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PRINCIPLES OF PATHOLOGY,
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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.
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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
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