience great uneasiness from the over-distended state of the stomach. In practice, we often take advantage of the thirst, to introduce a sufficient quantity of the super-tartrate of potash into the system. I believe that some who interdict liquids do so for no better reason, than because it has been stated by authors that dropsical complaints have been produced by drinking a large quantity of fluid! I shall now proceed to notice three varieties of dropsy,—viz, anasarca; hydrothrax; ascites. ANASARCA. The term anascarca; implies a preternatural collection of serous fluid in the cellular texture, and when partial, it is often called oedema. This form of dropsy generally comes on slowly, unless it succeed to scarlet fever, when perhaps the whole body is observed to become suddenly affected; it also occurs occasionally after taking a large drink of cold fluid when the body is much heated. In general the feet are at first observed to be affected in the evening, and to pit on pressure; the swelling gradually ascends higher, and sometimes distends the cellular tissue of the whole body. The urine is always scanty and high-coloured; the bowels are generally tardy, although now and then they are in a contrary state. The general symptoms, as well as ;the progress and termination of the disease, vary according to the organ affected. Some- times there is considerable fever, and dry skin; and the heat of the parts affected is sometimes increased, although in general it is diminished. Treatment of anasarca.—This must be conducted upon the principles already so fully mentioned. HYDROTHORAX. Hydrothorax may exist on both sides of the chest, or on one only, and may be complicated or not with effusion into the abdomen, and also with general oedema. In the commencement of hydrothorax, the symptoms which particularly indicate this form of the disease, are in general so slight as noi to attract much attention, and may continue to be so for a considerable period, although other circumstances denoting bad health exist. The general symptoms are those which accompany all forms of dropsical affection. Those which are peculiar to hydrothorax, are now to be mentioned. At first, slight difficulty of breathing is experienced, which is increased during exercise, but more particularly when the body is placed in the horizontal posture, and is generally attended by a dry and annoying cough. The feet are observed to be swollen towards the evening: the extremities become moie 92 730 DROPSY. and more cedematous as the disease advances, when the patient frequently com- plains of palpitation, increased dyspncea, which is worse at one time than at another, sometimes producing a dread of suffocation, particularly during the night. As the disease goes on to a fatal termination, the patient can never lie down, or even recline backwards, or go to sleep in any position, without starting up suddenly with increased dyspnoea. The surface shews signs of impeded circulation; the cheeks and lips in particular become livid or deadly pale ; and the pulse, if it had not hitherto been irregular and intermittent, now becomes so. At length the patient dies from suffocation and exhaustion, or becomes comatose. The progress of the disease depends much upon the organic lesion, and more particularly upon the disease affecting both cavities of the pleura, or one only ; in which latter case, its progress will be much slower, the symptoms much slighter, and the patient will be able to repose in the horizontal posture, but on one side only. Corvisart has observed, that in the cases where hydrothorax exists on one side, oedema also affects the corre- sponding extremity. Stethoscopic signs.—Before the discovery of auscultation, practitioners were always in doubt as to the existence of fluid in the chest; now, however, by applying the ear to the chest, and by percussion, in addition to the other symptoms, the existence of hydrothorax can be detected with the greatest certainty. In hydrothorax percussion produces a dull sound; and the respira- tory murmer is either not heard, or it is very obscure, except along the vertebral column, where it is heard more distinctly. The appearance and shape of the chest also afford us additional evidence, but they cannot be de- pended on without having recourse, to auscultation and percussion: the thorax will be observed to be more rounded than natural, and the intercostal spaces to be increased. Treatment of hydrothorax.—The plan of treatment must depend upon the cause of the effusion, which may be an organic lesion of the heart or lungs, or inflammation of the pleura, and these are to be managed upon the general principles already laid down in the general remarks on dropsical effusions. In cases of threatened suffocation, or even when the dyspncea becomes very severe, it will be proper in many cases to draw off the water; but we must be careful not to hold out the prospect of a cure from such an operation, although we may safely promise considerable temporary relief. We may nevertheless entertain some hope, if the effusion is confined to the chest, and has been produced by inflammation of the pleura, uncomplicated with disease either of the heart or lungs, and if the patient's strength be good. When treating of chronic pleurisy in the fifst volume of this work, a successful case of empyema is noticed, where the operation of paracentesis thoracis was per- formed by Dr. Pitcairn of Edinburgh; and there are others on record. ASCITES. Ascites, or dropsical effusion within the abdomen, may exist either alone, or complicated with hydrothorax and general anasarca. The symptoms, 88 DROPSY. 731 in other forms of dropsy, vary according to the nature of the cause. On some occasions, the disease is ushered in with well-marked symptoms, such as fever, pain in the loins or region of the liver, and corresponding disorder of all the functions of the body, announced by thirst, loss of appetite, sometimes nausea and vomiting, foul tongue, constipated state of bowels, scanty high-coloured urine, dry parched skin, &,c. After these symptoms have continued for some days, the abdomen will be observed to be distended ; upon percussion it will yield a dull sound, and fluctuation will be felt, unless the quantity of the effusion be small, or the intestines tympanitic. On other occasions, the disease goes on insiduously, the enlargement of the abdomen being often for considerable time attributed to corpulency; and the other symptoms, such as restless nights, and loss of appetite, to want of exer- cise and debility. At length the secretion of urine becomes almost suppressed, when symptoms indicating a cerebral affection sometimes take place, and cre- ate alarm; or along with scanty urine, the legs become cedematous, and ex- cite for the first time a correct notion as to the nature of the patient's com- plaints. In all cases of ascites, the most careful examination should be made respect- ing the slate of the thorax, as we1 shall be much more likely to be successful in the treatment of a case which is unconnected with any organic affection of the contents of the thorax, or with effusion into its cavities, We must have recourse therefore to auscultation and percussion, as we cannot judge with any degree of certainty from the dyspnoea or the posture of the patient. In ascites there may be great dyspncea from hurried circulation, or from the effu- sion in the abdomen encroaching on the thorax, from which causes also there may be inability to lie in the horizontal posture. , In females we may have considerable difficulty in determining between ascites and the diseases of the ovaria, in which there is considerable enlarge- ment ; and when treating of diseases of the uterus, it was stated how difficult it occasionally is to determine the existence of fluid in the abdomen. Treatment of ascites.—This must depend, as in other dropsies, upon the organ affected, and upon the extent and nature of the disease. With respect to tapping, it should be avoided as long as possible. We should be guided chiefly by the sufferings produced by the distension, as well as by the difficul- ty of breathing. I have been frequently on the point of directing the opera- tion to be performed, when absorption commenced, and afterwards went on rapidly ; and, on the other hand, I never once had occasion to regret delay. The same objection to the operation may be made, as was formerly urged, when considering ovarian diseases, that when once we begin to tap, we can- not leave off, as the effusion subsequently takes place with greater rapidity. Counter-irritation has appeared to me to be more serviceable in ascites than in some other Yorms of dropsy. FINIS. CONTENTS PART I.—GENERAL HISTORY OF INFLAMMATION AND FEVER— WITH THE PATHOLOGY AND TREATMENT OF INDIVIDUAL FEVERS. PAGE Chap. I.—Doctrines, Causes, Phenomena, and Effects of Inflammation 9 General Doctrines which have prevailed respecting inflammation ... 9 Causes of Inflammation.......---15 Division of Inflammation into varieties.....-- - 17 Phenomena of Inflammation.........-17 Terminations of Inflammation, with a short account of the Effects of Inflamma- tion on the principal Tissues........-19 Chap. II.—Fevers..... ......24 History of the General Doctrines of Fever.......24 Division of Fevers.......-.-.31 General Description of the Phenomena of Fevers ------ 32 Causes of Fever............37 Chap. III.—Intermittent Fever.........49 Phenomena of Intermittents..........50 Appearances found on Dissection........-52 Causes of Intermittents........--63 Pathology of Intermittents..........63 Treatment of Intermittents...........66 Chap. IV.—Remittent or Yellow Fever.......98 Symptoms............" Appearances found on Dissection .------• 101 Causes.............102 Treatment.............103 Infantile Remittent...........107 Causes ----*----......Mjj Appearances on Dissection........-108 Pathology..........; ; J Treatment.......... Chap. V.—Continued Fever....... Fever from Functional Derangement..... j Treatment........ Fever from Inflammation...... Symptoms of Inflammatory Fever ... - Treatment of Inflammatory Fever..... 734 CONTENTS. PAOK Congestive Fever -----------119 Symptoms of Congestive Fever --......120 Pathology of Congestive Fever - -'.......121 Treatment of Congestive Fever...... - 122 Mixed Form of Fever.........--123 Hectic Fever............128 Symptoms.....-......128 Treatment............12a General Pathology of Eruptive Fevers .......129 Scarlet Fever .--.-------- 135 Symptoms ------------ 135 Appearances on Dissection ...------ 137 ' Treatment......'......138 Measles.............140 Appearances on Dissection - - -.- - - - * - 144 Treatment ....-.--.--- 145 Small Pox.............146 Appearances on Dissection -..------ 147 Treatment ....--.---.- 148 Modified Small Pox...........149 Chicken-pox --------.-.-150 Miliary Fever.....--.....151 Treatment............152 Roseola.............152 Urticaria ..--.-------- 152 The Plague ,.........- - - -163 Treatment ....-.------ 155 PART II.—DISEASES OF THE ORGANS CONNECTED WITH THE DI- GESTIVE SYSTEM. Chap. I.—Difficult Dentition.........159 Chap. II.—Difficult Deglutition from Inflammation, Ulceration, and Enlargement of the Tongue j Cynanche Tonsillaris; Cynanche Pharyngea ; Inflammation and Ulceration of the (Esophagus - 163 Cynanche Tonsillaris.........- - 164 Treatment...........- 165 Inflammation on the Pharynx......... 166 Inflammation and Ulceration of the (Esophagus......166 Treatment............167 Chronic Affections of the (Esophagus........167 Chap. III.—Indigestion -- - - -- * * - - - 168 Flatulency and Tympanitis ---------- 172 Pyrosis or Water-brash ---------- 172 Heart-burn.....-.......I73 Gastrodynia --...........I73 Symptoms - ..........I73 Chap. IV.—Discharges of Blood from the Stomach and Bowels - - 175 1. Haemorrhage from the Stomach - - - - - - - 175 Treatment............176 2. Haemorrhage from the Bowels ........176 Symptoms --......* ... 177 CONTENTS. 735 PAGE Causes.............177 Treatment.....-......177 Piles..............176 Chap. V.—Common Colic ; Painter's Colic ; Ileous : Intus-Susception ; Intestinal Concretions ; Prolapsus Ani ; and Constriction of the Rectum...........179 Common Colic -...........179 Symptoms ---.........179 Treatment ---..........179 Painter's Colic.....-......180 Symptoms............180 Appearances on Dissection.........181 Treatment -----.......18i Ileus..............182 Appearances on Dissection, and Pathological Remarks - 183 Treatment............185 Intus-Susception --..........186 Appearances on Dissection.........186 Treatment.......- - - - x - 186 Intestinal Concretions - ' -.........187 Treatment............187 Prolapsus Ani -...........187 Treatment............188 Constriction of the Rectum..........188 Chap. VI.—Intestinal Worms.........189 Treatment.............19° Chap. VIL—Inflammatory Affections of the Organs contained within the Cavity of the Abdomen --.....-191 General Remarks on Inflammation........191 Enteritic Inflammation..........193 Peritonitis......--.....194 Symptoms - '............194 Cases - .........I95 Pathology ............I95 Treatment........- - - - 195 Puerperal Peritonitis, vulgarly called Puerperal Fever.....196 Symptoms.....------- 196 Appearances on Dissection .--.....- 198 Pathological Remarks..........198 Treatment............200 Comparative Results of do..........202 Chronic Peritonitis...........203 Causes - - ->..........204 Appearances on Dissection.........204 Treatment............205 General Remarks on Inflammation of the Mucous Membrane of the Stomach and Bowels ---...... Inflammation of the Mucous Membrane of the Stomach.....213 Causes.............214 Oil Appearances on Dissection - Treatment............214 736 CONTENTS. PAGE Inflammation of the Mucous Membrane of the Bowels.....215 Treatment............216 Chronic Inflammation of the Mucous Membrane......216 Treatment............217 Diarrhoea............. 217 Pathology......- - - - » - 217 Treatment............ 217 Bowel Complaints of Children......... 218 Treatment - ....... 220 Tabes Mensenterica............ 221 Appearances on Dissection......... 222 Treatment............222 Dysentery.............222 Symptoms of Acute Dysentery. ..--.-.. 222 Symptoms of Chronic Dysentery ........ 224 Appearances on Dissection, with Pathological Remarks .... 224 Causes.............228 Treatment.......... - . 228 1st, Treatment as it occurs in this country ■» * - - - - - 229 2d, Treatment as it occurs in warm climates - - - - - . 230 Treatment of Chronic Dysentery......-. 232 Cholera............. 232 Causes.............233 Phenomena............ 233 Appearances on Dissection.....---.. 235 Pathological Remarks --.........237 Treatment............ 238 Inflammation of the Muscular and Cellular Tissues.....241 Scirrhus of Stomach and Intestines - - -•.....243 Symptoms of Cancer in the Stomach, &c........244 Causes ........ .... 245 Treatment.....-......246 Chap. VIII.—Diseases of the Liver and Spleen - - - 247 Inflammation of the Liver.......... 247 Symptoms of accute Hepatitis......... 248 Symptoms of Chronic Hepatitis ......... 248 Appearances on Dissection.......... 249 Causes.........* . . . 250 Treatment ----...-.... 250 Taundice............. 252 Phenomena ------...... 252 Treatment............ 253 Gall-Stones ---..........253 Treatment ----.---.... 253 Splenitis.......- . . .'. . 254 Inflammation of the Spleen......... 254 Treatment............ 254 PART III.—DISEASES OF THE ORGANS CONNECTED WITH THE RES- PIRATORY SYSTEM - -........258 Chap. I.—General Remarks..........258 I CONTENTS. 737 ' , ^PAGE Chap. II.—Diseases affecting the Mucous Membrane of the Air-Pas- sages............. 264 Catarrh.............264 Treatment......-.....265 Bronchitis --........... 265 Chronic Bronchitus........-- 268 Stethoscopic Signs of Acute and Chronic Bronchitis.....269 Appearances on Dissection, and Pathological Remarks - - - 270 Treatment of Acute Bronchitis ........272 Treatment of Chronic Bronchitis....... - - 275 Inflammation of the Larynx ---------- 276 Croup -,.............277 Phenomena............277 Causes.............278 Appearances on Dissection - - - -,- - - - - 278 Pathological Remarks...........279 Symptoms............279 Treatment............283 Hooping Cough........... i 285 Phenomena............ 285 Appearances on Dissection......... 287 Pathological Remarks.......... 289 Treatment............292 Chap. III.—Pneumonia...........297 Phenomena............ 297 Appearances on Dissection......... 299 Treatment............ 300 Chap. IV.—Pleuritis...........304 Stethoscopic Signs .---------- 305 Appearances on Dissection ...------ 305 Treatment..........- - 306 Chronic Pleuritis ------------ 307 Empyema^............. 307 Stethoscopic Signs...........307 Treatment............307 Chap. V.—Hemoptysis -..-----.--- 309 Appearances on Dissection of first variety ....... 310 Treatment of first variety...... 310 Symptoms of second variety.........310 Appearances on Dissection of second variety ------ 310 Trearment of second variety - ' - - -.....313 Chap. VI.—Phthisis Pulmonalis.........315 Phenomena............315 Appearances on Dissection - -.....- -316 Treatment............ 322 Description of more rare structural derangements found in the lungs, viz., bodies of a cartilaginous, bony, calculous, and chalky nature ... 323 Melanosis of the Lungs..........324 Medullary Sarcoma of the Lungs.........326 Chap. VII.—Asthma...........330 Phenomena .. N --------- - 331 93 738 CONTENTS. PAGE i • Causes.............331 Pathology............331 Treatment............33S PART IV.—DISEASES OF THE CIRCULATING SYSTEM. Chap. I.—General Remarks..........339 Chap. II.—Palpitation, &c...........347 Treatment............348 Angina Pectoris --.......--- 349 Appearances on Dissection, and Pathological Remarks - - - - 351 Treatment............352 Chap. III.—Pericarditis and Carditis .......354 Causes............. 857 Appearances on Dissection --------- 357 Treatment............358 Carditis.............- 359 Appearances on Dissection --------- 359 Treatment............360 Chap. IV. —Hypertrophy of the Heart.......361 StethoscoDic Signs of Hypertrophy of the Left Ventricle - 362 Stethoscopic Signs of Hypertrophy of the Right Ventricle - 363 Treatment of Hypertrophy of the Heart.......363 Chap. V.—Dilatation of the Heart..... - 366 Symptoms ..... ......366 Stethoscopic Signs of Dilatation of Right Ventricle.....369 Stethoscopic Signs of Dilatation of Left Ventricle.....370 Tuberculous Formation.......... 370 Atrophy of the Heart...........371 Rupture of the Heart ----------- 372 Chap. VI.—Diseases of the Valves........374 Appearances on Dissection.....---- 374 Symptoms ...-•-•>----- 375 Stethoscopic Signs of Diseases of the Valves......375 Treatment............376 Chap. VII.—Diseases of the Blood-Vessels ------ 377 On Dissection ---.....---- 378 Ossification of the Arteries.........- 379 Aneurism............. 380 Treatment..........--- 382 Inflammation of Veins .....----- 383 Symptoms............ 383 Phlegmasia Dolens ....------- 384 Symptoms............ 384 Pathological Observations ..-.«..-- 385 Treatment -........... 387 Chap. VIII.—Plethora and Exsanguinity.......388 Plethora.............388 Causes.......-.---. 388 Treatment.........- - ^ - 389 Exsanguinity .......--.-- 389, Treatment..........- - 391 CONTENTS. 739 PAGE Chap. IX.—Cyanosis or Blue Skin........392 Symptoms............392 Pathological Opinions..........392 Treatment............393 PART V.—DISEASES OF THE BRAIN, AND OTHER PARTS OF THE NERVOUS SYSTEM. Chap. I.—General Remarks on Diseases of the Brain, &c. ... 393 Chap. II.—Inflammation of the Membranes of the Brain as it occurs in Adults.—Inflammation of the Brain, which terminates in Suppuration and Ramollissement. Inflammation of the Membranes of the Brain as the Disease occurs in Young Subjects, and which is commonly called Hy- drocephalus ........... 410 Inflammation of the Membranes as it occurs in Adults.....410 Phenomena - - - - -........ 411 Causes .......-.---- 414 Appearances on Dissection - - - - - - - - -415 Treatment............417 Inflammation of the Substance of the Brain.......422 Symptoms ....--.-----' -422 Causes.............' 425 Appearances on Dissection --------- 425 Treatment............427 Acute Hydrocephalus --.-------- 430 Appearances on Dissection - - - - - - - - -431 Pathological Remarks ----......431 Treatment............435 Chronic Hydrocephalus - . #- . ...... 436 Appearances on Dissection......... 437 Treatment............437 Chap. III.—Diseases of the Spinal Marrow......439 Inflammation of the Spinal Marrow and its Membranes - - . - • 439 Symptoms -.----.--... 439 Causes.............440 Appearances on Dissection ......... 440 Treatment............441 Tetanus.............441 Symptoms .-.--.----.. 441 Causes - - - - - -•- - - -'- - - 442 Appearances on Dissection ..-----.. 443 Treatment............443 Trismus Nascentium .-..----... 444 Hydrophobia ...-.----.-. 445 Symptoms............445 Appearances on Dissection.........446 Treatment............447 Chap. IV.—Epilepsy—Hysteria—Chorea—and Neuralgic Pains - - 448 ■ Epilepsy............. 448 Symptoms............ 44s Causes ...»-.-.--.-- 449 Appearances on Dissection -.-.----. 449 Treatment............ 451 Hysteria ....---....-.451 r40 CONTENTS. PAGF Symptoms............451 Causes -..-----.....452 Treatment............458 Chorea.............453 Causes.............454 Treatment..........- - 454 Neuralgic Pains - -v- - - " " * " --- 455 Causes . - - '.......... 455 Treatment............ 455 Chap. V.—Apoplexy and Paralysis......-- 457 Apoplexy............. 457 Symptoms ............ 457 Causes.........- 459 Appearances on Dissection ......... 459 Treatment............461 ■ Paralysis.............461 Symptoms............ 462 Causes.............463 Treatment............463 Chap. VI.—Insanity—Hypochrondriasis—and Delirium Tremens - - 466 Insanity.............466 Causes ......-.-.-.- 468 Appearances on Dissection ......... 4(39 Treatment.....__.......471 Hypochrondriasis ..-------.. 475 Causes.............476 Treatment -........476 Delirium Tremens ........... 477 >ART VI.—DISEASES OF THE EYE AND EAR......480 Chap. I.—General Remarks on Diseases of the Eye .... 481 Symptoms of Ophthalmic Inflammation.......482 Causes of Ophthalmic Inflammation........483 Treatment of Ophthalmic Inflammation - -.....484 Chap. II.—Inflammation of the Conjunctiva......489 Simple Inflammation of the external covering of the Eye .... 489 Symptoms ............ 489 Treatment -. - - -. - - - - - - - 490 Simple Catarrhal Ophthalmia.........490 Symptoms............ 491 Treatment............491 Purulent Ophthalmia of Infants.........492 Symptoms -........... 493 Causes............. 494 Treatment............495 Pustular Ophthalmia...........498 Treatment............498 Chap. III.—Inflammation of the Eye-Ball......499 Inflammation of the Sclerotic Coat........499 Inflammation of the Iris...........499 Causes.............501 Treatment............501 CONTENTS. 741 PAGE Amaurosis............- 503 Causes --....--.. v - - * 503 Symptoms............503 Treatment............504 Chap. IV.—Diseases of the Ear -...... . . 506 Otitis..............506 Causes............- 507 Treatment............507 Otorrhsea.............508 PART VIL—DISEASES OF THE SKIN-........509 Chap. I.—General Remarks on Diseases of the Skin - - * - 511 Classification of Diseases of the Skin L- - 513 Chap. II.—Erysipelas -.-.....- » - - 514 Symptoms - •.........* - 514 Causes............. 516 Appearances on Dissection.........518 Pathological Remarks.......- - -519 Treatment - - - -.....v - - - 519 Chap. III.—Papular Diseases.....- - -- 534 Strofulous.............534 Treatment...........- 534 Lichen -..........^ - - 535 Treatment............535 Prurigo ------.....-. 535 Treatment..........-- 535 Chap. IV.—Pustular Diseases.........537 ; Impetigo ---.....---.. 5371 Causes.............537 s Treatment............538 Porrigo........•-..-. 53$ Treatment - -..........53f < Scabies, or Itch - - - -- - - ..•- . -545! Causes.......... . . . 54; : Treatment - - - -x - - - - - - - - 542 i Ecthyma and Rupia -.....- - • - - -54< Causes --....-.-.... 54. Pathology.........--.54. Treatment - - - - - -......54? Acne .------.......54; Causes ........... ^ . 54', Treatment ------------ 64 i Sycosis .......... ~ - - 54 Treatment ............ 5^ c Chap. V.—Squamous Diseases - - - - -'- - - 57 Lepra......... .... 5. • Causes ...-.-------- 5..; Treatment - - - - - - - - - - - -5| Psoriasis -.--------.--- 5 Treatment............5 Pityriasis.............5 i Causes .....-------- 5 742 CONTENTS. PAGE Treatment............ 553 Chap. VI.—Vesicular Diseases.........555 Herbes.............. 555 Causes........... - 556 Treatment -...........556 Pemphigus and Pompholyx.........557 Chap. VII.—Purpura..........- 558 Causes............. 5^5 Appearances on Dissection.........566 Pathology............568 ' Treatment............ 5(jg Exudation of Blood from the Surface, without Abrasion of the Cuticle, com- monly called " Bloody Sweat" ........571 PART VIII.—DISEASES OF THE URINARY AND GENITAL ORGANS - 573 Chap. I.—Inflammation of the Urethra, Bladder, and Kidneys - 575 Inflammation of the Urethra - - - - -.- - - - 575 Symptoms............ 575 Appearances on Dissection......... 577 Treatment . ^ . . . ....... 577 Inflammation of the Mucous Membrane of the Bladder .... 580 Causes ............. 5§o Treatment............,580 Inflammation of the Kidney..........581 Symptoms............ 581 Treatment - - - ........582 ■*■ * Chap. II.—Calculus in Kidneys, Bladder, and other Parts of the Uri- nary Passages........... 583 Calculus in the Kidney ..--'......585 Symptoms - - - - ... . . . . . 585 Treatment............586 Calculus in the Bladder..........586 Symptoms.....-, ..... 587 Treatment...........-- 587 Calculus in the Urethra .......... 588 Calculus embedded in the Prostate........588 Chap. III.—Suppression of Urine, Retention of Urine, Incontinence of Urine............589 Suppression of Urine...........589 Treatment - -'- -........* 591 Retention of Urine...........592 Treatment.....'.......593 Incontinence of Urine..........593 CHAr. IV.—Hematuria, or Discharge of Blood from the Urinary Pas- sages .......►*-■*»-- 595 Treatment ----.---..... 595 Chap. V.—Diabetes...........597 Symptoms.....^.......598 ■ Appearances on Dissection --....... 599 Causes.............599 Pathology............600 ' Treatment............ 602 CONTENTS. 74J PAGE Chap. VI.—Syphilis...........606 Symptoms -•...........605 Treatment............607 Chap. VII.—Diseases of the Labia, and External Parts in the Female 615 Phlegmon.............615 Symptoms............615 Treatment............615 Peculiar Affection of the Pudendum, occurring in Young Subjects - - 615 Treatment..............618 • Chap. VIII.—Inflammation of the Testes - -.....619 Treatment............619 Chap. IX.—Diseases of the Uterus, connected with Inflammatory Action............620 Inflammation of the Uterus after Delivery.......621 Inflammation of the Os and Cervix Uteri in the ordinary state of the System - 623 Treatment............624 Vascular Sarcoma of the Uterus.........625 Treatment............626 Scirrhus and Cancer of the Uterus - - -.....627 Treatment.........i . . 62S Chap. X.—Prolapsus of the Uterus—Retroversion of the Uterus—Po- lypus of the Vagina and Uterus --.---.. 630 Prolapsus of the Uterus......- . - . 630 Causes.............630 "Treatment............630 Retroversion of the Uterus - - - -......631 Causes............. 631 Treatment ... ........goj Polypous Tumours of the Vagina and Uterus......632 Treatment............634 Chap. XI.—Tubercles of the Uterus—Bony Concretions—Hydatids— Aqueous and Flatulent Discharges......63d Tubercles of the Uterus..........g35 Treatment............63g Bony Concretiop ...........63g Treatment - - - » - x.......637 Hydatids.............q^ Aqueous and Flatulent Discharges -.......638 CuAr. XII.—Fluor Albus and Leucorrjnea......639 Symptoms............639 Causes --...■........ g40 Treatment............ 640 Chap. XIII.—Diseases of Menstruation.......643 Amenorrhcea - *. .......... 643 Retention of the Menses - - -........ 643 Causes.............g44 Treatment............g44 Suppression of the Menses ---..-... 049 Treatment......--.... 649 Dysmenorrhoea, or Painful and Difficult Menstruation.....650 744 CONTENTS. PAGE Pathological Remarks.........., 552 Treatment............ 554 Immoderate Flow of the Menses - .......656 Treatment - •»-..........g56 Menorrhagia............65g Causes..............657 Treatment.............g-~ Cessation of the Menses - - - -'......' 662 Treatment.....-......0g3 Chap. XIV.—Diseases of the Ovaria - -......664 Symptoms............665 Treatment.......... . gg7 PART IX.—GOUT—RHEUMATISM—SCROFULA—DROPSY - - - 673 Chap. I.—Gout.............675 Phenomena of a Paroxysm of Regular Gout ----.. 676 Phenomena of Chronic Gout.........ggi Phenomena of Retrocedent Gout ........g82 Causes of Gout, and Pathological Observations - - - - - 685 Treatment............ g89 Management of Gouty Subjects during the intervals.....g93 Chap. II.—Rheumatism........... g9g Acute Rheumatism...........g9g Symptoms.....-......g9(; Treatment............ g98 Chronic Rheumatism..........-701 Rheumatic Gout............ 702 Chap. III.—Scrofula - - - * - -*......'70S Treatment............707 Chap. IV.—Dropsy............712 General Remarks ------.-.... 712 Anasarca ----------.._ 729 Treatment............ 729 Hydrothorax............729 Stethoscopic Signs...........730 Treatment............ 730 Ascites - - - - . . . . .*. . . . 73Q Treatment............731 i v ■:7 s oti/-i..r ^ ^f MEDICINE NATIONAL LIBRARY OF MEDICINE o_ \ ^ ecu, c w7 "7 lM# .#■. w do Aavaan ivnouvn SNiDiasw do Asvaan ivnouvn NATIONAL LIBRARY OF MEDICINE 3NOIQ3W do Aavaan ivnouvn a. 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