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A^l HWail IVNOIIVN 3NI3IQ3W dO A II V D I II IVNOIIVN 3NI3IQ3W dO A II V B I I 1 IVNOIIVN 3NI3 l|ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATI a RARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATI rat NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF ME o DUE LAST DATE v da u i*n JUN 15 19SB ARY OF ME nvmii ivi R ARY OF ME ABVBan IVI I BR ARY OF ME \A\ i y\A i \a\ \A\y \ \A i/K 3NI3I03W dO ABVBail IVNOIIVN 3NI3I03W dO ABVBBIT IVNOIIVN 3NI3I03W dO ABVBan TV *VS ' A^V^S I A>*A'\\A • X W^J .' v^m ~ y • X -'ir>&/ -" 'vjsxWv x 1 X -1 NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF M NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF ME ( PRINCIPLES OF PATHOLOGY PRACTICE OF MEDICINE. PRINCIPLES PATHOLOGY PRACTICE OF MEDICINE. BY JOHN MACKINTOSH, M.D., LECTURER ON THE PRACTICE OF PHYSIC IN EDINBURGH, &C. &C. &C. FOURTH AMERICAN, FROM THE LAST LONDON EDITION. Y WITH NOTES AND ADDITIONS, BY SAMUEL GEORGE MORTON, M.D., FORMERLY PHYSICIAN TO THE PHILADELPHIA HOSPITAL; AUTHOR OF ILLUSTRATIONS OF PULMONARY CONSUMPTION, &C.&C. PHILADELPHIAt^ LINDSAY AND BLAK1ST0N. 18 4 4. /g44 Entered according to Act of Congress, in the year 1844, by LINDSAY & BLAKISTON, in the Clerk's Office of the District Courtof the United States, for the Eastern District of Pennsylvania. T. K. & P. G. Collins, Printers. TO HENRY WARBUETON, Esq., M.P. &C. &C. &c. THIS WORK IS INSCRIBED, AS AN HUMBLE TRIBUTE OF RESPECT AND GRATITUDE FOR THE GREAT BOON CONFERRED ON THE MEDICAL PROFESSION BY THE ANATOMY BILL, OBTAINED THROUGH HIS INDEFATIGABLE EXERTIONS ; AND FOR THE IMPARTIALITY, TALENT AND ASSIDUITY WITH WHICH HE, AS CHAIRMAN OF THE SELECT COMMITTEE OF THE HOUSE OF COMMONS, HAS CONDUCTED THE ARDUOUS INVESTIGATION INTO THE STATE OF MEDICAL EDUCATION, AND WHICH HAS EXCITED THE ADMIRATION OF PERSONS OF ALL PARTIES, BY THE AUTHOR. « TO SIR JOHN WEBB, K. C. II. DIRECTOR-GENERAL OF THE ORDNANCE MEDICAL DEPARTMENT, &c. &c. &c. My Dear Sir, In presenting you with two of the preceding editions of this work, I can say, with truth, that I was actuated solely by a desire of perpetuating a record of my esteem for your public and private worth, and of my gratitude for the many acts of kindness received from you in the course of more than twenty-five years, during which period I have had the pleasure and honour of enjoying your friendship. It is with no small degree of satisfaction that I take this oppor- tunity of again dedicating the Fourth Edition to you, in conjunction with Mr. Warburton, believing that it will not be the less acceptable on that account. I am, My Dear Sir, Your faithful and obliged Servant, JOHN MACKINTOSH. PREFACE TO FOURTH EDITION. The original object of this work was to provide those gentlemen who did the author the honour of attending his lectures, with a Text- Book, in the hope that it might be found useful to them in prosecut- ing their studies. For some time 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 labours 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 an humble attempt to establish a pathological system of medicine." [Preface to First Edition.) The success of this work has far surpassed the author's sanguine expectations; three large editions having been disposed of in the course of six years. In offering a fourth edition to the profession, the author, very sensible of the respect due to its members, and of the flattering man- ner in which the work has been received, has taken every precaution to render it worthy of a continuance of their patronage. It is con- siderably enlarged—the import of every paragraph has been well considered, many errors have been corrected, and the size of the type and the quality of the paper have been materially improved. He was so well aware of the imperfections of the work, that he courted the remarks of several friends, well qualified by their learn- ing, experience and ability, to undertake such a task ; he has availed himself of their written and oral criticisms, and endeavoured to turn them to the best advantage. The author stands particularly in- debted 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 inductive reasoner and an admirable critic. If all his sugges- tions have not been adopted, more particularly as to pursuing an abstract style of writing, 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, carefully collected and examined—he lays no claim to be con- sidered 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 diseases. He has been very sparing in the int^duction of hypothetical discussions, and when he has attempted to explain or establish any point by reason- ing, he trusts it will be found for the most part to be strictly inductive. B X PREFACE. 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 ot a profession of such unbounded importance to mankind, he has ever felt himself called upon, by the combined influence of reason and humanity, to treat professional statements, theories and practices in the most unreserved manner. No duty is more incumbent on a me- dical writer, on whose labours the lives and happiness of thousands 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 accused of bestowing praise from personal friendship, nor of condemning from personal animosity. He will never be ashamed or backward to confess an error, and he will feel no reluctance 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 has given the best proof of the candour which actuates his conduct in the article on cholera, in which he has felt himself obliged to repudiate all the opinions he entertained, when writing the former editions. The author 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 medical men can bear to know that the soundness of their opinions has been questioned; 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 always 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, j. But the author cannot believe the existence of real dignity and good feeling, where there is such a deplorable want of high-mindedness and moral courage:— besides which, these pages are written exclusively for the profes- sional, and not for the public eye. It cannot be denied that practi- tioners in medicine stand too low in the scale of public estimation, and that "something is rotten in the state of Denmark." But the author trusts soon to see an important change in the profession, the first steps towards which must be a considerable modification of corporation privileges, and a greater degree of care and discrimina- tion on the part of those who teach the different branches of medi- cine, in exciting industry and zeal among their pupils, and inducing them, by precept and example, to regard the profession of medicine more as a science, and the blessed means of doing good, than as a corrupt jobbing trade. Much substantial good might also be effected by examinators for medical diplomas, were they to feel that their own personal honour depended more on the high moral and profes- sional qualifications of the gentlemen admitted into the profession than on the amount of fees received. The facility of granting medical degrees in all the universities of PREFACE. XI Scotland, has been quite disgraceful. It would not be difficult to point out many persons who would be puzzled to conjugate a verb or decline a noun in any of the dead or living languages, and who could not, if their lives depended on the result, write or even speak their mother-tongue correctly, who, nevertheless, have had the credit of writing a long and elaborate Latin essay, and have successfully gone through a hocus-pocus examination before learned professors! This trade of granting degrees in physic on the part of the Univer- sity of Edinburgh, attracted the attention of the members of the Royal Commission appointed by his majesty to inquire into the state of the Universities in Scotland, who were astonished at the small increase of students, compared with the large increase of gradu- ates during the course of twenty years, from 1806 to 1826. At page 167 of the Appendix to the General Report, the Commissioners state, "that the increase from 1306 is very great, and cannot be accounted for by an increase of medical students; for, in 1806, the number was 764, and in 1826, only 896, that is, there was an addition of 132 students, but this bears no kind of proportion to the multiplication of degrees from 37 (in 1806) to 118 (in 1S26)." But with all due submission to the honourable commissioners, the result can be easily explained. The first principles of natural philosophy, which slum- bered in other places, advanced rapidly in the University of Edin- burgh after the year 1806 ;—a strong desire had prevailed to discover the philosopher's stone—this, it is well known, failed; but the Edin- burgh professors soon arrived at that supreme degree of mental per- fection, to find out the value of the precious metals, which they after- wards manufactured in a wholesale manner, by converting pieces of parchment into gold. It was not every professsor that was considered sufficiently skilled in philosophy to entitle him to participate in the handsome pecuniary dividend—no ! no ! Here, again, there was a monopoly confined to six professors, who would not permit the others to share the spoil. But as this transaction may not be credited, the author will quote another passage from the same Report: "It does appear quite unreasonable, that when there are belonging to the university a number of professors, who must be supposed equally skilled in medical science, there should be a monopoly of examina- tions to a particular part of them, apparently for no other purpose than that the persons so favoured may receive the addition to their emoluments arising from the fees paid to the examiners" (Page 167.) There is, likewise, a curious circumstance in the history of the Scotch universities. It is well known, that of these, St. Andrew's and Aberdeen had been in the habit of granting medical degrees upon certificates from qualified persons in the profession, without the personal appearance of the candidate, and consequently without the safeguard to the public of an examination. This was done for ages, and no public remonstrance was made from any quarter. The Uni- versity of Edinburgh went on with her monopoly and disreputable practices, and she quietly allowed the sister institutions to do as they pleased. But in the year 1833, the University of St. Andrew's, (simultaneously with the Universities of Oxford and Cambridge), XII PREFACE. remodeled her laws, reduced the graduation fees to the same standard as Edinburgh, improved the course of study and appointed compe- tent examiners, which satisfied the public that none but well quali- fied persons could obtain a degree at that university. But it did not satisfy the professors of the University of Edinburgh that it would not destroy their monopoly and rob them of their "loaves and fishes." It cannot be too extensively known, that the University of Edin- burgh allowed a system, injurious to the public and derogatory to medical science, to continue for ages without uttering one word of complaint; yet no sooner was an excellent system established, a system avowedly better than her own, then she commenced a war of agitation, by which she intended to shake the very walls of Wind- sor Castle, if his majesty would not put an extinguisher upon the St. Andrew's examiners. Memorials were drawn up, petitions were presented, the highest law authorities were retained ; other universi- ties and colleges were enlisted in the unholy cause; by an intrigue, the College of Surgeons of Edinburgh was induced to join hands in the crusade, and petition the king in council to do an illegal act. But the triumph of justice has been complete. Many persons of con- siderable eminence and of high moral worth repaired to St. Andrew's in the mean time, and having undergone strict examinations, received their degrees. The result has been, that a plan nearly similar to that of St. Andrew's has, it is believed, been adopted in London by the king and council, who by charter established a central board of ex- aminers, to grant medical degrees to all candidates who may be found well qualified, whether they have acquired their medical education within or without the walls of a university, that is, under professors or lecturers. Thus, aided by accidental circumstances, has the author, by devis- ing and planning the improvements adopted by the University of St. Andrew's, succeeded in destroying the most odious monopoly that ever disgracedJBritish legislation. The author feels that he is justi- fied in applying the term "odious monopoly," to any system that retards the progress of that science upon which the health and hap- piness of every one depend. The author trusts to the wisdom of Parliament for the speedy enactment of more liberal and equable laws respecting medical edu- cation ; the adoption of a uniform system for all the schools; and a more rational mode of granting degrees in universities. It is to be hoped that the new institutions, which must, as a matter of course follow the recently chartered establishment in London for the grant- ing of degrees, will be formed upon similar principles. Edinburgh, 31 Albany Street. PREFACE TO THE FOURTH AMERICAN EDITION. The high estimation in which Dr. Mackintosh's Practice of Medi- cine is held both in this country and in Europe, is sufficiently attested by the fact that it is now published for the eighth time, four editions having appeared in England and four in the United States. In presenting it again to the medical profession, I have inserted various materials which, but for the untimely and lamented death of the author, would have been far more ably supplied by his own hands; and, in the prosecution of this task, my object has been to express myself with brevity, ratRer than to embarrass the work with unnecessary details. All the added parts are enclosed in brackets; and I have been careful to preserve the original text entire, excepting a part of the cases illustrative of the treatment of intermittent fevers by bleeding in the cold stage: but as the author's own judgment led him to omit these cases in his early editions, and, as they were finally inserted merely to sustain a controversy on a point of practice which has few or no advocates*in this country, I have regarded them as superfluous, and have therefore omitted them. The section on the "Physiological Doctrines" has been retained, with slight alterations, as originally prepared by my friend Dr. Joseph Carson, and published in the former American editions. For, although these views and the practice which was based upon them are fast becoming obsolete in this country, their popularity is of so recent a date as to form an important feature in the medical history of our own times, while it still exerts its influence on the minds of many practitioners. It gives me pleasure to add, that, in the last letter I received from Dr. Mackintosh, written a short time previous to his death, he ex- pressed his entire approbation of the manner in which I had edited B* xiv PREFACE TO THE FOURTH AMERICAN EDITION. his work, and his gratification at the flattering reception it had met with by the medical public of this country. I much regret that Prof. Chapman's " Lectures on the more im- portant Diseases of the Thoracic and Abdominal Viscera," did not come to hand until the corresponding parts of the present volume were already prepared for the press; or I should more frequently have availed myself of a work which embraces forty years' expe- rience of a gentleman who, by common consent, stands at the head of his profession in the United States. S. G. M. Philadelphia. August 26, 1844. CONTENTS. Paee PART I.—GENERAL HISTORY OF INFLAMMATION AND FE- VER—WITH THE PATHOLO- GY AND TREATMENT OF IN- DIVIDUAL FEVERS. Chap. I.—Doctrines, Causes, Phe- nomena and Effects of In- flammaton. General Doctrines which have prevailed respecting Inflam- mation, 15 Causes of Inflammation, 21 Division of Inflammation into varieties, 23 Phenomena of Inflammation, 23 Terminations of Inflammation, with a short account of the Effects of Inflammation on the principal Tissues, 25 Chap. II.—On Fever, 30 History of the General Doctrines of Fever, 30 [Physiological Doctrines,] 36 Division of Fevers, 50 General Description of the Phe- nomena of Fevers, 51 Causes of Fever, 56 Chap. III.—Intermittent Fever, 68 Appearances found on Dissec- tion, 69 Causes of Intermittents, 72 Pathology of Intermittents, 85 Treatment of Intermittents, 91 Chap. IV.—Malignant, Remittest or Yellow Fever, 99 Appearances found on Dissec- tion, 102 Treatment, 107 Infantile Remittent, 112 Appearances on Dissection, 113 Treatment, 114 Chap. V.—Continued Fever, 116 Fever from Functional Derange- ment, 117 Treatment, 118 Fever from Inflammation, 120 Treatment of Inflammatory Fe- ver, 122 Congestive Fever, 125 Pathology of Congestive Fever, 127 Treatment of Congestive Fever, 128 Page Mixed Form of Fever, Typhus and Synochus, 130 [Typhoid Fever,] 134 Hectic Fever, 141 General Pathology of Eruptive Fe- vers, 143 Scarlet Fever, 148 Appearances on Dissection, 153 Treatment, 153 Measles, 158 Appearances on Dissection, 162 Treatment, 163 Small-Pox, 164 Appearances on Dissection, 166 Treatment, 167 Modified Small-Pox, 168 [Varioloid,] 168 [Cow-Pox and Vaccination,] 171 Chicken-Pox, 176 Miliary Fever, 177 Roseola, ' 178 Urticaria, 179 The Plague, 181 PART II.—DISEASES OF THE ORGANS CONNECTED WITH THE DIGESTIVE SYSTEM. Chap. I.—Difficult Dentition, 188 Chap. II. — Difficult Deglutition from Inflammation, Ulce- ration and Enlargement of the Tongue; Ctnanche Tonsillaris; Ctnanche Pharyxgea; Inflammation and Ulceration of the GEsophagus, 192 [Mumps,] 191 Cynanche Tonsillaris, 195 Inflammation of the Uvula, 197 Inflammation of the Pharynx, 198 Inflammation and Ulceration of the CEsophagus, 198 Chronic Affections of the Oeso- phagus, 199 [Diptheritis,] 200 Chap. III.—Indigestion, 201 Flatulency and Tympanitis, 205 Pyrosis or Water-brash, 205 Heartburn, 206 Gastrodynia, 206 CONTENTS. Page Chap. IV.— Discharges of Blood from the Stomach and Bowels, 208 1. Haemorrhage from the Stomach, 208 2. Haemorrhage from the Bowels, 210 Piles, 212 Chap. V.—Common Colic; Pain- ters' Colic; Ileus; Intus- susception; Intestinal Concretions; Prolapsus Ani; and Constriction of the Rf.ctum, 214 Common Colic, 214 Painters' Colic, 216 Appearances on Dissection, 217 Treatment, 218 Ileus, 220 Appearances on Dissection and Pathological Remarks, 220 Treatment, 222 Intussusception, 223 Intestinal Concretions, 224 Prolapsus Ani, 225 Constriction of the Rectum, 226 Chap. VI.—Intestinal Worms, va- rieties of, 227 Symptoms and Treatment, 229 Chap. VII.—Inflammatory Affec- tions of the Organs con- tained within the cavity of the Abdomen, 232 General Remarks on Inflamma- tion, 232 Enteritic Inflammation, 234 Peritonitis, 235 Pathology, 236 Treatment, 236 Puerperal Peritonitis, vulgarly called Puerperal Fever, 237 Appearances on Dissection, 239 Pathological Remarks, 240 Treatment, 241 Comparative Results of do., 243 Chronic Peritonitis, 249 Appearances on Dissection, 251 Treatment, 252 General Remarks on Inflamma- tion of the Mucous Mem- brane of the Stomach and Bowels, 253 Inflammation of the Mucous Mem- brane of the Stomach, 259 Appearances on Dissection, 260 Treatment, 261 Inflammation of the Mucous Mem- brane of the Bowels, 261 Treatment, 263 Chronic Inflammation of the Mu- cous Membrane, 263 Diarrhoea, 264 Treatment, 265 Bowel Complaints of Children, 267 Treatment, 269 Tabes Mesenterica, 270 Page Dysenterv, 27 Symptoms of Chronic Dysen- tery, 272 Appearances on Dissection, with Pathological Remarks, 273 Treatment, 277 1st. Treatment as it occurs in this country, 277 2d. Treatment as it occurs in warm climates, 278 Treatment of Chronic Dysen- tery, 28t Cholera, 282 Cholera Morbus, 282 Treatment, 283 Asiatic Cholera, 284 [Geographical Sketch,] 284 Phenomena, 289 Causes, 293 Morbid Appearances, 296 Morbid Appearances—Collapsed Stage, 227 Morbid Appearances—Third Stage, 301 Pathological Remarks, 303 Treatment, 305 For First Stage, 306 For Second Stage, 308 For Third Stage, 310 Saline Injection, 311 Inflammation of the Muscular and Cellular Tissues, 318 Scirrhus of Stomach and Intes- tines, 320 Symptoms of Cancer in the Stomach, &c, 321 Treatment, 323 Chap. VIII.—Diseases of the Liver and Spleen, 324 Inflammation of the Liver, 324 Symptoms of Acute Hepatitis, 324 Symptoms of Chronic Hepatitis, 326 Appearances on Dissection, 327 Treatment, 328 Jaundice, 331 Treatment, 332 Gall-Stones, 332 Inflammation of the Spleen, 334 PART III.—DISEASES OF THE ORGANS CONNECTED WITH THE RESPIRATORY SYSTEM. Chap. I.—General Remarks, 345 Chap. II.—Diseases affecting thh Mucous Membrane of the Air-Passages, 352 Catarrh, 353 Treatment, 353 Bronchitis, 353 Chronic Bronchitis, 357 Stethoscopic Signs of Acute and Chronic Bronchitis, 358 CONTENTS. Page Appearances on Dissection, and Pathological Remarks, 359 Treatment of Acute Bronchitis, 361 Treatment of Chronic Bron- chitis, 363 Inflammation of the Larynx, 366 Croup, 368 Appearances on Dissection, 369 Pathological Remarks, 370 Treatment, 371 CEdema Glottidis, &c. 374 Crowing Disease, 377 Treatment, 377 Hooping-Cough, 378 Appearances on Dissection, 380 Pathological Remarks, 382 Treatment, 385 Chap. III.—Pneumonia, 390 Stethoscopic Signs, 392 Appearances on Dissection, 393 Treatment, 395 Chap. IV.—Pleuritis, 400 Stethoscopic Signs, 401 Appearances on Dissection, 401 Treatment, 403 Chronic Pleuritis, 404 Empyema, 405 [Pneumothorax,] 406 Chap. V.—Haemoptysis, 407 Appearances on Dissection of first variety, 408 Treatment of first variety, 408 Symptoms of second variety, 408 Appearances on Dissection of second variety, 409 Treatment of second variety, 411 Chap. VI.—Phthisis Pclmonalis, 414 Stethoscopic Signs, 415 Appearances on Dissection, 418 [Pathology of Phthisis,] 420 Treatment, 426 [Change of Climate,] 430 Description of more rare struc- tural derangements found in the lungs, viz., bodies of a cartilaginous, bony, calcu- lous and chalky nature, 432 Melanosis of the Lungs, 433 Medullary Sarcoma of the Lungs, 436 Chap. VII.—Asthma, 439 Pathology, 440 Treatment, 442 PART IV.—DISEASES OF THE CIRCULATING SYSTEM. Chap. I.—General Remarks, 450 [Morbid conditions of the blood,] 458 [Of the blood in plethora,] 459 [--------- in anaemia,] 459 [---------- in fevers,] 460 [---------- in inflammation,] 461 [---------- haemorrhage,] 462 Page [Of the blood in dropsies,] 462 [---------in organic dis- eases,] 462 [---------in the neuroses,] 463 Chap. II.—Palpitation, &c, 465 Angina Pectoris, 467 Appearances on Dissection and Pathological Remarks, 470 Treatment, 471 Chap.III.—Pericarditis and Cardi- tis, 475 Appearances on Dissection, 477 Treatment, 479 Carditis, 480 Appearances on Dissection, 480 Treatment, 481 [Endocarditis,] 482 Chap. IV. — Hypertrophy of the Heart, 484 Stethoscopic Signs of Hypertro- phy of the Left Ventricle, 485 Stethoscopic Signs of Hypertro- phy of the Right Ventricle, 485 Treatment of Hypertrophy of the Heart, 486 Chap. V.—Dilatation of the Heart, 490 Stethoscopic Signs of Dilatation of Left Ventricle, 492 Stethoscopic Signs-of Dilatation of Right Ventricle, 492 Tuberculous Formation, 493 Atrophy of the Heart, 494 Rupture of the Heart, 495 Chap. VI.—Diseases of the Valves, 497 Appearances on Dissection, 497 Symptoms, 498 Stethoscopic Signs of Diseases of the Valves, 498 Treatment, 499 Chap. VII.—Diseases of the Blood- vessels, 500 Ossification of the Arteries, 502 Aneurism, 503 Treatment, 506 Inflammation of Veins, 506 Symptoms, 507 Phlegmasia Dolens, 507 Pathological Observations, 509 Treatment, 510 Chap. VIII.—Plethora and Exsan- guinity, 512 Plethora, 512 Causes, 512 Treatment, 513 Exsanguinity, 513 Treatment, 515 Chap. IX.—Cyanosis or Blue Skin, 517 Symptoms, 517 Pathological Opinions, 517 Treatment, 518 PART V.—DISEASES OF THE BRAIN, AND OTHER PARTS OF THE NERVOUS SYSTEM. XV111 CONTENTS. Page Chap. I.—General Remarks on Dis- eases of the Brain, &c. 521 Chap. II.—Inflammation of the Membranes of the Brain as it occurs in Adults.— Inflammation of the Brain, which terminates in Suppu- ration and Ramollissement. Inflammation of the Mem- branes of the Brain as the Disease occurs in young subjects, commonly called Hydrocephalus, 534 Inflammation of the Membranes as it occurs in Adults, 534 Phenomena, 535 Causes, 538 Appearances on Dissection, 539 Treatment, 541 Inflammation of the Substance of the Brain, 546 Symptoms, 546 Causes, 549 Appearances on Dissection, 549 Treatment, 551 Acute Hydrocephalus, 557 Appearances on Dissection, 558 Pathological Remarks, 561 Treatment, • 562 Chronic Hydrocephalus, 564 Appearances on Dissection, 564 Treatment, 565 Chap. III.—Diseases of the Spinal Marrow, 566 Inflammation of the Spinal Mar- row and its Membranes, 566 Symptoms, 566 Causes, 567 Appearances on Dissection, 567 Treatment, 567 [Spinal and Ganglionic Irritation,] 568 Tetanus, 571 Symptoms, 572 Causes, 573 Appearances on Dissection, 574 Treatment, 575 Trismus Nascentium, 575 Hydrophobia, 576 Symptoms, 577 Appearances on Dissection, 577 Treatment, 577 Chap. IV.— Epilepsy — Hysteria— Chorea — and Neuralgic Pains, 578 Epilepsy, 578 Symptoms, 579 Causes, 579 Appearances on Dissection, 580 Treatment, 583 Hysteria, 584 Symptoms, 585 Causes, 585 Treatment, 586 Chorea, 587 Causes, Treatment, Neuralgic Pains, Causes, Treatment, Chap. V.—Apoplexy and Paralysis, Apoplexy, Symptoms, Causes, Appearances on Dissection, Treatment, Paralysis, Symptoms, Causes, Treatment, Chap. VI. — Insanity — Hypochon- driasis — and Delirium Tremens, Insanity, Causes, Appearances on Dissection, Treatment, Hypochondriasis, Causes, Treatment, Delirium Tremens, Page 587 587 589 590 591 592 592 594 594 595 596 596 598 598 598 601 601 602 604 605 609 610 610 611 PART VI.—DISEASES EYE AND EAR, OF THE 619 Chap. I.—General Remarks on Dis- eases of the Eye, 619 Symptoms of Ophthalmic In- flammation, 620 Causes of Ophthalmic Inflam- mation, 621 Treatment of Ophthalmic Inflam- mation, 622 Chap. II.—Inflammation of the Con- junctiva, 627 Simple Inflammation of the exter- nal covering of the Eye, 627 Symptoms, 627 Treatment, 628 Simple Cartarrhal Ophthalmia, 628 Symptoms, 629 Treatment, 629 Purulent Ophthalmia of Infants, 630 Symptoms, 631 Causes, • 632 Treatment, 633 Pustular Ophthalmia, 636 Treatment, 636 Chap. III. — Inflammation of the Eyeball, 637 Inflammation of the Sclerotic Coat, 637 Inflammation of the Iris, 637 Causes, 638 Treatment, - 639 Amaurosis, 641 Causes, 641 Symptoms, 641 Treatment, 642 CONTENTS. xix Page Chap. IV.—Diseases of the Ear, 644 Otitis, 644 Causes, 644 Treatment, 645 Otorrhcea, 646 PART VII.—DISEASES OF THE SKIN, 649 Chap. I.—General Remarks on Dis- eases of the Skin, 651 Classification of Diseases of the Skin, 651 Chap. II.—Erysipelas, 652 Symptoms, 652 Causes, 654 Appearances on Dissection, 656 Pathological Remarks, 658 Treatment, 666 Chap. III.—Papular Diseases, 672 Strofulus, 672 Treatment, 672 Lichen, 673 Treatment, 673 Prurigo, 673 Treatment, 673 Chap. IV.—Pustular Diseases, 675 Impetigo, 675 Causes, 675 Treatment, 676 Porrigo, 677 Treatment, 677 Scabies, or Itch, 681 Causes, 682 Treatment, 682 Ecthyma and Rupia, 682 Causes, 683 Pathology, 683 Treatment, 683 Acne, 684 Causes, 684 Treatment, 684 Sycosis, 685 Treatment, 685 Chap. V.—Squamous Diseases, 686 Lepra, 686 Causes, 687 Treatment, 6S7 Psoriasis, 689 Treatment, 690 Pityriasis, 691 Causes, 692 Treatment, 692 Chap. VI.—Vesicular Diseases, 693 Herpes, 693 Causes, 694 Treatment, 694 Pemphigus and Pompholyx, 695 Chap. VII.—Purpura, 696 Causes, 703 Appearances on Dissection, 704 Pathology, 705 Treatment, 706 Exudation of blood from the sur- face, without abrasion of the cuticle, commonly called " bloody sweat," 708 PART VIII.—DISEASES OF THE URINARY AND GENITAL OR- GANS. Chap. I.—Inflammation of the Ure- thra, Bladder and Kidneys, 713 Inflammation of the Urethra, 713 Symptoms, 713 Appearances on Dissection, 715 Treatment, 716 Inflammation of the Mucous Mem- brane of the Bladder, 718 Causes, 719 Treatment, 719 Inflammation of the Kidney, 720 Symptoms, 721 Treatment, 721 Albumenuria, 721 Chap. II. — Calculus in Kidneys, Bladder, and other parts of the Urinary Passages, 724 Chemical characters of Urinary Calculi, 724 Calculus in the kidney, 727 Symptoms, 727 Treatment, 728 Calculus in the Bladder, 729 Symptoms, 729 Treatment, 729 Calculus in the Urethra, 730 Calculus embedded in the Prostate, 730 Chap. III. — Suppression of Urine, Retention of Urine, In- continence of Urine, 731 Suppression of Urine, 731 Treatment, 732 Retention of Urine, 735 Treatment, 735 Incontinence of Urine, 725 Chap. IV.—Hematuria, or Discharge of Blood from the Urinary Passages, 736 Treatment, 736 Chap. V.—Diabetes, 739 Symptoms, 740 Appearances on Dissection, 741 Causes, 741 Pathology, 741 Treatment, 742 Chap. VrI.—Syphilis, 747 Symptoms, 748 Treatment, 749 Chap. VII.—Diseases of the Labia, an d External Parts in the Female, 757 Phlegmon, 757 Symptoms, 757 Treatment, 757 XX CONTENTS. Peculiar Affection of the Pudendum, occurring in young subjects, 759 Treatment, 760 Chap. VIII. — Inflammation of the Testes, Treatment, CHAp. IX.—Diseases of the Uterus, connected with Inflamma- tory action Inflammation, of the Uterus after delivery, Inflammation of the Os and Cervix Uteri in the ordinary state of the system, Treatment, Vascular Sarcoma of the Uterus, Treatment, Scirrhus and Cancer of the Uterus, 769 Treatment, 770 Chap. X.—Prolapsus of the Uterus —Retroversion of the Uterus—Polypus of the Vagina and Uterus, Prolapsus of the Uterus, Causes, Treatment, Retroversion of the Uterus, Causes, Treatment, Polypous Tumours of the Vagina and Uterus, Treatment, Chap. XI.—Tubercles of the Uterus — Bony Concre- tions—Hydatids,Aq.ueous and Flatulent Discharges,777 Tubercles of the Uterus, 777 Treatment, 778 Bony Concretions, 778 Treatment, 779 Hydatids, 779 Aqueous and Flatulent Discharges, 780 Chap. XII.—Fluor Albus and Leu- corrhosa, 780 Symptoms, 781 Causes, 782 Treatment, 782 Chap. XIII.—Diseases of Menstrua- tion, 785 Amenorrhoea, 785 761 761 763 763 765 766 767 768 772 772 772 772 773 773 773 774 776 Retention of the Menses, Causes, Treatment, Suppression of the Menses, Treatment, Dysmenorrhoea, or Painful and Difficult Menstruation, Pathological Remarks, Treatment, Immoderate Flow of the Menses, Treatment, Menorrhagia, Causes, Treatment, Cessation of the Menses, Treatment, Chap.XIV.—Diseases of the Ovaria Symptoms, Treatment, Pa?e 785 789 791 791 791 792 794 795 798 798 798 799 800 804 805 ,806 806 809 PART IX.—GOUT —RHEUMA- TISM—SCROFULA—DROPSY, 817 Chap. I—Gout, 817 Phenomena of a Paroxysm of Regular Gout, 818 Phenomena of Chronic Gout, 822 Phenomena of Retrocedent Gout,824 Causes of Gout and Pathological Observations, 827 Treatment, 831 Management of Gouty Subjects during the intervals, 834 837 837 837 839 842 843 845 848 853 853 872 872 872 873 873 873 Chap. II.—Rheumatism Acute Rheumatism, Symptoms, Treatment, Chronic Rheumatism, Rheumatic Gout Chap. III.—Scrofula, Treatment, Chap. IV.—Dropsy, General Remarks, Anasarca, Treatment, Hydrothorax, Stethoscopic Signs, Treatment, Ascites, PART I. GENERAL HISTORY OF INFLAMMATION AND FEVERS.- WITH THE PATHOLOGY AND TREATMENT OF INDIVIDUAL FEVERS. 2 • ;*>- CHAPTER I. ON INFLAMMATION. HISTORY OF THE GENERAL DOCTRINES, CAUSES, PHENOMENA, AND EFFECTS OF INFLAMMATION. In the history of Medical Science, we find 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 subject—to the frequent occur- rence of inflammation—and to the wide range of diseases which owe their origin to this morbid action. According to many authors, inflammation and fever are thought to be mere modifications of the same pathological state of the system, while others speak of them even as synonymous 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 labours 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 regard- ing some of the phenomena as principal parts of the essence of inflammation. A great mistake has also been committed by medical inquirers following out an erroneous method of investigating dis- eases, forming false analogies, 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 of the symptoms hitherto universally attributed 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 Boerhaave, because they were inconsistent with the know- ledge 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 excretions, and by 16 INFLAMMATION. heat, or the application of any other cause which dissipated the thinner parts of the blood, thereby producing viscidity. When this thickened state of the blood did not exist before the production oi inflammation, he imagined that the larger globules of the blood f°u"d their way by some accident into the capillaries, and produced ob- struction. But when the perspiration, the flow of urine, or any of the other excretions were suppressed, then he supposed the capil- laries 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 of inflammation—viscidity of the blood, and an error loci, either of which he supposed capable of producing an obstruc- tion in the circulation of a part, giving 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 account more satisfactorily for the morbid terminations which occasionally happen, and therefore brought into play the humoral pathology, by stating that there is sometimes an acrimonious state of the fluids, which tends to produce gangrene. That part of his doctrine relating to viscidity cannot support the phenomena; 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 inflamed 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 difficulty is increased, when we reflect, that vessels frequently cir- culate red particles, which usually contain a colourless 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 humoral pathology declined Boerhaave's doctrines began also to lose ground, although the phenomena of in- flammation were, in many cases, ingeniously explained by their as- sistance; and it must be confessed that we have abandoned this doc- trine, 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 inflammation. On this occasion, little need be said respecting the views of these celebrated men, as it will be necessarv 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 inflam- mation, that almost every individual labourer in this field of investi- gation has adduced the same, or nearly the same doctrines, to explain the phenomena of both. Hence the pretty general belief'as to their identity. But it will soon be my duty to offer many reasons for dis- senting from this too sweeping pathology. INFLAMMATION. 17 This slight notice of the opinions of Boerhaave, Stahl and Hoffman, is sufficient to enable me to connect their views with those of modern date. The doctrines taught by Cullen were founded upon those of the last three physicians. He admitted the obstruction so much in- sisted 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 appli- cation of boiling water, blisters, and other stimuli. The only observation it appears necessary to make, 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 re- marked 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 inflammation, 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 showing, the spasm is occasioned by an accumulation of blood in these vessels. According to John Hunter, inflammation is to be considered only as a distracted state of parts, which requires another mode of action to restore them to a state of health; or, in other words, that inflam- mation 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 vessels, which consists sim- ply, in the first instance, in a distension beyond their natural 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-ves- sels 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 debility 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 opinions upon microscopical experiments performed on the web of the frog's foot. Each observed the same phenomena, but they have drawn different conclusions. Dr. Thomson, for instance, applied salt to a frog's foot; the first effect was to increase the velocity of the circula- tion, and to make the vessels larger to the naked eye, and of a brighter red colour. After the stimulant had been continued some time longer, 2* 18 INFLAMMATION. the red globules became «less distinct than before the application of the salt, and obviously less distinct from the rapidity of their mo- tion." _,, Dr. Wilson Philip performed experiments, prior to Dr. Inomson, on the frog's foot; and having first proved that he could create in- creased action in the capillaries without exciting inflammation, hap- pened to meet with one unfortunate 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 greatest, 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 spirit, 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 ap- plication of the spirits." No wonder. Distilled spirit 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 evaporation 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, cor- roborating 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 hap- pened, 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 inflamed 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 this 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 inflammation,* is the most correct. 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 al- tered functions of the part. Mr. Syme justly thinks, that " if this remarkable character of inflammation had been kept in mind, patho- logists would hardly have spent so much labour in disputing about contraction and dilatation of the vessels, since it is obvious, that mere difference of capacity, though it might, to a certain extent account * Published in Edinburgh Med. and Surg. Journal, vol. 30, p. 316. INFLAMMATION. 19 for the redness and swelling, could never enable us to explain the alteration of function, any more than a knowlege of the size of capil- lary vessels could instruct us as to the mode in which their secre- tions, &c, are performed during health."—And he maintains, that " redness and swelling ought to be secondary considerations in the investigation of the inflammatory state, in comparison with the grand distinguishing character of altered function." Three points seem to have been much overlooked by writers on inflammation. 1st, The influence of the nervous system; 2d, The changes in the qualities of the blood itself; and 3d, The disordered functions of the capillaries. I have performed experiments upon horses, which prove most satisfactorily the influence of the nerves, 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, which have been lame for months, cured by divid- ing 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 flocculent 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 nutrition and exhala- tion, and at the same time a stop being put to the conversion of arte- rial into venous blood. It has been long known, that increased action of the vessels does not constitute 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 human 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 accu- mulate, 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 in- flammation 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 arterial blood; this increases the embarrassment in all organs—hence the general constitutional disturbance. In the practice of physic this last circum- stance is too frequently overlooked. Physicians are apt to expect a cessation of the constitutional 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 con- demned for it by our continental brethren. Other physicians, again, do very great mischief by stimulating and throwing in bark and other 20 INFLAMMATION. 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 occur in which a more immediate change of treatment may be necessary; all that is wished to be impressed upon the reader in this part of the work, is, that such practice is too often had recourse to, more from an unfounded dread of the occur- rence of " 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 partly 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 consequence 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 number which con- tain red blood is greatly increased. It must be confessed, that in inflammation there is much undis- covered. Physiologists have to settle several disputed points in the doctrines of the circulation; and anatomists have to discover a great deal regarding the anatomy and physiology of the capillary and nervous systems, before pathologists can be expected to advance their part of the science of medicine in any remarkable degree. Considerable difference of opinion still exists among physiolo- gists, 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 possess 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 a much smaller diameter 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 in the body, and at the greatest possible distance from the heart, be divided, the blood will be perceived to flow per saltum the jets corresponding to the actions of the heart. As to the second point, if the extreme vessels are quiescent, not possessing any power of action 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 effected through the agency of the heart, bV the con- tractions of which the blood is propelled into the vessels generally INFLAMMATION. 21 it can, in all probability, have no power to send blood to one part, in preference to another. The results of experiments lead me to believe that some notable errors or oversights have been committed by Hunter, and many other experimenters upon the circulation. In the essay above alluded to, Mr. Syme, in endeavouring to refute the received notions respecting the circulation in the capillaries, 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 immovable, while the globules shoot through them in such a free, unconstrained manner, as to convince 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 account for it—but sometimes this way, some- times that—at one time quick, at another slow—and always con- tinuing quickest as well as longest in the smallest vessels. While in health, the motion of the blood is slowest in the capillaries." Having been an eye-witness to these experiments, I can add my testimony as to their correctness, and that every precaution was taken to guard against the possibility of any fallacy. Before concluding this subject, I beg to enter my protest against the employment of the term "debility," as too generally applied to the capillary vessels 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, be- cause 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 Inflammation. In stating the causes of inflammation, it is my intention to avoid adverting to occult causes. In medical investigations, it is very in- jurious to science to affect being overwise, 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 descanting 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 symptomatical 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 2-2 INFLAMMATION. 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 disease. One author, with whose writings most medi- cal men are well acquainted, in treating of the predisposing causes of hooping-cough, mentions, among others, "a serous temperament— a scrofulous constitution—dentition—a disposition to contract ca- tarrhal affections—the retrocession of eruptive diseases." The common causes in the production of internal inflammation are, exposure to cold; sudden vicissitudes of weather, particularly when the air is damp; irregularity of bowels; unwholesome diet; insufficient clothing; cold drinks, particularly when the body is warm ; depressing passions, &c. Almost all these causes tend to pro- duce inflammation in the same manner, by inducing irregular dis- tributions of the blood and venous congestion. The lost balance of the circulation is marked sufficiently well in the beginning of almost all acute diseases, by the accession of rigours, coldness, and paleness of the surface of the body. Some individuals are more liable to in- flammatory attacks than others, and some to inflammation of a par- ticular 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 application. Few persons escape inflammatory affections produced by specific causes. The contagion of small-pox is termed a specific cause, be- cause nothing is capable of producing the disease but its own conta- gion, in whatever way it is communicated. Measles is produced by a specific cause. Scarlatina also, and perhaps hooping-cough. Ery- sipelas is not to be ranked with these specific diseases, because it is not produced by a specific cause, as is too generally imagined. If erysipelas were produced twenty times, by inserting matter taken from an erysipelatous surface, expressly for the sake of experiment, still it cannot be ranked as a specific disease, because it has also fol- lowed an injury produced 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 in- flammatory affections, viz., malaria, sometimes denominated marsh miasm, and human effluvia, together with another and still more mysterious agent, epidemic influence. 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, particularly 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 phremtis will be the consequence; or to the lungs pro- ducing pneumonic inflammation, &c. Dr. Thomson, in his vvork on inflammation, states that this cannot be explained upon anv prin- ciple. The doctrine of determination of blood explains it so far and in my humble opinion quite far enough for all practical purposes' INFLAMMATION. 23 It is not, however, actual, but relative cold, which is so prejudicial to the human body; it is exposure to cold when the body has been pre- viously much heated. An individual, after sudden exposure to a cold damp atmosphere, may be attacked by inflammation of the lining membrane of the air passages. It becomes an interesting and important question to de- termine upon what part of the human frame the cold air acts. Dr. Thomson says, at page 57 of his work on inflammation: "In some instances, cold, or a diminution of temperature, seems to act more directly upon the parts with which it comes in contact. WTe have proof of this in the inflammation of the mucous membrane of the nose, fauces, trachea, and bronchiae, 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 that passes into the lungs, provided the body be sufficiently protected by warm clothing. In cold regions, if Dr. Thomson's hypothesis were true, an individual 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 and Captain Ross to the North Pole, enjoyed remarkably good health. There is another curious point which must be noticed. Extreme cold produces exactly the same sensations and the same effects upon the living animal fibre as intense heat. Take a piece of frozen mer- cury in the hand, and it will cause a sensation similar to that pro- duced by hot iron—inflammation and vesication follow; and if ap- plied 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, shall 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 em- ployed 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 ac- count the patient gives of his own sensations. Whereas in physic 24 INFLAMMATION. 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 may be violent vomiting, tenderness in the epigastrium, thirst, with more or less fever, while the disease is 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 com- plaints, the blood does not always yield it. The shape of the dish modifies this appearance, as does the manner in which the blood flows 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 considera- ble dependence, however, on the buffy coat, taken in connection with other circumstances, particularly when the surface is also con- cave, 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 destruc- tion 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. No pathological physician will join Dr. Gregory, a modern writer on the Practice of Physic, in the following dogmas: "Delirium marks inflammation of the brain; impatience of light, ophthal- mia; hoarseness, inflammation of the larynx; and dysp?ioea, 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 and erroneous assump- tions. The uncertainty of the pulse has been already mentioned. In- flammation 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 inflammations? The redness is occasioned, no doubt, by the enlarged * Blood is said to be « buffy," when the surface, instead of being of a reddish colour, presents a yellowish crust of greater or less thickness. There are various opinions as 10 the cause of this appearance. Some attribute it to the slower coS- lauon of the blood; others to an increased quantity of fibrine; or merely^o the hur ried state of the circulation. Of one fact I am ouite certain fmm rJnfif a u tions, that blood may be seen to be buffed wSlH is yif S'owW fr^m -d ohserv!i; before the stream has reached the cup. y fl°Wing from a vein> and INFLAMMATION. 25 size of the vessels, and the increased quantity of blood in the part affected. Vessels, which formerly 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 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 proba- bility, interrupted. Heat.—Boerhaave and others imagined that this symptom de- pended 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 doc- trines, 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 thermometer, but perhaps principally to dimi- nution 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 principally venous, in which case little complaint is made of pain. Terminations of Inflammation. Inflammation, (says John Hunter,) cseteris paribus, always pro- ceeds more favourably in strong than in weak constitutions; for, when there is much strength there is little irritability. In weak con- stitutions the operations of inflammation are backward, notwith- standing the part in which it is seated may possess, comparatively 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 labouring under internal inflammations, not because the diseased action has any peculiar tendency to terminate badly, but because the patients are too weak to bear the necessary remedies. In another place, Mr. Hunter remarks:—" It has been supposed that different species or varieties of inflammation arise from the dif- ference 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 3 INFLAMMATION. &c .........It is the adhesive in mem an, u me pa.^^- rAh~ h eether; it is the suppurative, if the parts are exposed. 1 his obser- vation, 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 gangrene." The first is, of course, the most desirable; 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 struc- ture 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 begins 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 cessa- tion of pain; the part, from being of a bright red colour, assumes a dusky hue; it crepitates from the extravasation of air in the cellular substance, vesications arise, a very peculiar odour is perceived, 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 following textures: 1. Skin. 2. Mucous membranes. 3. Cellular membrane. 4. Fibrous membranes. 5. Serous membranes. 6. 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, swell- ing and dryness; effusion of mucus, or of matter of a puriform cha- racter—a mixture of the two, appropriately termed muco-purulent; of a serous fluid, and coagulable lymph. These different products of inflammation are sometimes colourless, at others yellow, and some- times red like currant jelly. The mucous membranes are likewise liable to softening, thickening, passive haemorrhage, ulceration, con- traction, 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 INFLAMMATION. 27 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 bladder. Some parts of the mucous membrane of the same canal are more liable to inflammation and ulceration than others ; for instance, the termination of the ileum and the colon. Inflammation is more liable to terminate in the exudation 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 inflamma- tion having existed in the mucous membranes before death, because it may be found only in depending parts of the canals; and conges- tions 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 blood, 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 extensive and loose in its tex- ture, the disease tends to circumscribe itself by a sanatory process, 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 extensively, 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 affection is called carbuncle. 4. Inflammation of fibrous membranes. This is the tissue which is generally supposed to be affected in gout and rheumatism; the chief peculiarities are said to be, that it never terminates in suppu- ration, ulceration, or gangrene, and the functions of the brain are rarely disturbed during the course of the disease. It is said to ter- minate sometimes by effusion of a gelatinous nature, or deposition 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. All the phenomena and the terminations of these diseases, tend to con- firm a suspicion, that it is seated in the extremities of nerves, more particularly when we reflect upon the sudden metastases. At all events, it is rather strange 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 some may think, 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: at other times 28 INFLAMMATION. it looks like pus, and occasionally it is greenish, or resembles lees of wine ; often large masses of coagulable lymph are discovered gluing the parts together. Adhesions between the different viscera ot the thorax and of the abdomen seem to be effected by means ot inter- vening portions of lymph, which subsequently become organized. The quantity of the effused matter is sometimes small, amounting only to a few ounces, at others there are several pounds. I have seen ten, twelve, and even twenty pounds in one side of the chest. A bloody effusion is sometimes found, more particularly in the abdomen. Ecchymosis 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 inflam- mation of this class of membranes, more particularly in the perito- neum, pleura pulmonalis,* and arachnoid coat. Emphysema also occurs in the cellular tissue immediately under the peritoneum. It has been proved by experiment, that the peritoneum, however vascular under acute inflammation during life, loses its red appearance even during the act of death. In chronic inflammation, it is sometimes found very red in colour, and thickened in texture. Much has been written during the last few years upon inflam- mation of the arachnoid, by which science has certainly been benefited ; but it appears to me that considerable misconception has taken place upon this subject. Although red vessels are rarely to be seen in the arachnoid, so rarely that in my whole life two undoubted instances only have presented themselves, yet no one who has paid attention to the situation of effusions of matter within the skull, will deny the existence of inflammation in that tissue. But it is compara- tively rare. In my examinations (and they have not been few in /lumber) to ascertain this point, it has not occurred to me above six times to find effusions external 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 the serous membrane to the adjacent parts, should we be entitled to say, from any thing we yet know, that this was a con- sequence of peritonitis. In the cases to which reference has been made, the effusion is between the arachnoid and the pia mater, which are united by fine cellular substance—Me torong side, if it proceeded from diseased action in the former membrane, unless it has two serous surfaces, which is not maintained by any anatomist There is not, perhaps, in the whole body, a more vascular mem- brane 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 than the other membrane. 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 three splendid specimens * Tubercles are rarely seen in the pleura costalis. INFLAMMATION. 29 of this change in my museum, two of ulceration of the pleura pul- monalis and costalis, the other, of the membranes 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 confined to this tissue. 6. Inflammation of the solid viscera and glandular system. The first circumstance generally perceived is the presence of an unusual quantity of blood in the affected organ. The first change in the structure of the viscus is softening. 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 termi- nation 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 apoplectic effusions, together with tubercular degene- rations, 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 sometimes 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 refers 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 ter- minate speedily in suppuration. Sometimes, however, they suppurate very slowly, and occasionally 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 treatment. The truth is, that the importance of these points is felt too deeply to allow 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. 3* CHAPTER 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 great extent of our dominions abroad, where, it is believed, febrile diseases carry off more than four-fifths of those who die. If a person, after shivering, feels hot, restless, and thirsty, has a quick pulse, 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 is formed in the heart, and from thence extends itself to the rest of the body. It is one of the oldest notions in medicine, that fevers are produced by a concoction 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 state of the fluids. He con- ceived that the cold stage of fever was produced by the error loci, and all that followed was to be regarded as natural 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 improved upon by his colleague, Hoffman. They sup- posed that fever consisted in a tonic spasm, produced on the extremi- ties 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 constitutional commotion which attends fevers. According to Cullen, the human body is composed of certain or- gans, whose actions are regulated according to laws peculiar to ani- mal life, and superintended by a mobile and conservative energy, which is situated in the brain, acting wisely but necessarily for the general health, preventing mischief and repairing injuries, by a pre- ON FEVER. 31 established relation between the changes produced, and the motions required for the restoration of health, which actions are performed by the nerves. According to him, the muscular filaments are merely the extremeties 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 contagion, miasm, cold and fear acting as sedatives. This diminished energy produces a universal debility, and causes a spasm of the extreme vessels, and in this spasm the cold fit is sup- posed 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 in- creased 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 vessels, relaxation takes place, and health is restored by a copious sweat, or discharge of some of the other excretions. He di- vided the whole phenomena into three stages; first, the stage of diminished energy of the brain, and consequent debility; secondly, that of spasm of the extreme vessels; and thirdly, all that follows till the commencement of the sweating stage. Perceiving his doc- trines 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 naturse. But it is important that he should here speak for himself. " Upon the whole, our doctrine of fever is explicitly this :—The remote causes, are certain sedative powers 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 the 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 sanguiferous system; whence, by the inter- vention 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 excretories, 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 per- tinacity on spasm of the extreme vessels being a principal part of fever, should so completely have forgotten himself, as to assert that atony, which is the very reverse of spasm, is also a principal cir- cumstance in the pathology of fever. But he shall again speak for himself. "From the whole we have now said on the subject, 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 extreme vessels on the surface of the body, and that this atony, there- fore, 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; g2 ON FEVER. and that this takes place in fevers we conclude, not only from the de- bility prevailing in so many functions of the body ?enV°ni* *£!£ but particularly from symptoms which are peculiar to tne Dram itself" The meaning of " spasm of the extreme vessels," is morbid con- traction ; that 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 dis- appointed 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 unnecessary to enter into proof, for the purpose of showing the error of attributing to spasm of the extreme vessels any part of the pathology of fever; but it may be mentioned 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 that Cullen and others always confounded debility or actual weakness, with oppression from obstructed action. The de- bility which depends upon obstructed action is very different from that produced by starvation, a protracted 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 about by blood-letting, which is a remedy directly debilitating. If debility formed such a regular and indispensable part of fever, as the Cullenians assert, three circumstances ought to follow as necessary consequences. 1*/, 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, 3d, The longer such an action con- tinues, the greater will be the debility, and therefore the febrile symp- toms 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 instruction or exciting inquiry. What is the natural energy of the brain ? How is it pro- pagated ? It would be very satisfactory if the living advocates of this system would inform us, at what period of the disease the en- ergy of the brain exists in its most perfect state, and greatest strength. Is it at the period of attack, 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, because it has no precise * I have written more fully upon this subject, to show the great absurdity of the doctrines of Cullen, in a paper in the Medico-Chirurgical Review for January, ON FEVER. 33 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. Cullen too hastily rejected the humoral pathology, and seems un- fortunately to have almost entirely disregarded the effects produced by outward causes, and inward irritations, in producing irregular de- termination of blood, and local engorgements; which, I shall here- after attempt to show, are the great agents in exciting diseases, and especially fevers. It may be noticed in this place, that Dr. Mason Good, in his 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, en- dowed 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 prin- ciple of life, or life itself. It is, according to Brown, constantly vary- ing in its accumulation and exhaustion ; yet it differs somewhat from the nervous energy of Cullen, which is influenced by something unconnected with the matter of organization, and which he terms "vis medicalrix naturae,"—whereas Brown's excitability is passively exposed to the effects of such stimuli as it may chance to meet with, and yields to their influence. He divided all diseases into two classes: the first, caused by accumulated 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 simple as the arrangement, 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 pub- lishing 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 existence."* 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 mo- ment, with some modifications, in considerable force in Italy, notwith- standing the exposure of the fallacies of the system made by Rasori. 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 sensorial fluid. He regards the sensorial fluid as a mere secretion, capable of being exhausted in four different ways, through the agency of four separate faculties which he ascribes to it. 1*/, The faculty of Irritability, exhausted by internal stimuli, affecting simple irritable fibres. ♦Elements of the Practice of Physic, vol.i. p. 81. g4 ON FEVER. 2d, Of Sensibility, exhausted by stimuli affecting the fibres of the °r3rf,1S0°f Voluntarily, exhausted by stimuli affecting the fibres of those organs which act in obedience to the will. 4th, £id lastly, otAlssociability, exhausted by stimuli affecting organs associated in their actions by sympathy or long habit. By each of these means, Darwin supposes the sensorial povyer be- comes evacuated, as by food and rest it becomes replenished, often indeed with an accumulation or surplus stock ot power. He there- fore 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 power hereby accumulated to CXC6SS This subject might be pursued much farther, but more minute detail does hot 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 particular organ. Thus it has been attributed to inflammation of the brain—of the liver—of the diges- tive 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 particu- larly those commencing the study of medicine, against implicitly receiving the arbitrary doctrines of fever which divide the profession in the present day, viz. that fever is invariably produced by inflam- mation of one viscus, or set of viscera. Dr. Clutterbuck, a physician of reputation in London, has most ingeniously 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 he practises in the greatest commercial city in the universe, among a people whose minds generally speaking are more actively employed then 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 the bowels, it will be seen, that there may be considera- ble foundation for the opinions this gentleman has been led to advance. But I object to the arbitrary application of his doctrine* Broussais, to whom the profession stands greatly indebted, and whose merits like those of many others, have been more justly esti- mated abroad than at home, asserts that all fevers may be referred to gastro-ententis, simple or complicated. In France it is no wonder that Broussais should so frequently find the mucous membrane of the ON FEVER. 35 stomach and intestines altered both in appearance and structure, if the habits and modes of living of the people are recollected. The stewed meats, salads, oils and sweets, consumed by Frenchmen 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 produce 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. There are other individuals of the present day, who assert that fevers have never any connection with inflammation, except in as much as they occasionally excite it in their progress ; and in alluding to the appearances so frequently found on dissection, they trium- phantly 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 always 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. They are many persons who imagine that inflammation can- not exist in any organ or tissue of the body, in any degree, without a strong and quick pulse, thirst, restlessness, and considerable pain. Fatal error! The war of opinion in France respecting the pathology of fever, is at present too great to entitle us to expect candour from all the com- batants. Much talent 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 uni- versal truth of the new doctrine 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 we 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 Brous- sais, 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 vol- umes with cases and dissections, but their practice is too expectant on most occasions, and generally weak and vacillating. Having already expressed myself candidly respecting the errors 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 farther add an expression 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 his- 36 [PHYSIOLOGICAL DOCTRINES ] tory, it would be of little service in general, and occasionally would make " darkness visible." {Physiological Doctrines.] [Broussais, whose name has excited so much attention in the medical annals of this country, and whose doctrines have created no little disputation, is the well-known author of what is entitled the Physiological System of Medicine. We shall not stop to inquire whether this system is with propriety styled a physiological one, and based upon correct views of physiology; or, on the contrary, whether it rests upon false conceptions of vital phenomena: because it involves a question which can only be decided by the acquisition of a greater number of facts than we at present possess, derived from an accurate and well directed observation of the phenomena of health and disease. Our object, therefore, will merely be to present to the reader a few of the general principles of this system, together with the mode of reasoning by which they have been arrived at, and afterwards to give a concise view of the droctrine of fever, as founded upon these general principles. This then will be our apology for the length of the following preliminary observations. The animal frame consists of a number of organs, and these organs of different tissues, which modify their relative importance. The tissues are composed of solid and fluid elements, acting and reacting mutually upon each other by virtue of their molecular forces; the movements thus excited constitute organic action. The organs are formed to carry on, in a natural state, certain operations or functions, necessary in themselves, and conducive to specific purposes. They may be said to have an isolated existence when considered merely as to their dissimilar modes of operation; but they are, when regarded as portions of an elaborate and intricate machine, so intimately connected that each one, to a certain extent, is depend- ent upon the other; thus constituting a beautiful and complex whole, made up of equally complex parts. The several organs are connected with each other by a subser- viency of function; that is, the integrity of each one eannot be individually maintained without the assistance of the others- while at the same time there exists a sympathetic tie which pervades them all. For example, the brain and spinal marrow together with the gan- glionic system, possess the command of nervous influence, which is brought to bear upon the functions of the heart ; but it cannot exert this influence unless the latter keeps up its regular supply of arterial blood. The stomach, in like manner, cannot secrete the gastric liquor unless it is supplied with blood; nor can the heart furnish a supply unless the function of digestion is sufficiently active to elabo- rate the materials of nutrition. This arrangement holds with regard to all the organs constituting a circle of dependencies, any one of which being disturbed, the whole is affected. The other snecies of connection, though less intimate, is still of great importance • it is the sympathy which exists among them, causing all to be more or less disordered by the derangements of a single one, and leadin* to [PHYSIOLOGICAL DOCTRINES.] 37 remote or present injurious effects, in proportion to the degree of dis- turbance. This connection preserves harmony of action in organs which are not contiguous, and sustains their relative tone and force. For the purpose of elucidation, we need only cite the relation which exists between the brain and the stomach, the stomach and skin, &c. The organs have been stated to consist of tissues which differ in structure, uses and modes of life. They are combined in variable proportions, so as to adapt the organ to the purposes for which it was designed. To illustrate this, in the stomach are found four tissues, externally the serous, to enable it to glide with facility upon the neighbouring parts; next the muscular, to propel its contents; then the cellular, as a connecting medium; and finally, the mucous, to assimilate the food, and prepare it for its conversion into blood. In the construction of the heart are found three tissues—the serous, fibrous, and muscular, they being all required to perform its func- tions. The organs are divided into two great classes—one in- cluding those which are necessary to the maintenance of the indi- vidual ; the other, those which are in connection with the exterior world. Life is defined to be organism in action; it is supposed to be a state of activity in the organs maintained by the operation of stimuli. In order that these stimuli should act, a certain degree of suscep- tibility to their impression in the tissues and organs is requisite, which has been designated by the term excitability; and the state produced is called excitation; so that an organ in the full natural enjoyment of its functions, is said to be in a state of excitation. As far as we can judge, excitability is not the same in all the organs and tissues, since there is so vast a disparity of construction: but in each organ and tissue it remains unchanged as to nature, modified only by increase or diminution, and requiring an appropriate stimulus to bring it into action. Excitability is greater during youth, and diminishes in old age ; hence it cannot be prolonged indefinitely. The stimuli affecting our organs are the physical influences by which we are surrounded—as caloric, light, air, food, &c, which when not operating in excess, are fully capable of maintaining life; but when these stimuli are present in excess, or acquire more than their usual activity, an injurious impression is then produced, the excitability is increased, and super-excitability is the consequence: and as this is called irritability, the disordered excitation is termed irritation. The contrary of these, determined by opposite causes, and characterized by a depression of the excitability, and attendant inaction or torpor, is said to be a state of ab-irritation. According to this view it will be perceived, that we have two conditions; a physiological one, where life is maintained without excess or diminu- tion ; a pathological one, where life is carried beyond the natural standard, or falls short of its proper activity. Excitability must be a vital property, since it is not possessed by inorganic matter. The influence of any one organ upon the rest of the economy, is in proportion to its importance in the preservation of the individual. After birth, the brain, spinal marrow, heart and lungs appear of 4 38 [PHYSIOLOGICAL DOCTRINES.] greater necessity than the stomach, bowels, and other viscera ; because, if the former are seriously injured, death must almost immediately ensue; but the stomach, from the fact of its supplying the materials of nutrition, without which all the organs must perish, rises in the scale of importance ; and in this light all others ace but auxiliary to it. In a state of health it is rare to witness two organs at the same time excited in the same degree; that is, by a stimulant acting upon one and sympathetically transmitted to the other; since we observe, for instance, when the brain is in action the stomach is quiescent, and vice versa; but when several organs are roused at the same time by their appropriate stimuli, they react strongly upon one another, and excitement is generalized as much as possible. The degree of excitability predominates in certain organs according to the age, sex and constitution. The preponderance of vital action in any one organ which influences more or less the whole of the organism, is the foundation of temperaments. Individuals compared with each other present remarkable differences of excitability; this constitutes idiosyncrasy. When the functions of an organ are impaired, it is diseased. All disease consists in the alteration of the organic actions of one or more organs, leading to irregular exercise of the functions. Derangement of organic action in deep-seated parts, can commonly be appreciated only through the medium of the consequent functional disturbance, which never exists independently of the former. Symptoms then are nothing more than manifestations of disordered organic action. Irritation is defined to be the augmentation of the organic action of a tissue beyond the limits compatible with the free exercise of its functions. The following are some of the laws which it obeys: 1. Irritation is always primitively local; it commences in some one organ. The stimulating impressions are mostly made upon the external surface, or those in relation with the exterior world. The idea of irritation being brought about without the operation of stimu- lants is erroneous ; hence there is no disease strictly spontaneous ; all are referable to some cause. Irritation can never exist in all parts of the body at the same time, but can occupy by irradiation at once, one, two, or three organs. The maxim of Hippocrates, however, is founded in nature. "Duobus doloribus simul existentibus vehe- mentior obscurat alterum." It is due to the impress of stimulating agents, to the transmission of this effect from organ to organ by the sympathies, to the momentary abstraction of stimulus from an organ where the excitability is great-to the removal of excitement from an important organ, so that surexcitation is caused in another. In this case there is a positive sedative impression, diminishing the organic movements; as, for example, the effect of cold applied to the skin, which it debilitates while ,t excites the internal or/ans- so also hunger, &c. Hence, directly or indirectly, irritation i?fi st enZ dered in a single organ. l tnec" 2. Irritation may exist in an organ and v*t ;*„ ~ L announced by an, symploms ^^Zi^tr^Z"^ [PHYSIOLOGICAL DOCTRINES.] 39 the destruction of the individual, and examination after death re- veals its seat and nature. 3. Irritation deranges and weakens the functional actions of a tissue or organ in which it is located. The reverse, at first sight, would appear to be the case, because irritation is stated to augment the organic movements. The exercise of a function cannot be regular, however, when the organization of the tissue which exe- cutes it is impaired; hence irritation, by inducing derangement, is followed by embarrassment of function"; the vital movements are carried beyond their normal standard, and, as it were, clogged by excess of energy. Thus an inflamed stomach will digest as imper- fectly as one weakened by atonic influences; a single exception to this law exists—it is when nutritive irritation has increased the growth and power of an organ. 4. Irritation is susceptible of various degrees of intensity, which are evinced according to the tissues which it occupies, and the in- dividual. As tissues are anatomically different, they are not all equally susceptible of irritation, and there is a similar disparity among individuals. The extent which it occupies, the amount of accompanying uneasiness, the tumefaction of the part, and the energy with which it reacts upon other organs, will point out its intensity, which is in proportion to the number of these attendant circum- stances. Hence irritation is acute, when these are considerable: chronic, when less so, and the course which it runs is not rapid: con- tinuous, when it pursues an uniform course from origin to termina- tion ; and intermittent, when it appears only at intervals. The intensity of irritation depends upon two circumstances; the force of the stimulating impression, and the irritability of the tissue. If the causes are light, and the tissues little irritable, the irritation will be proportionally small; but where the opposite conditions exist, the effect is modified accordingly. Should the impress of stimulation be energetic, and the tissue possess little irritability, the effect may be light; but should the cause be light and the tissue very irritable, a high degree of irritation will be the consequence. A con- tinued form is that under which irritation is most generally mani- fested. The reason is plain ; an exciting agent acts forcibly upon a tissue; it exalts the irritability and produces an irritated condition. Although the cause may cease to act, yet the effect will be persistent, since the organic forces have been excited, and it requires some time to bring them back to their normal state. But an intermittent form may be presented. It is owing to causes which act at intervals. It takes place in organs whose functions are not continued, but peri- odical; or, it may occur from habit. Irritation is susceptible of six principal modifications; in other words, the local phenomena which accompany irritation show them- selves under six different aspects easily recognized. They are all attributable to the same law, viz., "ubi stimulus ibi afiluxus." The first phenomenon is an afflux of fluids to the irritated point, pro- voking the conditions afterwards mentioned. If this simple mode of explanation is not admitted, there would be as many hypothetical causes as there are forms of local derangement; there would have to 40 [PHYSIOLOGICAL DOCTRINES.] be a specific power for the production of each; and whether it is called a vis a tergo or any thing else, one would be necessary to excite inflammation, another serous congestion, a third lymphatic accumulations, and so on; but all these are obviated by reference to the idea of an irritation everywhere the same in character, but modified by tissue and other organic conditions. In the greater number of eases the part beeomes painful, hot, swollen and red, and there is more blood in the capillaries than necessary:—this consti- tutes inflammatory irritation. When the tissue is hot, painful, and tumefied, allowing blood to escape from its surface, hemorrhagic irritation is said to be present. If there is little or no pain, little in- crease of warmth, and the tissue affected is not reddened, but tume- fies, takes on a homogeneous whitish appearance, as if white fluids alone had entered the capillaries in excess, it is termed lymphatic irritation, or sub-inflammation. If the tissue is simply painful, there being no manifestation of change in colour, or increase of volume, nervous irritation is the designation by which it is known. In this it is supposed to reside entirely in the nervous filaments. The organic movements may be increased scarcely beyond the physiolo- gical action, but by long continuance may invigorate the nutrition of a tissue; this is the nutritive irritation of the physiologic.il school. And finally, should it be located in a tissue whose office is secretion, there may be an augmented flow of its peculiar product: and this forms secretory irritation. In all the structures in which these forms of irritation occur, with the exception of the nervous, it is requisite that an abundance of vessels should exist. If, however, a purely nervous excitement in a part be augmented, and the pain be greatly aggravated, an increased amount of fluid will be directed to it, and tumefaction ensue. Morbid congestion and increased nutri- tive action, leading to disorganization, are, therefore, in all cases, the effects of a sufficiently powerful irritation. In the foregoing account of irritation and its consequences, it is supposed that one organ alone is implicated; a succession of them, however, may be included within the circle of diseased action, and this is effected by means of the sympathies. Irritation rarely con- fines itself to the part originally affected, but is irradiated from this to others with a rapidity and energy which vary according to the irritability of the individual, the intensity of the irritation in the organ primarily affected, the importance of this one in the economy, its irritability, and the number and degree of its relations with others! Diseased sympathetic action is communicated in the same way, and by the same channels as physiological sympathy; and consequently, the organs which are most closely connected in a state of health wi'll be proportionably influenced when irritation is kindled up' Its transfer will be found strictly to adhere to this law. Thus the sto- mach, being connected with the brain and heart bv the most intimate union, will convey to them its morbid impressions, and cause them to assume a portion of its irritation. To exemplify the truth o( these declarations, the folio win- facts are brought forward. In infants, females, and those of a natlirallv excitable constitution, the lightest degree of irritation in an organ [PHYSIOLOGICAL DOCTRINES.] 41 will excite a train of sympathies which extends through the whole series, and becomes more or less general; while in old people, and those whose sympathetic relations are diminished and weakened, an organ will sometimes be seriously affected, and even destroyed, without reacting upon any other. Sympathies are more influenced by the intensity than by the mere extent of irritation ; and the reason is, that the number of sympathetic connections which an organ pos- sesses are limited, and an intense circumscribed irritation may excite the whole of them to their full extent, while a greater local diffusion of it can do no more than bring them all equally into exercise; so that the more intense this may be, the more decided will be the dis- turbance in other organs, and the contrary. A secondary may exceed and mask, to a certain extent, a primary irritation, and, as it were, become the predominant one. Hence, false inferences may be drawn from the symptoms as to the commencing seat of disease; the secondary irritation so far exceeding the primary that the latter is overlooked; when, if care be taken to ascertain the first symptoms which manifested themselves, they would be found to appertain to a remote organ. In this manner, also, the secondary irritation may continue after all traces of the primary.affection have vanished. An apparent exception to this law may exist where the primary irrita- tion is so intense in an influential organ, as to concentrate in it all the irritative action which, under ordinary circumstances, would be diffused through the organs generally. If the irritability of an organ is great, the more easily will its sym- pathies be excited. Of all the organs, the nervous system possesses the greatest in- fluence with regard to the sympathies; next are the stomach and intestines; then the heart, skin, lungs, &c. Sympathetic action among the organs is reciprocal; those which receive the greatest number of secondary impressions, produce the greatest number when they themselves are first the seat of irritation. Sympathetic irritation is similar in character to the primitive. Morbid sympathies are of two kinds; the first is manifested by organic phenomena, as congestions; augmented, diminished, or morbid secretions, &c; and these are termed the sympathies of organic life. The second is evinced by pains, spasms of the volun- tary muscles, convulsions, &c, which are the sympathies of relation. If the irritation is sufficiently intense in the organ secondarily affected, the character will be inflammatory; when it emanates from a pri- mary inflammation, a haemorrhagic action will ensue, as a conse- quence of haemorrhage; and so of the others. Diathesis, then, is nothing more than the tendency to the reproduction, in other organs, of a condition similar to the one which exists in the organ first affected; and, therefore, the diatheses are thus particularized; the inflammatory diathesis, the haemorrhagic diathesis, the nervous diathesis, the sub-inflammatory diathesis, the diatheses of secretory and nutritive irritation. This law is strictly maintained as long as the irritation is confined to a tissue similar to the one in which it primarily occurred; so that haemorrhagic or nervous irritations in mucous membranes, will sympathetically produce the same affection 42 [PHYSIOLOGICAL D0CTRINE6.] in a similar tissue; and sub-inflammation of the lymphatic ganglions will affect, in an analogous manner, the lymphatic system, anu .o on. If, however, the sympathetic or secondary irritation is not re- peated in the particular tissue in which it first originated, but in some other, the effect will be modified by the character of the tissue second- arily affected ; if, for instance, inflammation of the mucous membrane be sympathetically communicated to the lymphatics, a sub-inflam- matory condition will ensue. Some exceptions, however, are ad- mitted with regard to irritations transmitted to various points ot the same organic system; for haemorrhage, for example, may be the result of a transmitted inflammation, and the reverse. Sympathetic irritation is transmitted by means of the nervous cords, with or without the intervention of the brain. Both systems of nerves are conducive to this end; the cerebrospinal being the agents of the sympathies between the organs of relation; the ganglionic, of the organic sympathies; and the intimate connection between these two systems explains the attendant phenomena when both are in- volved. The danger of death by acute disease, depends upon the intensity of cerebral disturbance, whether primary or secondary; so important is the immediate influence of the brain in the preservation of life. Other organs, by undergoing morbid changes, lead to this result at a later period; but when such changes are considerable, they react upon the brain, and transfer the risk of dissolution to derangements of that organ. If, in acute disease, the skin, or any secretory organ, assume a trans- mitted irritation more intense than the original one, and, producing a free discharge of its peculiar secretion, a revulsive effect is brought about, the affection is said to disappear by c?*isis. There are crises which, instead of conducing to a favourable result, and leading to restored health, are productive of more alarming and threatening symptoms. It is said, in the language of those who have not scru- tinized the subject, that nature has attempted a cure, but failed, and has sunk under the effort; such is the case of retrocedent irritation in secretory organs, as checked perspiration, diarrhoea, &c. These are called false crises, and are attributable to the sudden attack of some very important internal organ necessary to life. The termination of irritation is more or less rapid according to the tissue involved, the cause producing it, or the character of the sympathies which it has excited. The state of irritation under which an organ or tissue labours, pro- ductive of increased vital movements, is called hyperemia. It will be necessary to devote a few words to sub-irritation or anaemia. In this case, life in an organ is below the healthy standard, the organic movements are depressed, and debility of its functions is the consequence. It is the very opposite of irritation ; hence a short account of its causes and laws will be sufficient for our purpose An anaemic condition of an organ is rarely primitive, but is rather the result of irritation located in some other viscus. The following ex- planation will convey a direct idea of what is understood to be its nature. Those organs which are not themselves irritated and do [PHYSIOLOGICAL DOCTRINES.] 43 not receive transmitted irritation, may nevertheless become greatly enfeebled; because organic activity is concentrated in others, and withdrawn from them. If this were not the case, the first law of irritation would be incorrect; for then there might be a repetition of it in all the organs, and universal excitement be present, which is an impossibility. For example, when the heart and vascular system are stimulated to increased activity by the existence of visceral irrita- tions, muscular power diminishes; when the locomotive apparatus is violently excited or convulsed, nutrition languishes, the secretions are impaired, the heart circulates blood irregularly, the brain is weakened in its intellectual operations. In maniacs, where the brain is in a state of high activity, the heart and muscular system may have ac- quired more energy, but the secretions are interrupted, the intestines rendered dry and insusceptible to stimulation, nutrition is suspended in them, and the sero-cellular tissues are in a state very opposite to that of inflammation. By this view of things the idea of diathesis, as-meaning general habit, is refuted. Anaemia may be produced in three ways: 1st, By the abstraction of all stimulation from an organ: 2d, By diminishing the stimulating influence which one organ receives from another by sympathy : 3d, By the intense excitement of some important organ concentrating activity in itself. An anaemic state is marked by the following appearances and symp- toms—Paleness, flaccidity, coldness and insensibility, diminution or total depravation of functions. Sur-excitation and intense local morbid congestion, are compati- ble with the general diminution of the forces. This is one of the most important truths of the physiological doctrine, and ignorance of it has led to doubt, uncertainty, and erroneous practice. Diseases essentially active in consequence of mistaken ideas of their nature, have been treated for those of opposite character. It is difficult to convince some persons that when exhaustion and marasmus are the predominant symptoms, a focus of irritation is present, and progress- ing with its ravages; the general condition is confounded with the local, because correct ideas have not been entertained of the latter; in other words, anaemia of a majority of the organs is taken as the standard of the whole. To conclude these remarks, we may state, that it is impossible to understand the derangement of the molecular action in the tissues of an organ; the most that can be accomplished is to investigate the sensible alteration of structure which they have undergone. To know the seat of disease, is to know in which organ and tissue it is located ; to understand its nature is to recognize in what consists the organic alteration which constitutes it. Pathological anatomy is employed in this research. The errors in pathology, says M. Boisseau, have arisen from the following causes: 1st, Symptoms have for too long a time been the sole objects of study: 2d, It has been supposed that they always faithfully represented the condition of viscera removed beyond the scrutiny of the senses; 3d, Physicians have neglected to look to the organs upon which each one of the morbific or therapeutic agents first exerted its influence, and the laws which preside over the 44 [PHYSIOLOGICAL DOCTRINES] propagation of this influence from one organ to another; 4th, It has been supposed that these agents must act upon the whole system at once, as they are recognized to influence a simple organ ; 5th, And finally it has been inferred, that as the whole organism is concerned, all the organs were primarily affected. Having thus explained the laws of irritation as announced by Broussais, we shall now proceed to consider his theory of fever founded upon them. According to this hypothesis, all fevers owe their origin to a local irritation or inflammation, by the reaction of which upon the other organs, through the medium of the sympathies, that group of phenomena is produced which is called febrile dis- turbance. Jill that class of fevers commonly termed idiopathic, together ivith certain forms of traumatic fever, are attributed to an inflammatory condition of the mucous membrane of the sto- mach and bowels, and are, therefore, denominated "Gastro-en- terites."* No matter what form the fever may assume, or by what name it may be designated, whether ataxic, adynamic, &c, it is still referred to this primary lesion. Essential or idiopathic fevers are, therefore, regarded as chimerical, not founded in nature or sustained by observation. In support of this doctrine he appeals to the history, symptoms, and post-mortem investigation of the disease. We shall see hereafter how far this theory is sustained by the researches of those who, in the same locality, and enjoying the same advantages, have entered upon a similar field of observation. To establish .the truth of the assertion, that the seat of fever is primarily local, he has recourse to numerous arguments, which will be detailed in suc- cession. "Inflammatory fever represents an excitement of the vascular sanguine system, which is the consequence of all local irritations; this is admitted by all nosological writers. A local excitement will always be found predominating; and nothing proves to us that it is not the immediate cause of that form of febrile movement which has been hitherto considered essential." " Modern writers, in considering inflammatory fevers as idiopathic (essential,) have not pretended that they were independent of local irritations, since they tell us that a debauch, a violent fit of anger, excessive pain of a wound, &c, every physical or moral cause sufficient to establish a permanent reaction of the vascular sanguine system, can produce fever."__"We are of the same opinion with them, that all the inflammations can produce fever, but are not prepared to admit that fever, which is acknowledged to arise from all local irritations, can ever exist of itself which it must do if it be essential." What is meant bv the terms' mucous fever, bilious fever, &c. if they do not depend upon corre- sponding irritations? According to those who use these expressions, thenrntations which produced such fevers are not inflammations and yet they are sufficiently severe to excite fever, and after death the * [" Gastro-enteritis is observed in two forms:—with predominant r.f ,u inflammation, and with that of enteritis. Gastric pain lossTf *™f,, f ,h-e gaSt"C, saw °,her wwnsJe " are "intermittent, continued, and exanthe- FEVER. 51 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, subdivided into four orders, viz. Fever from functional derangement. -----from inflammation. -----from congestion. A mixed form of fever between these three last, but in which congestion predominates, commonly denominated Typhus or Synochus. 4lh, Hectic Fever. 5th, Fevers attended with eruptions, subdivided as follows: Scarlet Fever. Measles. Small-pox. ---------modified. Chicken-pox. Miliary Fever. Roseola. Urticaria. 6lh, The Plague. General Description of the Phenomena of Fevers. The following are Cullen's definitions of febrile diseases, and of fever: First, of Pyrexia. " After shivering, succeed a quick pulse, increased heat, with inter- ruption 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 primary local affection." There are the strongest objections to all medical definitions. The following maybe urged against the two above quoted; they are symptomatical definitions; 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 indivi- duals belonging to the same family, and during the same epidemic. The symptoms develope themselves in various degrees; one symp- tom, 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 never attend any other—phenomena which may be therefore said to be pathognomonic 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 distinguishes it from another of the same family; 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, 52 FEVER. 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 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 evi- dent; the mention of these phenomena would have led to the sus- picion of local affection, which was contrary to his own dogmas. "Fever," says Dr. Fordyce, Part 1st, p. 7, "of all other diseases, is that one in which a pathognomonic symptom is least to be depended upon ; that is to say. an appearance which does not take place when there is no fever, or a fever which 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, lassitude, 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 differences 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 reaction; the symptoms 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 mutterin°- de- lirium, and sometimes coma, &c. In other cases the viscera of the thorax are principally affected, indicated by dyspnoea, cou^h, expec- toration, and tightness in the chest, &c. In a third set of cases, some of the viscera of the abdomen are implicated, announced by nausea or vomiting, uneasiness increased on pressure, obstinate constipation or diarrhoea, a morbid state of the alvine evacuations, discovered both by their appearance and odour; a tympanitic state of the abdo- men, and 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. FEVER. 53 In fever the functions of every organ are more or less disturbed, so that there is the best proof of universal disorder, and the appear- ances 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 very 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 sud- denly 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 constitution, they cannot stand the shock produced by the embarrassment of so many organs in the performance of their functions ; and farther, many individuals 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 inter- mil tent. 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 con- tinues 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 continues for days, or weeks, without intermission, and is therefore called " continued fever." It has several varieties, of which the following are brief sketches. First variety.—An individual feels impaired appetite; his bow- els out of order; his urine scanty and high-coloured ; he passes rest- less nights, and at length is sensible of increased heat of skin; towards morning he generally falls into a gentle perspiration, and enjoys a few hours sleep, from which he rises somewhat refreshed; he finds his tongue loaded, his breath more or less fetid ; 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, * 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. 5* 54 FEVER. and feels so much oppressed that he is compelled to confine himself to bed. Then, for the first time, medical advice is sought: the phy- sician can find no symptom which can be attributed to inflammation; there is considerable restlessness, but no great degree of suffering, except that which proceeds from a sense of oppression in the praecordial 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 com- monly quite sound, but there is, perhaps, slight alienation during the night. Abstinence from solid food, and a steady perseverance in gentle laxative medicines, soon produce an amendment. This is the form which I have denominated " 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 inflammation of some structure, within one or other of the three great cavities; and this is the form all writers term a pure inflammatory fever. But when the inflammation of any part runs high, it is then said to be an inflammation of a particular tissue or organ. It must be recollected, however, that inflammation of internal organs may go on to a fatal termination without strongly 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 frequently meet with in'these latitudes, where it generally developes itself in the following manner:—A per- son, after feeling more or less unwell for some days, or perhaps for some weeks, experiences chilly sensations, alternating with unusual 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 shght dyspnoea, is unable to take a full inso ration but has no pain. The tongue is generally moist, somet^esZ?ed? wS n^f^SlfSd t t^ed^ IZ^nT* ^■°lher Jhc« wb"e '»«"■ cidation of which has been so fully piontedou,by ffaSuJ*' the Palh°l°gical elu- FEVER. 55 and shrunk. The pulse is soft, sometimes quick, at others not above the natural standard. Even when to all appearance he is in a com- plete state of coma, he can be roused, when his expression of counte- nance will be vacant, and appear as if he were in a state of intoxi- cation. If questioned as to what he complains 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 abdomen. 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 mut- tering delirium ;" the tongue, which was moist for the first few days, is now observed to be dry and glazed, and tremulous; he passes his urine and fasces in bed; is always found upon his back, and however 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 helplessness—a bad symptom in any disease. In this state it is impossible 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. Re- covery is rare when the symptoms are so very severe, although the fatal period may be protracted to the end of the third week. Occa- sionally, 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 synochus. And this is precisely the form of disease which will be more particularly described hereafter, under the denomination of a mixed form of fever, from the want of a better appellation. The term typhus is objectionable, because it is sometimes used to denote a malignant or a putrid fever; at others it is employed to signify a nervous fever. The term synochus is also objectionable, for this reasoft, that it is stated to be of an inflam- matory nature, but there is a supposed union with a typhoid state of the system, which, although present, remains latent in the first stages, and subsequently developes itself; and we are told that the appro- priate remedies for inflammation 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; 56 FEVER. in fact, whatever doubts have been entertained with respect to the nature of all other fevers, this is almost the only one which is uni- versally allowed to be svpmtomatic. 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 re- mote causes into sedative, in order to support his dogma of debility; he could not consistently allow a cause of a stimulating and exciting nature. Marsh miasm he supposes capable of producing intermit- tents and remittents only, and he restricts the term contagion to human effluvia, capable of producing continued fevers only. He considers the common 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 con- ceive that too much has been hitherto 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 favour of contagion, is sometimes drawn from the well- known fact, of fevers spreading not only from one to another in a family, but also in the same neighbourhood; but the similar circum- stances under which the inhabitants are placed should not be for- gotten. The anxieties, the hopes and fears which alternately affect individuals attending others whom they love, the exposure to cold and fatigue, the night-watching and want of rest, the irregularity in taking nourishment, and the neglected state of the bowels, all tending to produce loss of balance in the circulation, and local disease, will go far to account for a number of individuals in the same neighbour- hood, and more particularly in the same family, being affected one after another. Neither should it be forgotten, that all these indivi- duals residing in the same locality, and living in a similar manner, 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 produce fever. Why one individual should be sooner attacked than another, and have the disease perhaps more severely it is difficult to determine. An interesting question here arises- What length of time does the contagion remain latent in the body, before it shows its effect? 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 con- fidence, 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 interest- FEVER. 57 ing facts, which are not sufficiently attended to in considering this subject. It is my belief, that contagion will not produce fever, ap- plied 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 contagion 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 labouring under the effects of some mental depression. From the evidence before us in the records of medicine, it appears that individuals 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 combustion, and therefore cannot, as some have supposed, be deprived of much of its oxygen. If its constitution were changed, it would affect all who breathed it, blacks 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, without being attacked by intermittent fever. I have myself had many attacks of this disease during a residence in a marshy district; there- fore, 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 paroxysms. From personal observation thus acquired, the first circumstances which attracted my attention were, that men were more liable to the dis- ease 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 dissi- pated, 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 constitution, 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 the climate. The dissolute are more liable to this disease than others, because they often expose themselves recklessly 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. Moisture alone has a great effect in producing disease, and its in- fluence is speedily observed on the mind as well as the body. But moisture alone will not produce intermittent fever; the influence of excessive heat must be superadded, and then there is a rapid evapo- ration from the earth's surface. It is this evaporation, I imagine, which is productive of so much mischief to European constitutions in warm climates, particularly where there is any tendency to col- lapse. Agues are not commonly prevalent during the rainy season, 58 FEVER. 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 satis- factorily 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 evaporation. 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 dysen- teries generally prevail. Dr. Fergusson has observed, 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 con- verted 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 intermittents, 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, dykes 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 influ- ence, agues are very prevalent, both among natives and Europeans at certain periods of the moon's age. I am informed by Mr. Mar- shall,* that in the interior 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 degrees. 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 temperature 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 unhealthy seasons. It will be seen that it is not my intention to deny the existence of some invisible substance suspended in or mixed with the air of the atmosphere, and which may produce intermittent fever.t A fact may be mentioned, on this side of the question, which must carry con- siderable 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 , VltMliTnTp^! rl0teS °n the Medical T°P°Sraphy of Ceylon-Hints to Young Medical Officers, &c. &c. marsh°mlaImterS S° ^ extraordinary lenSth of speaking of the specific gravity of FEVER. 59 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 breathing the air in the apartment where the sick person is con- fined; 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 contagion 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 con- centrated within a circle, 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 js produced by a certain state or condition of the atmo- sphere at present unknown, and which has baffled the exertions of every one who has entered upon its investigation. The term implies that a greater number of people are suddenly seized at the same period. An epidemic disease, after continuing for a longer or a shorter period, suddenly ceases, at a time perhaps when the greatest number of patients are affected. These are facts which appear to have con- founded those who assert that yellow and other fevers are invariably contagious. It does not appear that intermittent fever is ever contagious: but I am of opinion the yellow fever, and that which has been termed typhus in this country, are so under particular circumstances, and sometimes 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 fever which then prevailed in the West Indies was highly con- tagious, 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 Europe, 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 yellowness of the surface of the body, and vomit- ing of a dark-coloured matter, commonly called black vomit. These cases are considered by all candid observers to be the ordinary re- mittent fever, common to this and other places under similar influ- ences. The majority of the cases are found to occur in the lowest, worst ventilated, and filthiest parts of the locality. But in 1S04- 1810-1813-1814, 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 60 FEVER. afterwards spread by contagion, and had no trace of local origin. Considerable doubts were, however, entertained upon this subject; but in 1S14, 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 there is no proof of its having been im- ported. One or two others, with Sir William Pym, superintendent-general of quarantine, 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 Havana on the 12th May, 1828, and arrived at Gibraltar on the 28th June. I have carefully perused all the evidence produced through the medium of the medical periodical press, and published by the follow- ing gentlemen:—Mr. Fraser, late surgeon to the civil hospital at Gibraltar ; Dr. Smyth, surgeon 23d regiment; Mr. Amiel, surgeon 12th regiment; Mr. Wilson, late of the medical staff, who I believe retired from the service, partly from disgust, and partly from the per- secution to which he was subjected, and would not submit; Dr. Barry, physician to the forces. Also, Sir William Pym's replies to queries 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 consider- ing all the facts adduced in evidence by all parties, my deliberate opinions are as follows: 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 condition of the poor inhabitants, and the exceedingly filthy and badly ventilated 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 Dyg- den. Indeed, it does not appear that there was any cause to suspect this ship of bringing the seeds of the disease from Havana. In the first place, we see from her clean bill of health, signed by the authori- ties there, that " this city and its neighbouring towns are free from all plagues or contagious epidemic disease; as likewise the said captain, with the fifteen men of his crew, are in a perfect 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 Havana on the 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 FEVER. 61 of severe headache, and pains in the limbs, which increasing, they had to go to bed. Through sudorifics and purging medicine, they got well in eight days, so as to be able to attend to their duties. Dur- ing that time, five others had 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 ham- mocks, 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 29lh 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 appearances on dissection, observed in cases of remittent fever treated in the civil hospital at Gibraltar, in 1821, and the five subsequent years. Having compared these with the cases of 18*8, I 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. Smyth. " 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 may so use (he expres- sion.) at Gibraltar, from the termination of the epidemic fever of 1814, until the arrival of Dr Hennen, in 18-J6. that it was considered a most wicked heresy for a surgeon of a corps to return fevers under any other head than simple continued fever. The consequence is, that although febrile diseases are the most frequent of the numerous 6 62 FEVER. cases treated both in the military 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 o remittent and continued. The authors of such a measure 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 have been exposed to the tyrannical conduct of ignorant and obstinate medical superiors. 5th, That Sir William Pym's answers to the queries of the Span- ish 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 superintendent-general of quarantine in Great Britain. These answers are for the most part vague assump- tions—some being drawn from insufficient evidence—others from no evidence whatever—while many of them are at complete variance with the 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, the 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 imagina- tion that the superintendent-general of quarantine, or any other gen- tleman who had resided at Gibraltar, could have hazarded such an erroneous statement. The district in question (No. 24.) "is situated in a natural gorge of the mountain, and is rendered still more close by a high wall raised for the military protection of the town. The wall is called 'Charles the Fifth wall,' and is situated on the south of the town. The rear of the district (24), together with the whole town, is impe- netrably shut out from the influence of east winds by the rock itself. The district itself is particularly cut off from the beneficial effects of perflation by a high and impending semicircular bluff" of the moun- tain, in some degree insulating it from the rest of the town, on the north side. Charles the Fifth wail 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 blows from the west, which was not the case when the fever broke out. Besides, it is deserving of particular attention, that the superficial soil was filthy, 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 FEVER. 63 enters the mouth of this sewer on the beach, rushes upwards through the drains, and escapes through gratings (which are closely concen- trated 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 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 first two cases of the fever originated on the ground floor of a badly ventilated house in this district, and in the close neighbourhood of one of the openings of the drains; and about 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 communications, which I have copied from Dr. Smyth'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 would observe to your excellency, 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 govern- or, Dr. Hennen further stated: " In reference to my letter of this day's date, 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 ven- tilation, without drainage, and generally composed of the slightest materials; in tiers of beds as close as in a crowded transport, nume- rous 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 rea- son to suppose are unauthorized by the government." A commission was subsequently appointed by the governor's orders, to inspect the different districts of the town, which was composed of military 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 64 FEVER. for Sir William Pym's answer to the 3d question, in which he has given a confident assurance of the healthy situation and well-venti- lated 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 su- perintendent-general of quarantine in Great Britain. 6th, It is my opinion that the board of commission was not hap- pily chosen by Sir George Murray. No medical officer should have been nominated, or any other individual, however exalted his rank, who had previously expressed decided opinions on the subject to be investigated. 7th, I humbly conceive Sir George Don, the governor, acted con- trary 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 superintendent-general of quarantine, who immediately nominated his newly-acquired par- tisan, Dr. Barry, to be secretary to the commission. That Dr. Barry is an ingenious gentleman is well known ; that he changed his opin- ions very suddenly at the time of Dr. Hennen's death is alleged, and has not been satisfactorily disproved; and that he immediately adopted the opinions of his new chief is undoubted. Whether Dr. Barry, in his capacity of secretary, gave colouring to the evidence produced before the commission, or improperly put leading questions to the parties examined, to favour the views of his chief, is best known to those who were present at the investigations. 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 of the commission, I find another name as exceptionable as those of Sir William Pym, and Dr. Barry, viz., that of Dr. Broadfoot, superintendent of quarantined Gibraltar. Besides these, there are also the names of two official gentlemen, the captain of the port, and the town major, who were thus also improperly placed in a situation either to accumulate or re- ject evidence, which might show inattention or dereliction of duty to such an extent as to compromise their situations! The only unexcep- tional appointments on the commission were those of Colonel Chap- m man, civil secretary, and Judge-advocate Howel,andthe coincidence of their opinions is quite remarkable. Colonel Chapman's opinion is as follows:—"Judging from the evi- dence produced 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 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 iv ho wish to prove it, has totally failed." Judge-advocate Howel gave the following opinion:—« Upon a FEVER. 65 careful review of all the proceedings before the board, I am of opin- ion, that the evidence 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 origin in Gibraltar-" From Botta's History of Tuscany, the following statements are extracted respecting the epidemic yellow fever which prevailed in Leghorn, in 1S04. " It was occasioned, as it appears, by the pre- valence, 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, attacked 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 confirmation 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 another." " 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 authori- ties, to whom many of his medical brethren unhandsomely lent themselves, for having proved that the yellow fever existed in that city—that it was generated in the place, and had not a foreign origin. It is now more than forty years ago; and after reading the report made on the subject by his opponents, I can readily join Dr. Rush in his conclusion, that "it is impossible to review this report, without blushing for the shameful submission made, by the science of medi- cine, to the commercial spirit of the city." It may be useful to my readers to know the evidence which Dr. Rush produced to show the local origin of the fever, and it will be observed that an attempt was made on this occasion to fix its im- portation on a ship. " It was produced," says Dr. Rush, " by the exhalations from the gutters, and the stagnant ponds of water in the neighbourhood 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 neighbourhood of the ponds in the suburbs, were the greatest sufferers by it. Four persons had the fever in Spruce 66 FEVER. street, between Fourth and Fifth streets, in which part of the city the smell from the gutters was extremely offensive every evening. In Water 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 from 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 proceeds from the bodies of individuals crowded together in jails, hospitals and ships,have always been abundant sourees 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 occur- rence which took place last century in the Black Hole at Calcutta. One hundred and forty-six unhappy individuals 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 observed to take place after inocula- tion 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 employed have occasionally been asphyxiated; those who were standing at a little distance, were often affected with vertigo, fainting, nausea, loss of appetite, &c. History affords us remarkable instances of the occurrence of diseases decidedly epi- demic : the most ancient are those which will be found in sacred writ, in which we find, that on one occasion seventy thousand per- sons were destroyed by pestilence in three days' time; and we are told, also, that one hundred and eighty-five thousand persons were destroyed in the Assyrian camp in a single night. The most re- * It is to be regretted, that the term malaria is not restricted to foul air, according to its literal meaning. FEVER. 67 markable 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 doctrines of concoction, according to which it was supposed that a separation of the morbific matter had a ten- dency 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 prin- ciples of life, and its object is effected by a determination of blood to another organ: occasionally, a spontaneous discharge of blood takes place. From the time of Hippocrates, it has been generally believed that fevers have a tendency to remit on the 3d, 5th, 7th, 9th, 11th, 14th, 17th, 20th days, and even 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 eradi- cating the disease. When attending to this point, I 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 rigor took place— another from the period when the heat of skin occurred—and I have seen a third calculation made from the time when the patient con- fined 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 favourably, 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 termi- nation. Thus, in intermittent fever, the attack may come on regu- larly at the usual period, but each stage may occupy a shorter or a longer space of time in one paroxysm than another. Sometimes an individual dies in the cold fit, but much oftener the hot fit is not re- lieved 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 doctrine of critical days be true or false, if the physician acts wisely, and neglects nothing which can tend to reduce the diseased action. [* This question will be recurred to in the following pages.] INTERMITTENT FEVER. 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, fol- lowed 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 155S 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 increased comforts of the people, to their habits of cleanliness, and to the improvement 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 foundation, that a miasm producing intermittent fever, is generated in London, in the neigh- bourhood of St. James's Park. Intermittent fever is of very fre- quent occurrence 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 often relieved by the unaided powers of the constitution. Cullen's definition is, " Fevers arising from marsh miasmata, con- sisting of many paroxysms, with intermission, or at least with evident remission intervening, 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 situations 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 good ; but the worms were destroyed, and they got well. We have, in like manner, says he, agues from many dis- eases 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 Trans- actions, 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 North- fleet, is unaffected with intermittent fever, the adjacent hills suffer considerably from it. There are usually reckoned three kinds of intermittents, the tertian, the quotidian, and the quartan. But they ought strictly to be re- garded as the same disease, with a longer or a shorter interval; and the one frequently runs into the other. We often, however, see a INTERMITTENT FEVER. 69 double quotidian. I have observed, that the longer the interval, the more severe is the paroxysm, and vice versd; but there are many ex- ceptions. Tertian is employed to express that form of disease in which there is an interval of forty-eight hours from the commence- ment of one attack to that of another; Quotidian, twenty-four; and the Quartan, seventy-two. [Other forms—reduplications of these—are occasionally observed in the United States. As, for instance, double and triple tertians. The former may be mistaken for quotidians, a paroxysm occurring every day, but varying in'intensity, time of access, duration, &c.; every other paroxysm will, however, be similar. The latter exists when two paroxysms occur every other day, and a single one on the intermediate day. Innumerable types are described in the systematic treatises upon intermittent fever. We once witnessed the return of a single paroxysm every two weeks, for three months in succession; and with the utmost difficulty its recurrence was at last prevented.] Phenomena of Intermittents. When an individual has once had an attack of intermittent fever, he is afterwards more liable to the disease, and is sensible of its ap- proach 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 bluish colour; he has sensations of languor, and long fits of yawning; occasionally at this period there is headache, 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 a univer- sal 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 always laborious,short, and hurried, and the individual is unable to take in a deep inspiration when desired; a short hard cough frequently attends, without expectoration; there is great oppression at the praecordia. Some individuals complain 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 frequently 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 70 INTERMITTENT FEVER. every where, except in the extremities, is sometimes above the natu- ral standard. The paroxysm occasionally comes on without any rigor, instead of which the patient feels a slight sensation of cold, or severe headache, is lethargic, or affected with languor and yawning. Sometimes the paroxysm is announced by violent articular, lumbar, and frontal pains; and sometimesa 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 at 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 continues 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 occasionally 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 circumstance 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 op- pression at the praecordia; 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 an- nounce cerebral disturbance, viz., severe headache, tinnitus aurium, and throbbing of the carotids, &c. 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 ascertained, rise in the hot fit, even in this country, to 110°, 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 occasions the febrile symptoms continue for several days or weeks, when the disease is termed a continued fever; now and then there are marked remissions followed by exacerbations, when it is called a remittent: in addition to the last-mentioned circumstances, there are sometimes considerable irritability of stomach, black vomit- ing, 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 INTERMITTENT FEVER. 71 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 attended to the phenomena of intermit- tents, 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.* Many patients fall into a profound sleep for several hours, and then awake quite refreshed; others complain much of weakness, while some whose constitutions have not been previously injured, are able to resume their ordinary duties almost immediately. When this disease continues for some time, 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 complains of headache, intole- rance of light and sound; or he has a cough and dyspnoea, which will almost always be found to depend on inflammation of the lining membrane of the air passages; or he has constant thirst, flatulent dis- tension of abdomen, constipation, or diarrhoea, with griping pains in the bowels, a dull pain and sense of weight in both hypochondriac regions, more particularly in the right. The skin continues hot, and feels harsh; the feet and legs frequently become cedematous; the ab- domen permanently 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, and he may die in a few days of continued or remittent fever; or decided marks of inflam- mation of the brain, liver, lungs, &c, take place and he is cut off from the effects of disorganization in these organs. Such circum- stances are of frequent occurrence in warm countries, where inter- mittents prevail; many such melancholy examples will be found, by referring to the works of Sir John Pringle and others; but more particularly to Sir James Fellowes's reports of the destruction occa- sioned by this fever among our troops employed in the expedition 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 corroborates the above statements. This fever sometimes attacks individuals when labouring undef internal diseases, such as dysentery, hepatitis, &c, and I have fre- quently 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 con- * M. Andral, in the first part of his very excellent pathological writings, p. 477, mentions a very curious case. A young man, who had been hemiplegic on the left side of his body from his infancy, was attacked with tertain intermittent. He only perspired on thai half of his body which had not been paralysed. He slated ihat in his best health he never perspired but on one arm and leg, and one side of his face and neck. 72 INTERMITTENT FEVER. tinued for some time, the lower extremities frequently become (Ede- matous, the belly tumid, and sometimes even ascites takes place. 1 ne first does not denote danger, but the last always occasions an appre- hension of an organic lesion of some important viscus. Nevertheless, both may be occasioned by mere functional derangement. In these cases, the thirst is considerable, 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 ; 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 de- scribed 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 na- tural appearance and buoyancy. The heart, and veins near it, are gorged with blood ; and sometimes an effusion of blood, or blood serum, is found in the cavity of the pleura. In the abdomen,dark- coloured patches are sometimes seen on the peritoneum, occupying a considerable extent of the intestinal tube ; and, upon cutting through these portions, all the tissues are found highly injected, and it is pro- bable that this appearance has often been mistaken for mortification. The liver is sometimes 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 coagulated blood. I have seen the spleen in a similar 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 pathological and practical views yet to be detailed, I beg to subjoin a short account of some of the interesting cases and dissections de- scribed in the excellent work of M. Bailly,* whose zeal in the cause of science led him to visit 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 gij. of bark. "4th, Towards mid-day, he walked in the yard, felt very well, and laughed with the other patients. All of a sudden, he was seized with violent shivering, to which succeeded a very high fever, during which he had alternate flexion and extension of the forearms and ^l^^^^^1^^^^^^ dCS ™VreS Inl"™«entes, Simples et INTERMITTENT FEVER. 73 profound coma. He died in 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; colour of the cineritious matter of the brain much deeper than natural, approaching a dark reddish gray; a little water in the ventricles. No false membrane on the arach- noid. Great inflammation of the stomach, especially towards its great curvature, which was everywhere of a deep, generally diffused red. Many worms in the small intestines, which presented also in- flamed portions, especially where the ascarides had collected. "Case III.—Pierre Donati, set. 28, of a good constitution, was brought to the hospital of Saint Esprit on the 2d August, 1822. " An hour and a half after mid-day, he was seized with an acces- sion 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 fell again into the same state of coma. His pulse was frequent and strong; the skin burning. In the night copious sweating appeared, the intel- lectual faculties returned, and in 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 violent coldness, followed by heat and stupor, but never- theless, he always awoke when any one called him, and he opened his eyes. The forearms 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 perspiration, but not so abundant as the first. In the evening, return of sensibility and intelligence. 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; subsultus tendinum; he always lies upon his back; pulse full and strong. At half past 3 o'clock, sweat appeared, but less copious. After the sweat, he could not give an answer, and he was unconscious of his own state ; cessation of the contractions. Died at 10 o'clock in the evening of the 5th. "Dissection twelve hours after death.—Lively inflammation of the whole of the arachnoid ; serosity between the circumvolutions, with engorgement of the vessels; injection of vessels of the lyra. The brain being raised, there escaped half a pound of blood. Some points of a red colour 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, aet. 60, of a lean con- stitution, fell sick on the 17th August, 1822. He had the fever 7 74 INTERMITTENT FEVER. every day, beginning with shivering, and terminating in the night by sweating. At the same time he was constipated, and haa pain in the epigastrium. Was brought to the hospital of Saint Esprit on the 24th August. In the evening, the surface of his who e body was of a deep yellow citron colour; said this colour appeared during the last paroxysm; extremities cold, while he had a feeling of internal heat; tongue red and dry; pulse 10S, 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, ap- peared 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 colour. On open- ing the head, the dura 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 colour was scarcely perceptible; in- jection of the arachnoid; cortical substance of a deep colour: yellowish serosity between the convolutions. On slicing the brain, a number of red points were seen; a little water in the ventricles; the cere- bellum 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 colour 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 everywhere of the colour of lees of wine. Although it was well washed, there adhered to its surface a thick mucus, similar to the tenacious expectoration of patients labouring under pulmonary catarrh. The smaller curvature, and a portion of the greater, pre- sented 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 separated from each other, they communi- cated by their bases. The redness of the stomach was less lively towards the pylorus, but it begah 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 pressing 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 red, bloody, and swollen folds of the mucous membrane of the duo- denum, 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 colour was of the yellow of powdered bark: this is the only time I ever saw it in this state. The spleen was of the usual size, and quite diffluent. ' x . 1CT V:7^ntuVlIur\lL 4°' 0f a %ood constitution, was brought to the hospital on the 6th July. He was then without fever. In the INTERMITTENT FEVER. 75 evening the fever came on, preceded by shiverings, and followed by violent heat. Pulse strong, 120; coma. He lies upon the back. Right arm immovable. The left arm bent and carried towards the head. Sensibility everywhere. When an attempt is made to open the left eye, he appears to experience pain, and contracts the eyelids. Belly painful. "1th, 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; engorge- ment of the vessels which run on the convolutions, which are sepa- rated by watery exudations ; the left lyra greatly injected ; watery effusions at the base of the brain ; phlegmonous eminences in the stomach; which were of a gray slate colour; invagination of the small intestines; spleen voluminous and pulpy. "Case VI.—Vincent Orsini, set. 60, came to the hospital the 3d July 1822, in the following state : Coma; pulse insensible; extremities cold; demiflexion of the two thoracic 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, im- movable; 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 situ- ated between the dura mater and arachnoid. A fibrous tumour of the size of a large nut, adhered to the dura mater, under the posterior angle of the parietals, and compressed the brain; although the injec- tion of the arachnoid 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, est. 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 object. It was impossible to see his tongue, because his jaws could not be separated sufficiently. He only complained of pain when he was pressed in the region of the liver, 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 arachnoid was strongly adherent to the dura mater by granulations resulting from old inflammation; 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 cellular bands which alone offered some resistance JQ INTERMITTENT FEVER. 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 1 he intestines were inflamed in several points, and each inflamed portion corre- sponded to some knots of worms which were still alive. Ihe lung*, the spleen, and the stomach, were healthy. "Case IX.—Joseph Trotti, 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 con- tinued till the third paroxysm. 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: Agitation; impossibility of finding a position which procured rest; pain under the right false ribs, mounting to the top of the shoulder, and extend- ing to the left hypochondrium; pains in the articulations; head heavy; tongue covered with a white crust; bitter taste in the mouth, vomit- ing; 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 was 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; frequent eructations, urine always the same. As the tongue was white, and as he had no stools after the lavement, he took §i of manna, which produced a bilious stooi. In the night he had no sleep; delirium. " He became gradually worse, and died on the 14th 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 putrid and tuberculous; this affection commenced towards the convex part, extending itself on all sides, and descending towards the concave part; nevertheless, the greatest destruction was on the convexity; the rest was engorged and in- flamed, 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 colour- the ex- terior surface of the right lung was covered with a white c'rust, the inferior part adhered to ihe pleura costalis. INTERMITTENT FEVER. 77 "Case X.—Dominique de Marco, aet. 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 re- port of his parents, with an accession of the pernicious, comatose intermittent. He arrived at the hospital on the morning of the 8th July,and he was in the following state : Coma; decubitus on the back ; face red ; forearms bent and contracted ; pulse 112 ; convulsive trembling of the fingers; legs stretched and immovable ; sensibility everywhere. 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 watchful 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 stiff- ness of the right arm; he cannot show 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 rejecting it. He has taken seven ounces of bark through the course of the day. " 10M, in the morning.—Pulse 140, strong and full ; coma ; flac- cidity; general immobility; 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 convul- sions 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 ventricles; 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 consist- ence of that organ was natural. Stomach gray, externally, contract- ed, slightly inflamed ; small intestines presented two invaginations ; a portion of this intestine white, transparent, distended with gas; the rest gray 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. Liver gorged with blood ; spleen weighed between two and three pounds, and reduced into a gray, pulpy state. " Case XI.—Paul Tossini, aet. 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; somno- 78 INTERMITTENT FEVER. lence rather than coma; general pain of head. The patient only appears to be drowsy, for he is easily awoke, and understands suffi- ciently 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 depress 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 inter- vals, 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 patient 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 beginning to decline: the skin was hot and moist; the lips were encrusted; the pulse was not to be felt; respiration hurried; the two forearms bent, when it was wished to extend them; above all the right, violent pain was produced; preservation of sensibility, everywhere; sometimes the right eye a little open, the left being shut. He had several convul- sive movements this morning and towards mid-day. He took kino before the aceession at the moment when he already felt the cold. Increase of coma; died at half-past seven o'clock in the evening. " Dissection.—General injection of the arachnoid, particularly that part which covers the cerebellum and the lateral part of the com- mencement 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 pre- sented 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 Pompei, aet. 19, was seized on the 1st July, 1822, with an accession 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 consider- able epistaxis. He was in the following state : profound coma, eyes widely opened, directed to the right, fixed; expression besotted; gene- ral immobility; decubitus on the back ; insensibility of the extremities when pinched; they were quite flexible. He did not answer the questions which were put to him; the direction of the eyes did not change even when one approached him. He manifested pain when INTERMITTENT FEVER. 79 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 ques- tions put to him, but the coma went on increasing, 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. General 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 substance of the brain was of the natural colour. All the intestinal tube, without any exception, presented a red ap- pearance, 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 trans- parent, was penetrated with this congestion throughout its whole thickness; every thing indicated the first stage of a violent inflam- mation, 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 midday, the delirium 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 immovable ; 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, (lafie'vre algide) which we shall notice by and by, &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 following 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 80 INTERMITTENT FEVER. dry. (Bled to 8 oz.; lavement; tisane.) In the evening inciease of stupor, in consequence of the accession of another paroxysm, coma profound, eyes open, pupils contracted and immovable; the tore- arms bent upon the arms; no pain on pressing the belly. Sinapisms to the feet. . "24th July, in the morning.—Continuation of coma; pulse 1^4; head intenselv hot; flexion of the forearm ; it is impossib.e to depress the inferior jaw. Bled at the feet to S oz. In the evening, remission of the fever and of the convulsive symptoms; skm slightly moist; it was necessary to pinch his nose to make him swallow gij of bark. "25/A, in the morning.—Return of fever, and the flexion of the forearms ; continuation of the stupor; does not reply to questions: insensibility of the skin of the legs, that of the arms sensible; head intensely hot; decubitus on the back ; eyes open. Boiling water applied twice to the feet; the patient did not feel it very acutely. Pediluvium during six minutes ; snow applied to the head ; the pulse fell to S3. Return of intelligence; he swallowed voluntarily the bark; but a little 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 remained in this state till six o'clock in the evening: the coma returned, and he died at 7 o'clock. "Dissection.—A very vivid injection of all the arachnoid; be- tween 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 colour. "Case XXX.—Joseph Maoloney, aet. about 60, came to the hos- pital 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 with- out 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. "22d, in the morning.—Pulse more expanded; the ideas still con- fused, diminution of agitation, heat natural everywhere- 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 INTERMITTENT FEVER. 81 p. m., lancinating pain of belly; pulse small, frequent; extremities cold, and bathed in cold, clammy perspiration ; inferior extremities bent upon the belly. Bled from the arm; died in half an hour after- wards. " Dissection.—Injection of the vessels which ramify upon the con- volutions 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 fissure as in the other cases, but presenting an opening 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 flat- tened like jelly, and the other portion remained attached to the dia- phragm, which they were obliged to cut to expose the spleen com- pletely; 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-coloured within; bladder natural; liver gorged with blood. "Case XXXVIII.—Angelo Galetti, aet. 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 com- plained 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, forearms, arms, cheeks, of an icy coldness; the belly, chest and forehead were of rather a lower tem- perature 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 po- sition 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 colour, so that the violent injec- tion of which they were the seat, had existed throughout 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 externally; on being opened, it presented an inflammation, the violence of which was greater towards the rec- tum, where the mucous membrane was so intensely inflamed, that some blood had been effused, which, mixing with the mucus, formed a thick coating, which adhered to the whole of its surface. The colour of all the interior of the colon, and especially.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 extre- mity, an infinity of little depressions, from half a line to a line in 82 INTERMITTENT FEVER. diameter, and some of which contained in their bottom a small spot of blood, which was easily removed. The folds of the mucous mem- brane were, besides, nearer each other, and more numerous than ordinary. The mucous coat itself was thickened. 1 he liver was healthy. The spleen large and prettv hard, but of a redness ot 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. "Case XXXIX.—Vincent Crescenzi, aet. 60, of a thin but healthy habit of body, fell sick on the 19th August, 1822. He was attacked with fever, which set in with shiverings, 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 hospital of Saint Esprit on the 19th August, 1S22. The fever re- turned in the morning, preceded likewise by shiverings, and accom- panied by the same symptoms as in the evening; the stomach was painful on pressure; the patient experienced a great heat in the inside; anxiety; depressed countenance; the features were as if flat- tened 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 qold clam- my 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 cere- bellum natural; heart and lungs healthy. Stomach gray externally and contracted. Inner surface of a bright red, deeper still towards the pylorus. Foldings of the mucous membrane better marked than usual. Small intestines gray 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 inflam- mation, 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, between the state of de- generation and health. This inflammation could be compared onlv to that of the 30th case. ' J « Case XL.-Vincent Cola Paolo, of Rimini, aet. 40, of a <*ood constitution residing at Roma Vecchia, entered the hospital on 7th July. Had been attacked with a paroxysm of fever on the previous INTERMITTENT FEVER. 83 evening. On the morning of the 7th, his state was the following:— Hands colder than those of a dead person ; pulse 108, small, con- tracted ; 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 par- ticular aspect which characterizes those labouring under the fever; but the hands have always an icy coldness which extends halfway up the forearm; 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 reluctance. Hasan inclination to sigh. He lay on the side, with the legs bent upon the abdomen; the fit commenced, the cold gained upon the trunk, re- spiration 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 en- gorged ; the stomach is much inflamed in its pyloric half, the rest of the intestinal canal healthy. "Case XLI.—Angelo Donni, of Milan, aet. 35, weak, lymphatic constitution; preparer of macaroni. On the 5th July, 1822, he en- tered one of the grottos of Monte Testaccio, 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 him- self. 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 character, that according to his account, the medical men 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 11th 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 ex- pression 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 occasioned by the cessation of the motions of the heart. He was merely supported, and recovered, and he was then enabled to ascend more than thirty steps, in order to reach the clinical ward. When in bed, the following was his condition ; pulse frequent, weak; tempera- ture 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, 84 INTERMITTENT FEVER. 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 gvnj. Extract of bark, theriaque, aa gij. Laud. liq. anod. camph. emuls. aa 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 the 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 drowsiness; 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 dur- ing life. "Dissection.—Stomach highly inflamed between its great cur- vature and the pyloris. Intestines presenting traces of inflammation in some parts. 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 minut- est 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. Gray substance of the brain, of a pale, rather than of a deep hue; choroid plexus pale; serosity between the circumvolutions; brain of a soft consistence." 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 were 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 enteritis, 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 liver was softened; in four gorged with blood; and in one case the gall-bladder was inflamed. In two cases there was pericarditis. In three, peritonitis. In one, pneumonitis. In one case there were inflammation and enlargement of parotid. These statements respecting the appearances on dissection in in- INTERMITTENT FEVER. 85 termittent fever, will be found fully corroborated in the works of Morgagni, Pringle, Cleghorn, 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 56, it is unneces- sary to do so in this place, further than to repeat my conviction, that the effects of internal irritations, sudden variations 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 dimi- nished circulation of blood in the extremities, then a sense of cold- ness, 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 functions become impeded. The lungs show their gorged state, by the short, difficult, 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 additional proof of the embarrassed state of the lungs, showing that the blood is not properly decarbonized. 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 probably be attributed to an accumulation of blood in 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 oppression at the praecordia, may be fairly attributed to the same causes. The mus- cular prostration, and feeling of sinking, are not owing to actual debility, but to obstructed action, in consequence of the above-men- * This is the state termed congestion, which implies, that the balance between the arterial and venous systems is deranged for the time, the latter being overloaded or congested wiih blood; and not that the circulation in any organ, or set of organs, is entirely obstructed: which, nevertheless, does actually happen in those extreme cases in which reaction does not take place, and the individuals die in the cold stage. 8 86 INTERMITTENT FEVER. tioned condition of organs. The proof of all which circumstances is to be found in the fact, now well known, that abstracting Wood, in the cold stage, will immediately remove not only the difficulty ot breathing, the pain in the head and loins, the disordered 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 spasms 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 vessels 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 respira- tion, 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 increase the uneasiness; the heart partakes also of the debility; this debility of the heart produces an accumula- tion of blood in the great vessels, and this occasions 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 spasms. 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 de- scribed, but instead of attributing 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 debility; and accordingly we find, that stimu- lants employed at this period have produced good effects in checking this disease, while evacuations, as blood-letting, which at another period of the disease, might have been proper, if employed in the first stage, never fail to be attended with most dangerous conse- quences; or it is, to use the words of Celsus, mominem jugulare.'" I shall now show that this is a statement which Celsus never made with reference to the cold stage of intermittent. On a careful refer- ence, I find no allusion made to such a practice in his works • but in INTERMITTENT FEVER. 87 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 state- ment made by Sir John Pringle, who, in allusion to the good effects of bleeding in the camp fever which he describes, observes, on page 210, (Observations on Diseases of the Army, ed. 1768,) "A person unacquainted with the nature of this disorder, and attending chiefly to the paroxysms and remissions, would be apt to omit this evacua- tion, and to give the bark prematurely, which might bring on a con- tinued 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 intermissions. In order to«make Cel- sus's maxim (he quotes the above passage from lib. ii. cap. 10,) con- sistent with this practice, we must interpret his term impetus febris in the sense of this chilliness or cold fit which preceded the hot one in the fevers which he describes,,/^ 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 pre- cise—he makes no allusion to the cold stage. Does not this show 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 reaction; 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 reaction. In this man- ner Dr. Gregory and others make the spasm of the extreme vessels the cause of the diminution of blood on the surface ; and then he observes—" The blood thus driven upon the internal parts, must ac- cumulate 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 " the principles of life;" or, in the language of Cullen, to " vis medicatrix nature," which is ever in action, to pre- vent injury, and to remedy the evil after it has occurred. The phe- nomena which are ascribed to the state of reaction, are those, the combination of ivhich is denominated fever; namely, hot and dry skin; quick pulse ; thirst and loss of appetite ; restlessness and anxi- ety; headache, 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 88 [INTERMITTENT FEVER.] partly to the suppression of the secretions and excretions; also, proba- bly, to some change in the nervous system, but principally to the in- creased quantity of blood driven to the surface of the body. Sweating stage.-It has been stated, that, in cases in which no organic lesion exists, the pains and uneasy feelings begin to subside after the commencement of the sweating, and soon afterwards dis- appear. 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 depleting 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 ac- curate observations 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. [The pathology of intermittent fever has ever been a vexed ques- tion in medicine, nor shall we attempt to solve it; at the same time, we propose to give a brief view of those modern doctrines, which, originating with the French pathologists, have been more or less adopted wherever medicine is cultivated. The physiological school apply their idea of irritation, somewhat modified, however, to explain the phenomena of intermittent fever. The fundamental principle to be established is, that irritation can admit of total disappearance for a longer or shorter period, and then return at stated intervals with its previous intensity, leading finally, to alteration of the tissues of organs. It is contended that periodicity is natural to a state of health; that the activity, and consequent functional energy of many of the organs, are not constant, but roused at certain periods, while during the intervals they are in a state of comparative repose; thus the brain has its waking and sleeping hours ; the stomach digests its food, and becomes quiescent; even the heart and lungs undergo diminution of energy. But there are more marked periodical occurrences, as the menses, hemorrhoidal fluxes, &c, which give both force and plausibility to this position. On referring to the modification of irritation by the tissue in which it is located, it will be found that in those which are so anatomically constructed that it can easily be produced, and as rapidly removed, periodical irritations are universally seated. Such tissues possess a looseness of structure, and abound with nervous filaments and blood- vessels. Those which are low in the scale of vital activity, which are closely allied to the osseous structure, and which, when once diseased, go through long and protracted changes, are not affected by periodical irritation. The tissues, then, in which this form of deranged organic action is manifested, are those which possess the highest degree of vital activity, as the brain, mucous membranes, and the hollow viscera. For reasons analogous to those which induced Broussais to locate the primary irritation of continued fever in the stomach and intestines, he is led to maintain that the primary seat of intermittent fever, is in the same viscera; and without searching for the cause of periodicity, is satisfied of its existence as a fact [INTERMITTENT FEVER.] 89 Intermittent fever, therefore, is regarded by him as gastro-enteritis running through its stages in a limited time, and terminating by a translation of irritation to the skin, inducing profuse perspiration; thus constituting a true crisis* The phenomena of the paroxysm are accounted for in the same manner as those of fever generally, some of the preliminary symptoms being referable to the organ primarily affected, the others to sympathetic disturbances. In pro- portion as the first is intensely affected, will the symptoms be acute, and the sympathies called into action, giving rise to attacks of greater or less violence. If any one of the vital organs be so much deranged as to threaten life, as, for instance, the brain or lungs, a form of dis- ease appears which is termed pernicious intermittent; or if attended with putrid or adynamic symptoms, it is called malignant inter- mittent. Intercurrent intermittent and remittents are only shades of the same disease; the irritation subsiding at intervals, but not totally disappearing, and then again occurring with fresh energy, changing the type of the fever, but not its essential character. Con- gestion in important internal organs, is the most formidable attendant upon these intermittent irritations; the blood is so forcibly, and in such quantity determined to them, as to suspend their functions, or even to destroy them in debilitated persons, or in those who are prone to irritation. This effect is what is designated by the " lost balance of the circulation;" and means nothing more than diminution of excitement, and anaemia of external organs, while an irresistible attraction of fluid exists in the central. The analogy between con- tinued and intermittent fever, (the latter being regarded as identical in nature with the preceding, only running its course in a shorter time,) is strikingly demonstrated by the easy transition of one into the other. Thus, by stimulating a patient labouring under the aggra- vated symptoms of intermittent, the periodical irritation can be con- verted into continued; and frequently the continued form may, by soothing measures, be made to assume a partial and even perfect periodicity. The irritation being disturbed, the transfer to the skin, or crisis, will be imperfect; which is another cause of prolonged irritation, and change to the continued form. Hemorrhagic and neuralgic irritations sometimes assume an intermittent character; hence the close affinity noticed by authors, between them and inter- mittent fever. M. Broussais endeavours to confirm his reasons for establishing the primum mobile in the stomach and bowels, by reference to the different organic lesions which are found to ensue from protracted attacks: as, chronic inflammations of the mucous coat of the stomach, with thickening and alteration of texture; enlarge- ment of the liver with alteration of function leading to jaundice; dis- ordered digestion, and its concomitant evils ; and enormous increase of the spleen, vulgarly denominated ague cake \ these all result from that form of irritation constituting inflammation. M. Roche has thrown out some ingenious reflections upon the * ["Each regular attack of intermittent fever is the sign of a gastro-enteritis, the irritation of which is transferred to the cutaneous exhalents, producing a crisis; if the irritation isnot completely displaced, the fever is remittent; if it ceases to remove at all, it becomes continued."—Examen des Doctrines Medicates.] 8* 90 [INTERMITTENT FEVER] disease which at present occupies us. He contends that fevers cannot assume the intermittent type, unless the causes are of the same periodical character; and upon an examination of them, it will be perceived, that they are intermittent in duration. Intermit- tents most generally abound in the spring and autumn. Now it will be acknowledged that, during these seasons, there is the most marked difference between the temperature of the day and night, and con- sequently, at short intervals of a few hours, an alteration of action and reaction takes place in the human frame, which soon may be converted into habit. The impression of marshy exhalations is precluded during the day, in consequence of their being diffused and dispersed into the upper atmosphere by the effect of solar heat: but as soon as the effect of this is removed, the upper strata are condensed and precipitated in a concentrated form, so as to have acquired peculiar violence ; when, coming in contact with the skin and mucous membranes, they are absorbed, and produce the phenomena which constitute an accession of intermittent fever. If the action of marsh miasmata be inter- mittent, it is not astonishing, that the malady which is produced by them is equally so. According to this author, the accession of the paroxysms is repeated by virtue of a tendency of our organs to re- produce certain acts which once had taken place, even when the cause first provoking them had ceased to operate. Very frequently the repetition of a paroxysm does not occur, in consequence of a withdrawal of the causes; this is countenanced by the fact, that removal from an infected district cures the disease in numerous instances. M. Brachet has paid some attention to the phenomena of inter- mittents. Basing his theory upon the peculiar views which he takes of the offices and connections of the two nervous systems, the cere- brospinal and ganglionic, he attributes the primary lesion to their derangement, to the exclusion of irritation as understood by the physiological school. The ganglionic system presides over all the actions of organic life, as nutrition, secretion, &c; while the nervous system of relation has charge of the connection with the exterior world. According to him, the phenomena of intermittent fever, are such as can only be produced by derangement of the healthful influ- ence of the first communicated to the second ; and no matter whether the modifying impression is made externally by atmospheric or fife n?Vf tauGS place internall7 by marsh miasm, the first resl o? nf.T °n ^ "erVeS0f the 0r§anic movements. That the result of this impression is not inflammation, he proves by the fol- £7 ^nSJT"* ^^ the end of 5ctober> "*£ he took taT rr10?' midnight, a cold bath in the river the second half ,„ h "*? °f \qUarter of an ho«r's continuance; unti he was-,hlpH°;ir; fr°m this he Went on Protracting the time each bath he h?HH remam ln the water a whole hour. Arte reaction wUh in * a m a "?"" bed'and underwent considerable wh h he wen tosteel ^ffS'foUowed ^ Profl,se sweati"S ; after 7hlt»n!L II- P' At the exP»ration of seven days M Bra- chet omitted his experiments; but was surprised to findJdurTng the [INTERMITTENT FEVER.] 91 following day, that between twelve and one o'clock p. m., all the attendants of a true intermittent paroxysm made their appearance. As he experienced no inconvenience during the interval, he allowed this artificial fever to proceed, and experienced six distinct attacks. Upon the seventh night following the last bath, he was called upon to ride some distance upon professional business, a short time prior to the expected invasion; the exercise thus taken produced excite- ment of his system, which was kept up by placing himself near a large fire, and from that time no accession reappeared. This account corroborates, in a measure, the statement of M. Roche, that inter- mittence of cause will produce a habit, more or less difficult to coun- teract, in proportion to its fixedness. In speaking of these conclu- sions of M. Brachet, it is understood that the paroxysm is simple in character, and unaffected by organic lesions which would modify its type, and be productive of such complications as are found in these fevers of serious grade. Malignant intermittents assume forms which are characterized by acute symptoms, arising from serious lesion of some particular organ. If it be the brain, there will exist phrenitis, apoplexy, &c. If the heart, the various manifestations of cardiac disease; if the liver, he- patic derangement; if the lower bowels, dysentery may be the com- plicating attendant. The danger of these different complications is, of course, measured by the importance of the organ and the force of the attack.] Treatment of Intermittents. It was formerly a matter of high dispute among physicians, whether an intermittent fever ought to be immediately cured, or allowed to run its course. Many believed that the system is benefited by the disease—that the febrile symptoms, in fact, are the natural cure of some other disorder in the constitution—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 laxa- tives, to keep the bowels open. The best maxim in physic is, to get rid of diseased action as quickly as possible, as there is no saying what mischief is to follow in the train of consequences. "There could not be a moment's hesi- tation," says Dr. Fordyce, "in determining to restore the patient to perfect health at once, were there 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 medicine 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; recommending the brown, the yellow,or the red, with such decided preference? Why should they prefer arsenic or zinc, if any one were uniformly suc- cessful ?" 92 [INTERMITTENT FEVER.] The discovery of such a remedy has always been a great deside- ratum; and although no one remedy has yet been found out, I believe bleeding, in the cold stage, conjoined with laxatives, and the occa- sional use of the sulphate of quinine, to be as certain a mode of treating intermittents, as any other set of remedies 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 differ- ent management 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 intervals, to prevent a return of the complaint. In the cold stage, which generally lasts from half an hour to two or three hours, the first thing to be done is to endea- vour, 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 reaction. 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 considerable relief, when a sufficient degree of heat can be applied to the epigastric region. It appears to be more efficacious than the general warm bath, in which I have seen the 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 reac- tion, and cut short the cold stage; and there can be no doubt that it has sometimes succeeded; but I have seen much injury ensue in many cases. This enables us to account for the horror entertained by the older writers, at cutting short the cold fit, because it was never attempted 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 succeeded, and in two or three instances, local inflammations. [Opium is sometimes given with decided effect to arrest the cold stage of intermittents. The usual method is to administer thirty drops of laudanum in a tumbler of hot lemonade, and if the desired result is not obtained in a quarter of an hour, give half the quantity in the same medium. The ague is in most instances, speedily ar- rested, sometimes in a few minutes, and followed by the hot stage, which latter is rendered shorter and more tolerable by the opiate treatment. Emetics also assist in abridging both the duration and severity of agues, nor is there any objection to the use of ipecacuanha or mus- tard for this purpose. There is often a disposition to vomiting; and by promoting it, the stomach may be relieved of undigested food or irritating secretions, and becomes better prepared for the reception of curative remedies at the close of the paroxysm.] Bleeding, in the cold stage, will, in a great majority of instances, cut INTERMITTENT FEVER. 93 it short; in fact, it will rarely fail in stopping the existing paroxysm, and, on many occasions, it has prevented a return of the disease to which the patients had been long subject, and by which they were nearly worn out. It is difficult to determine 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 orifice in the vein, 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 convul- sive 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 ab- stracted, they will cease altogether, and with them will vanish the painful sensation of cold. The pulse will be found stronger, 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.* I wish to impress upon the minds of my readers, that by venesec- tion in the cold stage of intermittents, we stand upon vantage ground, by affording 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 dis- eases, 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, as well as by materially shortening the duration of the diseased action. 4th, The chance of a return of a paroxysm is diminished; or if it should recur, 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 administration 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 * [The author, in support of his views of the advantage and importance of bleed- ing in the cold-stage of intermittent fevers, has given a condensed history of nume- rous cases treated in this way, both in Europe and in India. Though these cases are published in our last American edition, we have thought it unnecessary to re- print them on the present occasion, inasmuch as the author's views are sufficiently elucidated without them; and also because the treatment in question, however ap- propriate in the apoplectic or congested state of vital organs, is seldom requisite in the management of the common forms of intermittent fever in this country.] 94 INTERMITTENT FEVER. is far more efficacious than bleeding during the hot stage, or in the intervals. Several cases are quoted, in which bleeding was had re- course to in the hot stage to moderate threatening symptoms, but without preventing a return of the disease at the regular period ; and in these same instances, bleeding in a subsequent cold fit, had the effect, not only of stopping the existing paroxysm, but of preventing its return. If any other evidence were wanting to show 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 prevailing disease was intermittent fever, and in the course of six weeks, 8000 sick were sent to England, and 3000 more soon followed. While only 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 Parlia- ment, that several months after the return of the army, there were on the sick list 217 officers, and 11,296 men! All this took place, notwithstanding the scientific employment of bark in every form. 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. Keliie, in the 1st and 2d volumes of the Annals of Medicine.* [After many experi- ments this gentleman came to the following conclusions: 1. If dur- ing the cold stage of an intermittent, the tourniquet be so applied as to obstruct the circulation in either the arms or legs, the hot stage will follow in the short period of three minutes. 2. The cold stage may be wholly prevented by-applying the tourniquet before the paroxysm begins. 3. The result of thus preventing or abridging the cold stage, is to render the hot stage shorter and milder. Ten or fifteen minutes' pressure with the instrument is sufficient to produce the desired effect; and it was found that a more protracted com- pression tended to defeat rather than promote the desired object.] The tourniquets appear to act, by confining the blood in the extremi- ties, and preventing so much at least of the congestion in internal organs. 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 symp- toms of local inflammation, bleeding is to be had recourse to, either invent^/ LaUeTand! * menti°ned by B°iSSeaU' P" 523' as if il were th* ™Sinal INTERMITTENT FEVER. 95 general or topical, which has always been employed by judicious practitioners in 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 symptomatical physician. It is more than doubtful, whether such medicines ever diminished the violence, or shortened the duration, of the hot stage of an intermittent. Treatment in the siveating 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 patient 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 exists 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 intermittent 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 frequently. I have seen fatal affections of the heart arise in the train of consequences from intermittent fever. Bronchitis is also of frequent occurrence. These facts are stated from my own expe- rience; and, except the last, respecting 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 exists, 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 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 fevers, which had previously resisted all other means; and he assures us at page 366, that although he would not altogether proscribe bark, yet he believes that bleeding alone, in most cases, above all, in our climate, would bring about a more substantial re- covery. He also makes a very strong statement at page 375. " In the commencement of an intermittent fever," says he, "one is almost always sure to destroy it by a large bleeding;" and he shows that this disease is not so fatal to poor debilitated subjects, as 9Q INTERMITTENT FEVER. to those who are better off, and better fed. For example the mor- tality at Rome, where great misery prevails, is 1 in 26 of the whole population; whereas, in the marshes in the neighbourhood of he Sienne, the mortality is in the enormous proportion of 1 to 10 ot 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 distin- guished author been aware of the safety and success of the 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 bleed- ing." Speaking of the advantage of bleeding in this disease, he says at page 383 :—" Car fen except e toujours lesfievres intermit- tentes pernicieuses, dans lesquelles on n1 aura-it pas le temps d'em- ployer la saignie, si on ne se rendait pas maitre de mouvement nerveux par ceprkcieux anti-piriodique" 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, stimu- lants and bark, in considerable 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 necessary, 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 overloadihg the stomach and bowels with indigestible lig- neous fibre, and I have seen it cause serious intestinal irritation, as displayed by griping pains in the bowels, diarrhoea, and painful te- nesmus. On examining the stools in these cases, they seemed chiefly to consist of bark, with a considerable quantity of rnucus, occasion- ally tinged with a little blood. That preparation of bark which is known by the name of the sulphate of quinine, is the greatest im- provement in modern pharmacy, and the knowledge of its beneficial effects in simple intermittents, affords sufficient proof of the virtues of the substances 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 experience 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 disease." My youthful readers may rest assured, that the same observations are equally ap- plicable to the sulphate of quinine. They 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 im- pressed upon the mind that experience has taught me to beware of INTERMITTENT FEVER. 97 any preparation of bark while the patient has fever, complains of oppression at the praecordia, or has a loaded tongue. Sydenham's recommendation, of prescribing bark in the intervals, has been supported by subsequent experience. Bark is given in sub- stance, in decoction, infusion, and in extract; but no one who has seen the superior efficacy of the sulphate of quinine, will, I am per- suaded, 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 before 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 sud- denly cut short, as it was in those who tookthe twodoses of four grains each. He also states, that in two cases the sulphate of quinine did not subdue the fever till the dose was increased to twelve grains; and Lerminier 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 created troublesome nervous symp- toms, such as violent palpitation of the heart; oppression; the glo- bus hystericus; general uneasiness; flying pains in different parts of the chest and abdomen.* 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 the expected paroxysm; 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 afterwards ventured upon ten, but a violent headache followed, which continued for nearly three days; I have given ten grains, however, 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 recommended; the best of these is the effusion of quassia. Opiates have been exhibited imme- diately before an expected paroxysm, sometimes with benefit, but they generally produced 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 9 Clinique Mldicale, p. 488. 98 [INTERMITTENT FEVER.] of the stools; and upon the bowels being put in V™?**™*™'^* disease has given way without further trouble. Vrom™e™!* M1*1 intermittent fever is a disease of debility, many practitioners give nourishing and stimulating diet, with wine, in all cases; run aner the above pathological account, and the appearances found on dis- section, a word more need not be said to show the impropriety of such treatment. In some instances, nourishment and stimulants prove beneficial, where there is no local disease ; but in others such treat- ment must prove prejudicial. The patient should be clothed accord- ing to the season of the year, and the temperature of the climate. He should avoid exposure in bad weather, (particularly in our climate during the prevalence of easterly winds,) and keep to the house after sunset, till he be sufficiently recovered. [With regard to the exhibition of quinine, some remarks remain to be presented. In this country it is seldom requisite to administer more than twenty grains during the first interval, and half that quan- tity during the following one, to effect a cure. Instances, however, frequently present themselves, in which the exhibition of a larger quantity than is necessary to attain this end, would be positively in- jurious ; and practitioners have adopted the safer plan of giving a grain or two grains each hour, and limiting the quantity to the num- ber of grains above specified. It has been stated that this indispensa- ble remedy sometimes fails: it is, therefore, important to inquire into the causes of failure, and how they may be avoided. With regard to blisters, and all stimulants, in fevers, there is said to be a specific point in which they are to be employed : if they are applied before this has been attained, an increase of disease is the consequence. This point is a state of reduced local or sympathetic excitement in organs which, when stimuli are applied to them, will not cause re- action to be transmitted from one to another. Should the stomach be irritable, the quinine will most probably be rejected: but even should this not happen, it is liable to cause sympathetic irritations which may prove extremely embarrassing ; as, for example, increase of fever, determination of blood to the head, oppressive constriction of the chest, &c. It is, therefore, necessary first to obviate the general excitement; and to prepare the stomach and bowels by the milder cathartics, and such other means as the occasion may demand, in order to obtain a perfect intermission before we administer the quinine. Cases, however, not unfrequently occur, in which the intermis- sion is complete, but owing to irritability of the stomach or repug- nance to medicines, the patient cannot take by the mouth a sufficient quantity of quinine to prevent the expected paroxysm. Under these circumstances we have two resources,—injection into the rectum and the endermic application of the medicine. For the purpose of injection, ten or fifteen grains of the sulphate of quinine should be dissolved in four ounces of mucilage of gum arabic or flax-seed, and administered at a single operation; and this must be repeated three or four times at intervals of three, six or eight hours, according to the duration of the intermission. The endermic plan is equally, but not so speedily available. A YELLOW FEVER. 99 blister is to be applied to the epigastrium during the apyrexia, and the vesicle clipped at several points without removing the epidermis. To this vesicated surface apply six or eight grains of powdered quinine, (either alone or mixed with a little starch,) four times a day, for two successive days. I have seen this practice succeed most happily when the system had resisted all other modes of treatment; and if the patient remains quiet, the irritation of the surface is not distressing, and can always be relieved by the application of a poul- tice without removing the quinine. There is a tendency in intermittents to return in about two weeks after the paroxysms have been stopped; and in order to break up this liability, I am in the practice of anticipating the paroxysm by recommencing the use of quinine two days before its expected recur- rence; and by pursuing this plan two or three times at equal inter- vals, the morbid habit may, in most instances, be speedily eradicated. Dr. Hartle, of Port Spain, in the West Indies, has made extensive use of piperine as a substitute for quinine in those cases in which the latter has proved inefficacious. Seizing the first indications of the intermission, he gives three grains every hour until eighteen grains have been taken, and during the next following intermission, he repeats the same dose every three hours. Dr. Hartle speaks in the strongest terms of commendation of the piperine, which in certain cases he combines with blue-pill; and we may here remark, that the latter may often be administered with quinine to great advantage, especially in cases which present a persisting gastric irritation, as manifested by a furred tongue, nausea, &c. The bark of the common dog-wood (Cornus Florida,) is extensively used in some parts of the United States as a substitute for the pre- parations of bark. It is chiefly given in strong decoction.] MALIGNANT REMITTENT, OR YELLOW FEVER.* This is a fever in which there are remarkable remissions, followed in a few hours by exacerbations; so that it bears some resemblance to an intermittent. 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 derangement, which runs more quickly into disease of structure than is observed in the fevers of this country. Remittent fever has a wide range of cha- [* The author, in his arrangement of fevers, page 51, and again in this place, uses the terms remittent and yellow fever as synonymous. This nomenclature is so op- posed to the received opinion in this country, that I have prefixed the word malig- nant to the heading of this chapter, in order to prevent ambiguity. The subsequent chapter on continued fever, embraces also the history and treatment of various modi- fications of remittent fever.] 100 YELLOW FEVER. racter; 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 Ins place of residence. In its severest form, the viscera of the three great cavi- ties 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 without rigor; on other occasions, the rigor is severe. Uenerally speaking, there is some previous indisposition, such as headache and giddiness; want of appetite ; symptoms of indigestion ; oppression at the praecordia; constipation of the bowels ; a feeling of debility and fainting, and bad nights. Sometimes it happens that the patient dies before reaction 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 occured," says Dr. Fer- gusson, "to a well-seasoned soldier, mounting the night-guard in perfect health, to be seized with furious delirium while standing sen- try, 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 impossi- ble 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 reaction, heat of skin, and determination to the head, announced by the following well-marked symptoms: face flushed ; conjunctiva injected, the eyes look heavy, and often feel burning; the expression of the countenance 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. Intolerance of light, and 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 much bile, and accompanied with a discharge of fla- tus, belched up with great violence; the urine suppressed. The pulse is various even in people similar in age, constitution, strength and habits; but in plethoric subjects who are seized soon after their ar- rival in warm climates, the pulse is quick, full, and bounding for a few hours, at least, after the reaction is fully developed. In some it redness and sense of heat in the e^'Zhed t'^ete'SS; YELLOW FEVER. 101 quick or laborious respiration, burning pain in the region of the stomach, with great thirst and excessive vomiting, announce a for- midable disease; 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 is 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 subsides; the head is confused, or delirium appears; the breath- ing 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 occasionally falls asleep, but instantly awakes in great terror ; sometimes he starts out of bed furi- ously 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 distress the patient 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 manifested by the recurrence of all the symptoms in an aggravated degree. In the second stage, there are remissions, also, particularly towards its termination, when the 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 matter vomited is of a dark colour, resembling coffee grounds, and is termed the " black vomit." The breathing becomes more laborious; the tongue has perhaps 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 cold as marble; there is a trou- blesome hiccup, which, perhaps, has existed throughout 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 according as the brain, ihe lungs, and contents of the abdomen, are more or less affected. 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 ex- hibits a variety of nervous symptoms, such as convulsions, rigidity of the extremes, tremors, subsultus tendinum, and picking the bed- clothes. Where the head is more slightly affected, the senses are only occasionally obscured; the patient may be said to be lethargic rather than comatose; he is easily roused, and, when roused, his countenance has a drunken or besotted appearance. 9* 102 YELLOW FEVER. 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 organs. There may be cough also, attended or not with pain, followed by expectoration. I never saw a case of remit- tent fever in which the functions of the chylo-poietic viscera were not very seriously involved, as indicated by nausea and vomiting, thirst, pain in some region of the abdomen, meteorism, and altered condition of the stools. It has been mentioned that the functions of the kidneys seem to be almost, 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, as in cholera. 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 constipated, or after having been for some time so, he may now complain of diarrhoea ; 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, the senses become rather obscured, the breathing is affected in no other way than being short, and he cannot, even when he makes an effort, dis- tend his lungs freely; he complains most of oppression at the prae- cordia. 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, per- haps, of violent pain in some region of the abdomen; the breathing is oppressed, 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. It will be sufficient to repeat, that 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 dif- ferent organs within the abdomen may be affected, producing other varieties; and of these there may be various modifications and com- plications. Appearances on dissection.-These appearances vary much, ac- cording to the duration of the disease, and the organ which has been chiefly affected; some dying ,n 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 who have lost no blood Some individuals may have died of remittent fever with organic lesions produced by previous diseases. JW™££&£* [YELLOW FEVER] 103 stances must be kept in view when we are employed in the investi- gation of morbid appearances. Some blood is generally found in the heart and large vessels near it, and also in the lungs, if the individual has not survived long, or been largely depleted. Pleuritic effusions are sometimes seen, and recent adhesions; the lungs themselves, in some instances, show vari- ous stages of inflammation, and the bronchial tubes are extensively diseased. In the abdomen as in the thorax, 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 a similar manner. The stomach and bowels, when slit open, are found to contain more or less of the dark-coloured matter which has been vomited during life, and the mucous membrane very vascular, of a deep red colour, 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 follow- ing points:—Whether the vessels which make such an appearance are in the mucous membrane or not? Whether the whole coats of the intestine are discoloured or not? Whether this colour is owing to inflammation or infiltration ? At what particular points ulcera- tions are most frequently met with, together with a particular descrip- tion of the appearances of the ulcerated surfaces, and the adjacent 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 showing the recent vascular appearances; if to enrich my rapidly increasing museum, the greater obligation will be laid upon me, and no remuneration which it is in my power to bestow, will be thought too great a sacri- fice for such a boon.* [The late lamented Dr. Lawrence has left the notes of fourteen cases of yellow fever, examined by him, in the city of New Orleans during the years 1817-18-19—which contain the following interest- ing facts In all except one, it was found that the stomach presented the appearances of active inflammation, particularly throughout the mucous surface of the larger curvature. The case which formed an exception, exhibited the stomach of "a dark dirty colour in some parts of its internal surface. The small intestines were, in every case, in a state of inflammation, particularly the duodenum, which, in several instances, was marked with dark livid spots. The stomach of one individual was "very large, and distended with air, contain- ing some black, coagulated stuff mixed with a mucous substance. This mucous substance was very copious, and much resembled the villous coat of the stomach. In fact I had no doubt, but that some of it was the villous coat; as this coat, particularly about the middle * It may be mentioned, that nothing affords me greater pleasure than to spend an hour in my museum with any pathological inquirer. 104 [YELLOW FEVER] of the stomach, was remarkably thin, and could be taken off with great ease. In some places were dark-looking patches, intimately united, resembling the coasulated substance in black vomit. I soon had scraped off the mucous coat from these places, and the dark matter was removed with it, as if it was the mucous coat itself, merely changed in colour. This would lead to the inference that the black vomit is nothing but a rejection of the disorganized villous coat of the stomach." The lungs and other viscera were generally found in a sound condition, with casual lesions, however, some of which were attributable to former disease, others to that which was of more recent origin ; but there was no uniformity of occurrence. Dr. Jackson, in his history of the epidemic yellow fever which invaded Philadelphia in 1S20, has presented the result of the post mortem investigations which were then made. The following details are worthy of attention. " The brain did not exhibit marks of active inflammation. The veins of the dura and pia mater were mostly turgid with blood. Effusion of serum under the dura mater was found in three cases which had terminated with convulsions, and a larger proportion of it than ordinary appeared in the ventricles. The substance of the brain in no instance displayed any strong marks of disease. The viscera of the thorax presented no appearances that indicated their partaking largely of the diseased action of the system. It was among the abdominal viscera, that was to be discovered the evidence of the fatal storm, and of these the stomach was a uniform and principal sufferer. This viscus presented different appearances. I was much surprised to find it, on the first examination I made, without any marks of inflammation. The villous coat was of a rather whiter aspect than is usual, but a considerable quantity of black, coffee-like fluid was contained in the stomach. In eight or ten instances a nearly similar state of that organ was discovered, there being no inflammation, or a slight blush, mostly about the cardiac portion, being alone observable. The flowing out of the matter which constitutes black vomit, appears to have relieved the loaded vessels in those cases and to have terminated the inflamma- tion; but the death of the organ still ensued. It would seem, as I believe Dr. Physic has remarked in his dissections, that the formation of black vomit is an effort of nature to terminate violent inflammation of the stomach. But in the far greater number of instances, the stomach was highly inflamed. The inflammation was always con- fined to the villous coat, the muscular and peritoneal escaping the affection. It was not uniformly diffused over the surface, but would be deeper in one part than another. The cardiac portion was gene- rally more inflamed than the pyloric, and sometimes a greater intensity was observable between the superior and posterior sur- faces, a well-defined and distinct line separating them. No erosions or abrasions were discovered, though the villous coat was at times nearly livid, and broke with ease upon pressure with the nails The matter constituting black vomit was met with in every examination. [YELLOW FEVER ] 105 In two instances, in which it had been thrown up during life, with the usual characters, a fluid more resembling blood was found after death." The liver varied in appearance, never constantly presenting the same aspect: it was usually gorged with blood, but not always. The gall-bladder was sometimes distended with bile the colour and consistence of tar. In two instances, the internal coat and lining membrane of the ductus communis were inflamed. The spleen and pancreas generally natural. "The intestines most commonly were more or less inflamed, not in a uniform manner but in patches. They were in one subject con- tracted in some parts so much, that the little finger could scarcely be passed through them, and were swelled and distended in other parts. Three or four introsusceptions were formed in this case, but which were unattended with any inflammation at the spot where they ex- isted. This patient had taken large doses of calomel and had died strongly convulsed. The intestines always contained considerable quantities of black mucus, bearing a resemblance to the flocculi of black vomit. In some cases it was evidently sanguineous. The urinary bladder was sometimes much contracted and contained no urine ; at other times small quantities were found in it. "The whole of the system of the vena portae was always distended with blood. It was at first supposed that the blood, being thus fluid, was in the dissolved state so often mentioned by writers. But Dr. Hewson, wishing to make some experiments, collected portions of it in cups. In the course of ten or fifteen minutes, it was firmly coagulated; and this was found in subsequent observations invariably to occur. The notion, therefore, of the blood being dissolved in this disease, frequently described by writers as observed in their dissec- tions, is not correct. "The opinions that were held with respect to the nature of black vomit were various and loose, until the examinations instituted by Dr. Physic in 1798-99. It was demonstrated very satisfactorily, that it proceeded solely from the stomach, that it did not partake in the slightest degree of the nature of bile, which had been the commonly received doctrine; and in fact that the liver had no share in its pro- duction. Dr. Physic considers black vomit to be a diseased secretion from the vessels of the stomach. This opinion is entitled to great attention, and is rendered very probable by the arguments and experi- ments with which it is supported. But from the great turgescence of the whole portal system always found distended with blood, I am disposed to believe that the inflammation of the stomach and of the other abdominal viscera in this disease is venous, and not arterial, and arises from an engorgement of the veins extending to their minutest division and first origin. Should this view be correct, black vomit, it is not unlikely, may arise from a sanguineous effusion from the capillary extremities of the veins. The matter of black vomit does not maintain invariably the same characters, but recedes more or less from, or approaches to, an appearance of blood. I have seen several cases in which the discharge towards the termination became nearly sanguineous; and a similar fluid was also found in the intes- tines. 106 YELLOW FEVER. "Dr. Rhees,the resident physician at the city hospital, instituted a series of observations on the black vomit, with a solar microscope. Innumerable quantities of animalcnlae were found to exist in it. A sinsle drop contained many thousands, apparently acongenes ot them. The black mucus of the intestines exhibited the same phenomena. When the fresh matter thrown from the stomach was examined, the animalcule were alive, and in constant motion, but if taken from the dead subject, or inspected after standing some time, they were always dead and quiescent. Comparative examinations were made of the discharges from the stomachs of patients ill with autumnal, bilious, and remittent fevers, but no similar appearances were discovered.1'] Causes.—It has already been shown that the extremes of cold and heat are not. very productive sources of disease. Fevers ate pro- duced more by sudden changes of temperature, or by heat conjoined with moisture, than by heat itself, however intense. The state of the mind has also great influence, as well as the habits of the indi- vidual. It has often been remarked, that there is great mortality among troops after their first arrival in a tropical climate. This is some- times to be attributed to a want of due care on the part of the govern- ment, in choosing the season at which they ought to arrive at their destination. 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 after its termination ; perhaps the loss will be dou- ble. Great care should be taken 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 ex- cellent 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 expect that they will indulge themselves in many ways beyond due bounds. Cheap new rum, and an abundant supply of delicious fruits, attract their attention, 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 of air when the body is over-heated; in fact, it requires considerable time before a European obtains know- ledge to manage himself properly. Some are fool-hardy, and take no care of themselves whatever; 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 convinced that it is a matter of the first im- portance 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 YELLOW FEVER. 107 affected, provided his bowels be in a proper state, his mind free from apprehension, and his habits good. 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, except 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 stated, that no species of fever upholds the doctrines of Broussais more completely than the remittent. Treatment.—There have been as great revolutions in the treat- ment of the fevers of warm climates, as in that of any other class of diseases. The supporters of the doctrines of putridity have, of course, always avoided bleeding even in the first stage, when they admit the existence of inflammation, for fear of the debility which they expect in the latter stages. They begin by clearing out the primae viae, and then have recourse to bark in very large doses with- out regard to the state of the stomach, local inflammations, or any other circumstances. This is the practice recommended by Clark, Lind, and others. They prescribe opium for the purpose of keep- ing the bark upon the stomach, and give wine and brandy in con- siderable quantities, with the view of supporting the strength, keeping off the stage of collapse, and preventing 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 col- lapse 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 post- poned 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 affecting the system with mercury as speedily as possible, employ- ing bleeding in small quantity, and only occasionally, more with a view of enabling the system to receive the mercury, than as a pow- erful 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 after- wards 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 principle 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 sufficiently 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 108 YELLOW FEVER. 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 patient'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 beforehand 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 nearly thirty years ago; and it appeared to be attended with great success. Some practitioners trust almost exclusively to the action of mer- cury, and in India more particularly, it is deeply to be regretted that a great waste of human life has consequently taken place. Some years ago, Dr. Haliday, of the Honourable East India Company service, was, by order of the Marquis of Hastings, put under arrest, and deprived of rank and pay, for showing, by most incontrovertible evidence, that in the general hospital of Calcutta, the enormous quantity of 26 pounds of calomel were consumed by 886 patients: And that under the painful 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 mortality was reduced about one-half: In fact, that the mortality bore almost an exact ratio with the quan- tity of calomel exhibited. After a delay of many years, Dr. Haliday was restored to his rank by the express order, more than once repeated, of the India directors. This transaction has never been brought before the British public, but having carefully perused all the evi- dence, I have no hesitation in declaring that as a piece of persecu- tion, from beginning 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 effaced, upon the memory of the then Governor-General of India and all his advisers, 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. Haliday; and mercury is now not 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 mer- cury, under judicious management, cannot be altogether dispensed with. In 1796, the deaths in the West Indies under Dr. Chisholm's mer- curial plan were never exceeded, amounting to nearly one-half of the whole number of troops. * The author regrets want of sufficient space to speak more fully of -the transaction, but he cannot avoid annexing an extract from a ietter addressed by the East India Directors to the governor-general, after full investigation. "In the mean time we authorize and direct you to remove the restrictions you have placed to the further employment of Dr. Haliday, 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. Haliday was doomed to undergo still further persecutions. YELLOW FEVER. 109 The bold and decisive use of the lancet in this disease has met with an able and influential advocate in Dr. Jackson, who was in- spector of army hospitals in St. Domingo, and subsequently in the Windward Islands. This distinguished 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 benefit; after this he gave calomel in doses of from five to thirty grains, re- peated every third or fourth hour. Bleeding has been strongly objected to, on account of the condi- tion of the blood. In some cases it appears of a very dark colour, and streaked with red and bluish lines; it coagulates very imper- fectly, 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 recommending a repetition of the operation, as I have long been aware that it exists more or less in all severe cases of congestion. It has been frequently seen by my pupils, in cases of intermittent fever, in which I bled in the cold stage; and also in cases of congestive fever. It has also been noticed in Asiatic cholera, and a similar condition of blood may be seen in patients affected with the common cholera of this country, and has been observed in some severe cases of bronchitis. 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 bleeding 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 petechise from blood-letting, in cases in which the pulse retained its fulness or ten- sion. 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 dis- section, 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-excited. 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 I believe every experienced tropical physician will agree with me in cautioning young practitioners against their indis- criminate 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 that are employed for moderating the action of the heart and arteries. When in the West Indies, I have often regretted not having 10 HO [YELLOW FEVER] a command of leeches, and am persuaded, that upon a proper repie- sentation, the government would take steps, at whatever expense,, 10 secure a proper supply to (he medical officers of the army ana navy. There is no disease in which dissection reveals so many or3anic 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 disuse. Dr. Currie has distinctly stated, that it is not admissible in cases where there is any internal inflammation ; there- fore, 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 sponging thebody with water, or vinegar and water, which ought to be very frequently repeated. The application of blisters and other contra-irritants is highly serviceable after bleeding, &c, but should neverbe had recourse to in this, or any other fever, in the early stage of the disease. Stimulants sometimes appear to save life, but in candour it must be mentioned that I have also seen them very prejudicial; nothing in the whole practice of physic requires more caution and experience than their 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 superior to wine. In the last stage, great care should be taken to support the heat of the extremities. Partly from the notion of the resemblance between remittent and intermittent fevers, and partly from this disease being supposed to be one of putridity, bark has been employed. By some it is recom- mended 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 en- tertained, that the sulphate of quinine will be of signal service in many cases. [The method of treating yellow fever by large doses of calomel has for years been pursued throughout the United States, particularly in the south. The efficacy of this practice has latterly been questioned, and physicians have in a great measure yielded to the change in public sentiment. It is at least evident, that the exhibition of the enormous quantities of mercury which have been given both in this disease, and in other forms of fever, is not attended with the unfail- ing success which alone could warrant its employment; and the con- sequences have been so frequently destructive to health and comfort, as to lead to the opposite extreme of total proscription of this powerful article: a circumstance much to be regretted, as in proper doses, and [YELLOW FEVER.] Ill at suitable periods of the disease, its use is highly serviceable. If the general system is affected with considerable reaction,.venesection is required ; but in most cases the prompt application of leeches, or cups, as near as possible to the diseased organs, is followed by a decided amelioration of the symptoms. They should not be placed, however, so immediately in contact as to run the risk of increasing excitement. As an auxiliary measure, the sedative impression of cold has a beneficial effect, and is peculiarly grateful to the patient: iced drinks, ice applied to the head, if this organ presents symptoms of disordered action, and the injection of cooling enemata into the bowels, are the modes of application. The use of small doses of calomel, or blue pill, will admirably promote the cure when the force of the local irritation has been reduced; and it only remains to un- lock the secretions, and gradually restore them to a natural state. To sum up the most approved plan of treatment in concise terms, we are to remove all irritating causes; mild, soothing,diluent substances are to be administered; while local and general symptoms are to be relieved by the means already indicated. The allowance of such diet as is suited to the condition of the digestive powers, will be regu- lated by the principles which guide us in inflammatory conditions of the stomach* Yellow fever has, of late years, been treated on a new plan in the United States, viz., by giving quinine in very large doses at a par- ticular stage of the disease. Thus, from twenty to sixty or eighty grains are administered at the commencement of the fever, while the morbid action appears to be in process of formation, that is to say, within six or eight hours after the accession of the malady. When taken under such circumstances, the first effects are a very slight increase of the febrile symptoms; the pulse, perhaps, becomes quickened, the respiration more hurried, and the usual consequences of stimuli are present. This condition, however, is but transient, and is promptly followed by corresponding depression. All the more violent symptoms subside ; the temperature of the surface is lowered; pain diminished; the pulse is gentle and subdued; the skin is co- vered with a healthy moisture ; in short, the chain of morbid associa- tions becomes broken, sleep is superinduced, from which the patient awakes refreshed and subsequently better, and from twenty-four to thirty-six hours is considered in a state of convalescence. The treat- ment is, of course, not exclusively confined to the employment of quinine, though this is the chief remedial agent. The usual means of obviating tendencies to local irritation must be resorted to. The skilful practitioner will modify his curative measures according to the necessities of the case; cupping, leeching, the warm bath, and local applications, may be used as circumstances call for their em- ployment. The quinine is administered in a single dose; the object being to bring about the sedative influence of the remedy before any of the organs, as the head, stomach, &c, become specially affected by the disease. If it should fail to produce the anticipated effect, * For evidence of the advantage of this plan, we refer to the cases of Drs. Barton and Harris, treated in New Orleans during the year 1833, and reported in the Ameri- can Journal of Medical Sciences. 112 INFANTILE REMITTENT FEVER. the case is too far advanced for a second trial, and it must bleated on general pathological principles. Let it be remembered, Iowever| that in thirty or forty cases which have been subjected to( s "ovel curative method, no? one has terminated fatally. The action ot the quinine has been uniformly most salutary, operating like acta, and dissipating the symptoms of the malady ere they become con- centrated on different organs."* . On this point we have no experience of our own ; but as it comes from medical men of acknowledged ability and extensive practice in yellow fever in New Orleans, and other southern cities, we gladly insert the facts as announced bv them; at the same time, we believe it has been proved that this course of treatment has not effected the same happy results in subsequent years, but on the contrary, has often been attended with entire disappointment; a fact which is amply accounted for in the known variableness of yellow fever in differ- ent seasons even in the same localities.] INFANTILE REMITTENT. Many diseases occurring 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, inflammation, 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; the bowels are constipated, or there is diarrhcea, but the former is more frequently met with; or there is frequent desire to go to stool, but little is passed; if there be any evacuation, it is discoloured and fetid. Iu colour, the evacuations are not always dark, but some- times white, showing a deficiency of bile, and sometimes bluish, but always offensive, often mixed with mucus, and occasionally 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 tympanitic. It prefers to drink cold water, and frequently shows signs of increased abdominal pain after a copious draught; the stomach is occasionally very irritable, and every thing is vomited j the tongue, being at first moist and loaded, Medical Examiner, 1840. INFANTILE REMITTENT FEVER. 113 and occasionally very red round the edges, soon becomes dry over a triangular space at the tip. On some occasions it is difficult to keep the hands and feet sufficiently warm, while the face is flushed and the rest of the body parched. If proper treatment be not soon pursued, the functions of the brain occasionally become disturbed, and it is difficult, in many cases impossible, to determine 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, auscultation will announce a more or less extensive inflammation of the bronchial membrane; and if the disease be not subdued, wheezing and expectoration follow. Sometimes the child appears to be recovering for a few weeks, and then relapses; during the remissions he gains flesh and strength, but the abdomen remains tumid, and in this condition he may continue getting better and worse till the mesenteric glands become enlarged, or dropsical effu- sion 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 immediate cause of death, and I have had many opportuni- ties of ascertaining that inflammation of this tissue has been excited by the extension of ulceration from the mucous membrane, through the muscular and serous tissues. The mesenteric glands are found very generally enlarged, sometimes enormously so, and seem to con- sist of a cheesy-looking matter, which is usually described as de- pending on scrofulous action, but perhaps hastily, and 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 the other coats, as is observed in many cases of phthisis puhnonalis. When there is no ulceration, we sometimes 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 aside 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 splenic extremity, which have penetrated through all the tissues at one point; in other places they appeared to be converted into a gelatinous mass. From careful examination, it would seem that this kind of disorganization 10* n4 INFANTILE REMITTENT FEVER. is the effect of previous inflammation. This aPP68™"^8.? "c^f considerable interest of late years, and has been""^"^tImo nent by Cruveilhier and others, and in this country n any Y^ra a8°» by Underwood. The profession stands greatly indebted to Dr. John Gairdner of Edinburgh, who has collected a great number of meet ing cases, some of which occurred in his °wnf Prac^eVa,,dr^ph will be found in the first and second volumes of the Medico-Chirur- gical Transactions of Edinburgh. . ___ It has been stated in the description of the complaint, that symp- toms of cerebral and pulmonary disease sometimes become lighted up; but on watching the progress of the affection, these are observed not to form essential parts of it; nevertheless, the appearances some- times 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 shows various degrees of inflammation, and occasionally 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 fre- quently exposed. Teething sometimes produces symptoms like those above described. Pathological remarks. 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 respect- ing the nature and seat of the disease, that it depends 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 bis- cuits, 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, or heat of skin, if gentle laxatives, frequently repeated, do not mitigate the symptoms. Fo- mentations 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 reaction, 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 INFANTILE REMITTENT FEVER. 115 somewhat painful to the touch ; his thirst was considerable, the re- spiration quick, the face flushed, with some headache, and he com- plained of noise and light; the tongue loaded with a white fur, moist everywhere but 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 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 fre- quently had recourse to and with marked relief, but always of short duration. Gentle laxatives 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 complained 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 surprised me very much; it was so large that I was induced to examine it minutely, when three hard masses were discovered, surrounded with a great quantity of mucus. Upon close examination, they proved to be a dollar bis- cuit, 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 gentle- men who were attending my lectures at the time, and is now in my museum. 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 appeared that the boy was frequently in the habit of bolting what- ever 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 per- severance in contra-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 ab- domen, with a scanty secretion of urine, a preparation of calomel, squills, and digitalis, in doses proportioned to the age and strength of the patient, will be found serviceable, together with drinks acidulated wfth 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 almost hope- less. 116 CONTINUED FEVER. REMITTENT AND 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. Culleu's definition — "Fevers, without intermission, and without being produced by marsh miasmata, but with remissions and exacerbations, though not always considerable, continuing; two paroxysms in each day. Often have I seen slight continued fevers terminate in regular in- termittent, 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 finely spun; for if there be 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 inflammation, but who will not allow the existence of "any primary local disease," 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 languor, lassitude, and other signs of debility, py- rexia; without any primary local disease." The reader will see at once the absurdity of this symptomatical pathology, 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 " 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 Cul- len's disciples will be found to fall into the same error, but they be- come 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 • FEVER FROM FUNCTIONAL DERANGEMENT. 117 and phlogistic diathesis appear, and prevail during some part of the course of the disease; while, at the same time, these circumstances do not constitute the principal part of the disease, nor are to be expected to continue during the whole course of it; and it is well known that, in many cases, the state of violent reaction 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 avoided; and even although, during the inflammatory state of the disease, it 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 follow. It was Dr. Baillie's opinion, that typhus was as rare as Cullen states inflammatory 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 strong- holds: and they will rarely be found guilty of declining an engage- ment from fear of another enemy which may appear when they are weakened by the combat. Soldiers and sailors can very rarely con- ceal a fever; so that they are brought at once to the medical officers, who, therefore, see the disease early, and before it becomes compli- cated. A great deal, also, depends upon the treatment pursued in the first stage. If a physician were always afraid in the first stage of fevers to apply the proper remedies when inflammatory symp- toms presented themselves, lest a low or putrid tendency should subsequently 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, fever from inflammation; thirdly, fever from congestion; fourthly, a mixed form of fever, consisting of a combination of these three, but in which congestion generally predominates at last, com- monly 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 nou- rishment. It is not, in general, very formidable; but cases are occa- sionally met with which are abundantly alarming, and difficult to treat, from the impossibility of fixing upon anyone 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 118 CONTINUED FEVER. patient often feels chilly, which he is apt to attribute to the weather —increasing weakness and languor, which he thinks are owing to impaired appetite; he has restless nights, with burning heat in his hands and feet, and some thirst. At last his whole sur ace is hot; he perhaps 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 circulation 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 v.c.ssi- Sude-thus the heat of the body is not a degree higher under a burn- ing tropical sun than in this country, which so far prevents cold from producing a lost balance of the circulation. Second, 1 he elasticity of the coats of both arteries and veins, tends also to prevent the state of congestion, because they are capable of considerable distension, and are still contractile. These are assisted by the free anastomosis which subsists between the vessels of a part. This is well illustrated by the experiments which have been performed on the frog's foot, to determine the nature of inflammation. When a part is first irritated, the momentum of the blood is greatly increased ; at last a vessel becomes obstructed, a globule of blood cannot pass through it, but it is seen to make a retrograde movement, and to 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 fevers, and to which I shall now make only a short allu- sion. In some cases, when the eruption is tardy in making its ap- pearance, alarming symptoms, and even convulsions, 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 before 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 in the constitution to remove internal accumu- lations of blood, if they be in any 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 reaction, which in its turn may create inflammation of the organ most affected with the congestion. We have next increased secretion, as a natural means of removing the congestion. In the treatment of all diseases, the physician has to determine whether it will be most advisable to leave the case to the natural efforts of the constitution, 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 reaction, or that the system will sink under the task. He CONGESTIVE FEVER. 129 has also to fear the effects of the reaction, which may terminate in extensive local inflammation. Anxious to escape these evils, he will follow the plan pursued by Sydenham in the case recently quoted, 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 previously 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. I have frequently proved, before a number of witnesses, that it is not in- consistent 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 stream, and suddenly stop before a table-spoonful is evacu- ated. Some think this is owing to an alteration in the position of the arm —others, to the tightness or slackness of the bandage. Phy- sicians 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 some time 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 plunged 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 am- monia, in the proportion of eight or ten grains to an ounce of water. He should be encouraged to drink warm fluids. The caution and discrimination which ought to be pursued in drawing blood in such critical circumstances, 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 goes 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 repeated every three or four hours. General bleeding is admissible only in the earliest stage of con- gestive fever, unless in cases in which the pulse is still strong and full. Should the proper time for venesection have passed,stimulants are sometimes found serviceable, but must be administered with caution, and relinquished for perhaps debilitating remedies, upon the first appearance of reaction. If, at any time in the subsequent pro- gress 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. ISO CONTINUED 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 three forms: 1*/, Severe cases of congestive fever, in which there is slight or suppressed reaction, followed by inflammation. 2d, The functional fever, subsequently united with congestion, and consequent accumulation of blood in different organs ; this forms, I apprehend, the typhus of authors. 3d, The inflammatory fever,subsequently united with congestion ; this is the synochus of authors. As to the first variety, it has been fully explained in the last article, and the same remarks need not be here repeated. The second 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 much embarrassed, all the symp- toms of congestive fever take place,the patienthaving been debilitated by the previous diseased action. The third variety commences in the manner which has also been already described in inflammatory fevers, but subsequently the ba- lance of the circulation becomes more and more lost, and congestion follows; in which state of the system, the inflammatory action is sup- pressed, 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 im- plicated, and in the worst cases which occur, they generally are all affected, either simultaneously 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 second variety, and when alone any thing like active practice should be had recourse to, the symptoms certainly denote debility, which are as yet occasioned by oppression and ob- structed action only; and often have I seen cases immediately and permanently benefited by drawing blood, in which, had the opera- tion been postponed for twenty-four hours, it would have been quite inadmissible. It may likewise be remarked, that much of the op- pression 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 affection 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 addition- ally, 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 TYPHUS AND SYNOCHUS. 131 bronchitis appearing in some stage of the disease, and very often it is the primary affection. In all the fevers which are called putrid, and which are accompanied by dark-coloured 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 some- what livid and circumscribed redness which is seen so often on the cheeks in the fevers called typhoid, is principally owing to the embar- rassed state of the lungs; and exactly the same circumstances take place in synochus. In the third variety, bleeding may be had recourse to with benefit, later in the disease than in the others, and often have I seen it decid- edly 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 pu- trescency," is to be treated by tonics; " bleeding and purging are among the foremost objects of prohibition." Nevertheless, in the next page, the following contradictory statement is advanced ; "hence the fever will be aggravated from local irritation, and the affected organ will be in danger of inflammation, if not of gangrene." There is no class of diseases in which the stethoscope 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 gene- ral debility appear to be very great, and the extremities cold. To a patient in such a state, most medical men would naturally 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 twelve years, I have seen many severe cases of fever, in which marked benefit was produced by withdrawing stimulants, and the patients have ultimately recovered after being leeched and blis- tered. Let it not, however, be supposed that I am an enemy to stimulants in all cases of fever; on the contrary, 1 have seen patients occasionally snatched from the grave by their judicious employment. What is wished to be impressed upon my readers is, that in all fevers we have to dread local congestions 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, who can at the same time verify the following statement:—that much mischief has occasion- ally followed, and that therefore I feel fully as anxious about the result of a stimulant as of 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 no doubt can be quoted, where stimulants, in large quanti- ties,have been administered from the beginning of the disease, and the patients have recovered. But the best way for any one to come to right conclusions regarding this question, is, to judge from the general result of what he has himself seen. I have had many op- 132 CONTINUED FEVER. portunities of observing that recoveries were slower, and relapses more frequent, in cases 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 great an accumulation has taken place. Many of my friends have seen the happy results of administering emetics in such cases, and more particularly, my dispensary pupils will not forget many instances of this among our poor patients during the late epidemic fever in Edin- burgh. Cleanliness, free ventilation, and quietness, are three great and essential circumstances to be attended to in the treatment of fever. The alvine evacuations should be removed instantly out of the room; and it is of great consequence 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 aggravatetf- 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 much injury has been 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 ulti- mately saved without the 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 hap- pened, that I am obliged to run all hazards from bad air, bad nursing and filth, rather than send my patients to the infirmary of Edinburgh, 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 attendants, who ought to be well aware that the tempera- ture 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 accounted for by one or other of the following circumstances: 1st, A difference in the character of the prevailing epidemic, and the constitutions of the persons affected; for example, a functional fever will bear stimulating remedies which would kill a person la- bouring under an inflammatory fever, particularly if the inflamma- TYPHUS AND SYNOCHUS. 133 tion affected a vital organ. A stimulant given in congestive fever may operate beneficially; whereas, in functional fever, or in inflam- matory fever it would be very injurious. A well fed, and previously healthy soldier, who has no cares, will in general have a high-toned fever; whereas a poor, ill-fed, and badly clothed labouring 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 analyzed, perhaps it will be found 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 throughout 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 their own opinions with matters of fact in their statements. 4th, The prevailing habit of drawing sweeping conclusions from one or two facts. 5th, Unphilosophical attempts to bolster up erroneous views by special pleadings. The proportion of deaths in fever, in my dispensary practice, from the beginning to the termination of the last severe epidemic in Edin- burgh, was as follows:—Out of the first hundred and forty cases, there was only one death. This patient was anxiously attended by a highly respectable practitioner in this place, who was then my assistant; he died during a relapse after he had sat up. The pro- portion of deaths, however, subsequently increased, so that in No- vember (1827) the calculation of deaths was 1 in 37. This includes several individuals who were in the last stage before we were applied to; also the case of a girl who died during a relapse from accidental loss of blood after the application of leeches ; an old High- lander, who would take no other medicine than his own mountain dew ; and an old woman, above 60, who, when convalescent, took a shivering fit and died immediately. The appearances found on dissection, in our fatal cases, were as follows:—In two cases there was well marked arachnitis, viz., by ex- tensive effusion of coagulable lymph, which was deposited between the arachnoid and dura mater. In both there was great vascular turgescence; some effusion into the ventricles; and in one of these there was white ramollissement in the centre of the brain. In two men, and one old woman, the vessels of the brain were found very much gorged with blood and the pia mater, throughout its whole extent, had its vessels amazingly distented with dark blood. The preparations were dried on glass, and can even now be .seen in this stale. In these three last-mentioned cases there was some effusion under the arachnoid, and the ventricles; and on slicing the brain, 12 134 CONTINUED FEVER. an unusual number of large bloody points were observed: there was also bronchitic effusion, and in one of ihem a considerable portion of the lungs was in a state of softening and intensely red. In the old woman, who died so suddenly during a rigor, when apparently convalescent, there was little disease in the mucous membrane of the stomach and bowels; but in one of the men, there was extensive vascularity of this membrane, but no ulceration ; the mucous mem- brane of the stomach corrugated, and the whole of the splenic ex- tremity was studded with red points, which were seen through a great quantity of thick viscid mucus, which, being washed off, and the stomach stretched, these red points were discovered to be vessels, which existed in immense numbers ; the vascularity was greater, however, in the mucous membrane of the bowels, particularly throughout the whole of the ileum, and a great part of the colon. In the other man, when the abdomen was opened, the small intes- tines had a black appearance, as if in a state of mortification; they were found filled with a bloody-looking exudation, which, from its weight, had borne them down into the cavity of the pelvis. It was thought at first that this matter was the sole cause of the discolora- tion ; but, upon cutting open the intestine, it was found that they owed this colour principally to great vascularity; there were no ulcerations. There are dried preparations, and drawings of the ap- pearances in this case, in my museum. In other cases, there were ulcerations in the ileum and colon, of which also the preparations and drawings are in the museum ; and I am inclined to believe that, if these appearances were properly looked for, they would be more frequently seen. In one case, the left kidney was enlarged, as well as the ureter; its pelvis, on being cut open, was found to contain about six ounces of pus, and the inner membrane was very vascular. In the body of the old woman, who, it has been above stated, died suddenly during convalescence, the diseased appearance was, that both lungs were found as black as they usually are when affected with melanosis. I was not at the dissection, being engaged at the time in delivering a lecture; but Dr. Crellin, who conducted the examination, sent for me, and it was proved to the satisfaction of all present, that this appearance was not melanotic, but produced by venous engorgement. I had never before seen the whole of both lungs so completely engorged ; they sank in water, but after being washed, they regained not only their natural appearance, but their proper degree of buoyancy. The characters of the ulcerations shall be stated in the second part of the work, when treating of inflam- mation of the mucous membrane of the stomach and bowels. [Elaborate investigations into the phenomena of that formofcon- l!nU»eA ?VTer whlch/esemb'es the typhus of camps, have been made by MM. Louis and Chomel; and the joint labours of these two dis- tinguished pathologists, have presented to the public a mass of facts which greatly enrich the history of this prevalent febrile affection. The term typhoid fever is preferred by both these authors, as being most applicable to the protean shapes of the disease, and as reconcil- ing the conflicting names under which it has hitherto been described. It has also the advantage of not originating in any preconceived idea, [TYPHOID FEVER.] 135 founded upon groups of symptoms which are merely incidental. Typhoid fever, according to the signification which is given to it, embraces a wide range, and includes various modifications which hitherto have been considered distinct. Upon consulting the records of endemic and epidemic fevers which have assumed the form of typhus, the minute details of their exterior symptoms will be found sufficient to convey accurate ideas of their more prominent characteristics; but when we search for information as to the extent, the precise nature, and the location of the anatomical lesions accompanying them, the descriptions will be found exceed- ingly defective. The peculiarity of the researches of Louis and Chomel into the nature of typhoid fever, consists in drawing the attention of the pro- fession to certain symptoms referrible to existing lesions which had not before been regarded as peculiar to this affection. From these they deduce a diagnosis established upon the sure basis of nature ; and, from the certainty which exists of an invariable diseased con- dition of particular organs, direct the attention to the consequent dangerous results. The prominent and material facts are all that we can now present; but these shall be given as faithfully as the occasion will permit. The invasion of typhoid fever is not always the same, nor are the symptoms invariable. Precursory indications of the attack may exist, or they may be wanting, but most commonly the attack is sudden. Of 112 cases, 73 were attacked suddenly, and 39 laboured under premonitory symptoms. The phenomena of invasion were as intense in those who were warned of its approach, as in those who were not; viz., intense headache, sometimes preceded by diar- rhoea; alteration of the features, stupidity, muscular weakness, ab- dominal pains, &c. Chomel has divided the march and progress of the disease into three periods, each including seven days, and characterized by par- ticular manifestations; these are called septenary periods. Symptoms occurring during the first period.—Headache in all cases, debility and stupor, diarrhoea, meteorism, increased sensibility of the abdomen, especially in the right iliac region, gurgling when pressure is made upon the lower part of the belly, epistaxis, and finally the eruption designated by the name typhoid eruption. During the first period, the change of countenance is very striking: the features are without expression, and evince an indifference and apathy which are peculiar, and from which the patient can scarcely be roused. In consequence of great weakness, the patient sleeps upon his back, and, if forced to sit upright, dizziness and vertigo compel him to resume the horizontal state. Insomnia is a frequent attendant, partaking of that form of disturbed rest which is called coma vigil. The mouth becomes sticky, its humidity diminishes, (he saliva is thick and small in quantity; this is the first degree of dryness, which afterwards becomes complete. The colour of the tongue is far from being as uniform as is stated, or of as much con- sequence as some imagine. It is, at the commencement, red at the tip and edges, with a white film on each side; but for the most part, 136 [TYPHOID FEVER*] this reddening of the tongue does not present itself until the termi- nation of the first period, and is preceded by a whitish, suburral condition. The lips and teeth become dry and incrusted at the same time that the mouth is parched. Sore throat is not an unusual symp- tom. Loss of appetite, nausea, and vomiting are frequently noticed. Great thirst is an usual attendant. Diarrhoea is one of the most constant symptoms of this period, ap- pearing in nearly every case ; it may, however, be postponed to the commencement of the'second. It differs as to the number of the evacuations, and the character of the matter voided. Meteorism or flatulent distension, is owing to the presence of gas in the bowels, and in obscure cases can only be detected by percussion ; but at times the abdomen rises above the level of the thorax, and considerable unea- siness is the consequence. Gurgling noises are owing to the combined effect of gas and the liquid contents of the. bowels, passing from portion to portion, favoured by the peculiar condition of the ileo- coecal valve. At the commencement the general reaction is high, with well- marked inflammatory symptoms, but these in a few days diminish ; the pulse retains its frequency, but loses its fulness and force,becoming small and weak. The skin is aridly hot, and frequently continues so throughout the disease. The heat is in the first instance accompa- nied with moisture, but soon becomes dry and mordicant. Epistaxis is an important circumstance, and its frequent occurrence is peculiar to this affection. The respiration is affected with the sibilant rale; there are cough, and expectoration of transparent, viscid, tenacious mucus. The last phenomenon we shall mention is the typhoid erup- tion. Of 54 cases in 1S31-32, but two presented this symptom as early as the sixth day; in the remainder, it was witnessed during the second and third periods. Death is rare within this first term; it happened once in 42 fatal cases. Symptoms of the second period.—At this time we have new symptoms submitted to our inspection, and modifications of those which already exist. Generally, upon the seventh or ninth day, the typhoid eruption makes its appearance. This consists of small, rose- coloured spots, from half a line to two lines in diameter, of a rounded or oval form, scarcely elevated above the skin, and which are readily removed by pressure, but return immediately when it is withdrawn. These spots are scattered over the abdomen, sometimes upon the chest, and rarely upon the thighs, arms and other parts. To cha- racterize typhoid fever, the number of them should at least amount to five-and-twenty. Their continuance is by no means uniform, dis- appearing in two or three days, or remaining twelve or fifteen. When they are about to disappear, their colourlDecomes less intense, and finally fades away entirely. No conical form or vesicular con- dition is ever apparent. Of 70 cases, 16 were without them. The time of appearance may, however, be late in the progress of the disease, and it has even been observed as late as the 39th day Another eruption is witnessed during this period, characterized by the form of vesicles called sudamina. They are minute, elevated and transparent, and can be more readily perceived upon viewing [TYPHOID FEVER.] 137 them obliquely, and although not exclusively confined to typhoid fever, they, for the most part, appear twice in the progress of the disease, first at its commencement, and again towards its termination. There exists a remarkable disposition to the formation of sloughs, and the production of foul sores upon different portions of the body, especially where pressure is kept up, or irritating substances have been applied. Ulceration, however, is not confined to the external parts, but is observed in the mouth, throat, and on the tongue and lips. Leech bites and minute incisions, may exhibit the same tendency to ulceration, but this circumstance is rare. It is at this time that pre- vious stupor and prostration become more marked, occasioning perfect helplessness, and involuntary discharges from the bladder and bowels. Finally, difficulty of deglutition, consequent upon organic lesions of the throat, or upon weakness; spasmodic action of the muscles of the face and extremities, or complete rigidity of them ; delirium ; in- crease of meteorism and diarrhoea; bloody alvine discharges, together with great fetor of the perspiration and pulmonary exhalations, are the most essential symptoms of this second period. Symptoms of the third period.—The phenomena of this period vary according to the change which may be undergone, whether to a safe state of convalescence, or to a still more alarming condition, shortly terminating in death. If the former event is about to hap- pen, all the symptoms are gradually ameliorated. But should the contrary termination threaten, symptoms indicating the near approach of dissolution will be apparent. The stupor becomes profound; the mouth secretes a grayish, sanious, fetid discharge. The urine has an unnatural, disagreeable smell. Respiration is more and more embar- rassed ; the pulse is small, weak, and fluttering; the skin becomes cold and clammy, and the countenance has that peculiar expression which is designated fades hippocralica. In this condition the patient dies, or convulsions may precede the concluding scene. Of forty-two cases which terminated fatally, ten died during the two former periods; the remainder,after the third had been entered. Anatomical lesions.—There are peculiar organic changes so con- stantly attendant on this disease, that an exception rarely occurs; but there are others, found in different organs, which are not so in- variable, and which may be regarded as accidental. The anatomical leisons may, therefore, be separated into two classes, constant and inconstant. The first occupies the mucous follicles of the intestines and the mesenteric ganglia. The follicles are of two kinds, isolated and clustered; and their mode of alteration and appearance is by no means the same under all circumstances, but varies according to the period of the disease and the form which it may assume. It is a difficult matter to determine when alteration of the follicles com- mences, as death never happens prior to the seventh day. Of 55 subjects inspected by M. Louis, the earliest period at which death took place was the 8th day. When under these circumstances an incision is made into the abdomen, the intestines are noticed dis- tended with gas, which augments their transparency, and permits us to distinguish exteriorly numerous opaque spots corresponding to the diseased follicles. Examining into the nature of the change in 138 [TYPHOID FEVER.] the latter, they will be found prominent and swollen, and from having their edges brought into relief, present somewhat the form of mush- rooms. Their colour varies in intensity, but is always more or less marked, exceeding the redness of the surrounding mucous coat. Their size and form retain as little uniformity as their colour: the largest are elliptical, exceeding, in rare instances, two or three inches in length, and half or a whole inch in breadth ; these occupy the glands of Peyer. The smaller ones are round, and have their seat in the same glands; but besides these there exist isolated and scat- tered prominent follicles, rounded and swollen; the latter are the glands of Brunner. The usual location of these appearances is upon the side of the intestine, opposite the mesenteric attachment, and they are more numerous, denser and larger near the valve. The plates (placques) give to the feel a sensation as if a solid, elastic substance was introduced between the intestinal tunics. Upon the seventh day, in a single case, and at periods not long after in other cases, the mucous membrane covering them had undergone no appreciable change; if any thing, its thickness was rather diminished than in- creased. If these enlarged glands are cut into perpendicularly, the mucous membrane is first divided; then a layer of yellowish-white matter, homogeneous in consistence, firm and brittle, the cut surfaces being smooth and shining: the thickness of this matter varies from one to two lines, and beneath is found the cellular tunic. An orifice is rarely noticed in the clustered follicles, but is readily detected in the isolated. At this stage the mesenteric ganglia, situated between the lamina of this attachment, which are nearest to the diseased follicles, are increased in size and become red. They are even observed as large as a pigeon's egg. There is sometimes complete softening, while at others their firmness is rendered greater. These are the most im- portant lesions, but in their development an uniform state of pro- gression is observed. Ordinarily those nearest the ileo-ccecal valve are the first to become affected: and, in the early stages, as they recede from this focus, a greater degree of healthiness is noticed: but, as the disease advances, a greater number become affected. The same circumstance holds both with regard to the follicles and the ganglia. Sometimes several feet of intestine are implicated in this manner. Later in the disease, other conditions are perceived : the mucous membrane investing the follicles becomes rugose, hollowed out, and disappears entirely, leaving an excavation which pene- trates more or less deeply into the subjacent layer; but as this lat- ter is not entirely removed, there remains a portion of the gland to show the progress of the alteration. According to the combined ob- servations of Louis and Chomel, it was determined that ulceration commences from the eighth to the fifteenth day. Ulceration pursues the same course as tumefaction; beginning at the same place, and being more frequently observed in the glands of Peyer. The aspect of the ulceration presents two varieties: in one, it commences in the mucous membrane, originating at a minute point and extending until the whole gland is involved: in the other the ulceration begin! with softening of the yellowish matter, and a process is gone thfougrT e- [TYPHOID FEVER.] 139 sembling gangrene, by which the whole substance is removed : the remains are evident by inspection, but diminished by suppuration, while the investing mucous coat is in a comparatively healthy con- dition, or only partially displaced. This latter variety is more fre- quently met with in the clustered follicles. Fully formed ulcers assume conditions which it is important to notice: their edge or bot- tom preseuts no remains of the substance of the follicle in a partially broken down state; it has entirely disappeared, leaving a vacuity in the mucous membrane. The form of the ulcers is various: some being elliptic, others round : they are also equally dissimilar in size ; and in some cases the borders are so smooth as to convey the idea of their being made by a punch. In some, the mucous membrane alone has been removed, the bottom of the ulcer consisting of cellular tissue; but in others the cellular and muscular layers of the intestine are likewise deficient, the exterior peritoneal coat preventing com- plete perforation. During the first and second periods, it is rare that the ulcers are as numerous as the prominent follicles. Opportunities are sometimes afforded of witnessing the mode in which these ulcers heal. It is precisely the same mode that ulcera- tion of the skin undergoes in the process of cure : minute granulations sprout up, and are converted into the reticulated tissue, which forms a true cicatrix. Cicatrization, after it has been completed, is plainly demonstrable; but after a length of time it becomes confounded with the untouched mucous structure, and no trace of it is to be detected. Corresponding to the advanced change in the follicles, is a condition of the ganglia closely allied to suppuration, and in some cases pus is found in their substance. Lesions of organs, inconstant as to their presence or absence, appear at times as accidental accompaniments of the pathological conditions which have been somewhat minutely described. They are, ulcera- tion of the mouth, tongue, pharynx and oesophagus—injection, soft- ening, alteration of the relative thickness of the mucous coat of the stomach, very rarely ulceration: similar changes occur in the intes- tines; alteration of the size, consistence and colour of the spleen ; and less frequently of the liver: varied conditions of the pulmonary ap- paratus are occasionally present, for the most part the consequences of inflammation. And lastly, lesions of the brain and its appendages.* A few words with regard to the diagnosis, the nature of the affec- tion, and one or two interesting facts connected with the peculiar anatomical lesions, will conclude this very brief account of the re- searches of Louis and Chomel. At the immediate onset of the dis- ease, it is extremely difficult to determine the character which will be assumed, and some time must elapse before the precise symptoms * [The preceding remarks on the morbid conditions of the gastro-intestinal mucous membrane, are republished with little variation from our first edition. Nothing of the kind was embraced in the first London edition; but in the last, some of these facts were embodied by the author in his chapter on the " Inflammatory affections of the organs contained within the cavity of the abdomen." As I have considered these lesions in their relations to fever, and as the author, on the other hand, has viewed them chiefly in respect to local inflammation, I have thought it better to let both expositions appear separately, than attempt to combine them in a single chapter. See Chap. VII of the present volume.] 140 [TYPHOID FEVER] enable us to form an accurate opinion. Nevertheless, even during the first few days, a pretty correct conjecture may be drawn lrom the occurrence of several attendant circumstances. Thus, if the attack be sudden—if, from the first, persistent headache be established, with giddiness and tottering in the gait, combined with well-developed fever, suspicion will be awakened; but if, still further, upon the second or third day, there exist diarrhoea, prostration, commencing stupor and nasal haemorrhage, this suspicion will be almost converted into certainty. But it is most prudent to suspend our decision until more fully determined symptoms appear; and these are meteorism, typhoid or rosaceous eruptions, low muttering delirium, sudamina, fuliginous aspect of the mucous opening, &c; which remove all doubt and ob- scurity. A question presents itself, how far the disease termed typhoid fever is connected with the lesions which have been described. To deter- mine this, we must recur to the division which was made of the anatomical derangements into two classes, constant and occasional. Now it being conceded that the latter are but accidental, important truly as complications, but not necessary to the existence of the dis- ease, the constant lesions will constitute the objects of our inquiry. Are they so uniformly present in all cases as to warrant the appella- tion constant? In all but a very few rare instances they have been found. These instances have occurred in the hands of such able observers as Andral and Louis; and it may still be regarded as un- decided whether they were true forms of typhoid fever, or depending upon circumstances which were wholly independent of it. As to the secondary or primary nature of the lesions, a great deal could be said. The intensity of the symptoms, however, bears no proportion to the number of diseased follicles, inasmuch as numerous cases occur in which these are deranged but to a small extent: in two cases, but a single ulcer could be detected. M. Chomel is inclined to the idea that in this respect the affection is allied to the exanthemata. A remarkable termination sometimes happens in this affection: it is the sudden and unexpected occurrence of peritonitis, which fre- quently succeeds the exhibition of cathartics: the cause of its produc- tion is dependent upon intestinal perforation, and consequent escape of the liquid contents of the bowels into the abdominal cavity; an event which is almost necessarily fatal. Critical days.—There are certain changes, as the author has already observed, (page 67,) which occur in most forms of remittent and continued fever, such for example, as the increased exacerbation on the alternate day, the increase of the febrile symptoms, once or twice in each day, and lastly, there seems to be a law of nature by which fevers tend to a termination on certain days in preference to others. This doctrine, which originated with Hippocrates, was denied by Celsus, and is still the subject of great diversity of opinion It is remarkable, however, that De Haen has put Hippocrates to the test on his own data; for on analyzing all the cases of fever recorded by the "father of medicine," he finds the doctrine of critical days to be sustained by the results; for of 168 terminations of fever 107, or more than two-thirds, took place on the critical days. The latter HECTIC FEVER. 141 are the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth and twentieth; and the fourth and sixth have always been regarded as frequently but secondarily critical. I think it will be admitted by most practitioners who have given attention to this question, that when we can unequivocally establish the day on which fever commences, the disease will, in the great ma- jority of cases, be found to terminate on some one of the assumed critical days. "The following table," observes Dr. Tweedie, "con- structed from 630 cases where the commencement and termination of the fever could be fixed with tolerable precision, certainly presents a remarkable correspondence with the ancient doctrine. DAYS. DAYS. Critical Non Critical Cases. Critical Non-Critical Cases. 3 6 14 63 1* 4* 18 15 10 5 80 16 11 6* 6* 34 17 34 7 129 18 2 8 26 19 4 9 80 20 0 10 17 21 15 11 69 22 3 12 80 23 0 13 15 Dr. Tweedie further remarks that of these 690 cases, (which occurred under the observation of Dr. Welsh, in the Edinburgh epi- demic of 1819,) the crisis took place in 470 on critical days; in 52 instances on the subsidiary critical days, and in but 108 cases on the non-critical days; and he adds, that these data are founded on the several types of remittent or continued fever, at a time when syno- cha and synochus were prevalent diseases.*] HECTIC FEVER. Hectic fever is generally supposed to be symptomatic; even Cul- len embraces this opinion. It may be defined to be febrile symp- toms, occurring in the course of some internal chronic disease, when the patient is much debilitated. Heberden states that irritation in any diseased organ will give rise to it. An opinion has been pretty general, that hectic fever is produced by no other cause than the absorption of pus; and when pus was not found upon dissection, it was hastily concluded that it had existed, but was all absorbed; or that hectic fever is sometimes idiopathic. My own belief is, that this combination of symptoms has no necessary connection whatever with pus; and according to my experience, it most frequently (al- » Library of Practical Medicine, Vol. I. p. 143.] 142 [HECTIC FEVER.] though certainly not always) depends on inflammation of the mucous membranes, and more particularly that of the stomach and bowels. Symptoms.—Hectic fever is attended with great and increasing debility; a weak quick pulse; each paroxysm commences with chilliness, succeeded by reaction, which is soon followed by copious perspiration. Indeed, sweating is at all times easily excited by any exertion. The surface is pale, except the cheeks, which present what is very aptly styled the "hectic blush;" and there is frequently great wasting of the muscles. The appetite is impaired, the stomach occasionally very irritable, and in nine fatal cases out of ten, diarrhoea comes on during the course of the disease. The discharge from the bowels is always very fetid. The breathing is anxious. The patient is generally restless, and frequently complains of pains that are ascribed to rheumatism. [It is, however, remarkable, that with all the general disturbance of the functions, the tongue is often perfectly clean to the last, the appetite good, and the digestion seemingly unimpaired. In many instances, moreover, I have observed the absence of headache or any cerebral excitement or distress, even during the height of the febrile paroxysm. The latter usually comes on in the afternoon or early in the evening, and continues through the night; but towards morning it passes off with colliquative perspiration, leaving the patient in an exhausted condition, both of mind and body. Beside this principal paroxysm of fever, there is often a second and milder one in the morning, which runs its course more rapidly, and is less depressing in its effects. The period between the paroxysms is almost invariably a mere remission and not an intermission of fever, and the pulse continues at ninety or upwards, abating in.force, but not much in frequency. The advanced stage of hectic fever is often marked by ulcerated throat, an aphthous state of the mouth, with a remarkable trans- parency of the citeguments, and a preternatural brightness of the eyes.] It is said that this disease is liable to be confounded with intermit- tent fever; but the history of the case, and the appearance of the patient, will readily distinguish them. Treatment.—As hectic fever depends upon a morbid condition of some structure of the body, our attention must be directed to the seat of the disease. Surgeons very often cure patients of hectic fever, by cutting off a diseased limb which had produced the constitutional symptoms. There is no case in which the difference is so strikingly shown between routine practice, and that which is directed by sound pathological views. The routine practitioner will be invariably found to treat some of the symptoms thus:—Has the patient no appetite ? Give him a tonic—Is he purged ? Prescribe an astring- ent.—Is he griped? Give him an opiate.—Is the urine scanty? He must have a diuretic—Has he profuse perspirations ? Let acid drops be exhibited.* [* Yet it must in candour be confessed, that there are numerous modifications of disease in which we can do little else than palliate symptoms. Thus every practi- tioner must have met with examples in which life has been prolonged 'and suffering GENERAL PATHOLOGY OF ERUPTIVE FEVERS. 143 A pathologist, it must be admitted, is often obliged, in the present state of our knowledge, to act empirically; but his remedies will always be found to be few in number. If the patient have diarrhoea, he will endeavour to ascertain upon what morbid state that symptom depends ; if there be pain in the abdomen previous to an evacuation, if the pain be increased by taking a cold drink, if the tongue be red and glazed, if there be aphthous ulcers in the mouth and throat, if the stools are mixed with mucus, or are watery and fetid, he knows he has to treat inflammation, and probably ulceration of the intes- tines. This leads him to apply a few leeches to the abdomen, if the patient's strength be not greatly reduced, followed by contra-irrita- tion; and then, if there be any remedy that he knows will relieve the patient, that remedy he will prescribe. It is truly lamentable to see the symptomatical physician, one day treating the diarrhoea with astringents, and the next waging war against the perspirations. —This subject will be more fully illustrated hereafter. Opiates are frequently of considerable use in soothing the patient's sufferings. GENERAL PATHOLOGY OF ERUPTIVE FEVERS. The diseases, which fall to be described under this head, are to be considered as fevers, attended during part of their course by eruptions. Whatever difference there may be in the appearance and form of the eruption, they have a certain general character common to all, viz., that febrile symptoms precede the eruption. According to the humoural pathology, the fever is produced by a concoction of the humours, by which a peccant matter is thrown to the surface, forming the eruption. Other pathologists look upon these diseases as peculiar and essential affections of the epidermis, some- times followed by inflammation of the chest and its accompanying fever; and they account for the sore throat which occasionally occurs, by its continuity between the skin and the diseased internal organ. My own opinion is, that the eruption ought to be regarded as a mere symptom of this class of diseases. Yet it cannot be denied that there is something very peculiar in it—peculiar inasmuch as the eruptions present external characters, differing from each other, as well as from other eruptions, and that the diseases occur only once in a lifetime. After a long and patient investigation, comparing the symptoms with the appearances found on dissection, I have come to the opinion that the mucous membranes are the seat of the disease, the nature of which is inflammation, more or less acute and exten- sive; and that the part generally most implicated, is the mucous membrane of the lungs, particularly in measles and small-pox; while mitigated, by checking a diarrhoea, or a colliquative perspiration, by direct and what might be called empirical remedies. These observations will be practically applied in the chapter on Phthisis.] 144 GENERAL PATHOLOGY OF that of the bowels is the part chiefly, if not principally, affected in urticaria, roseola, and military fever.* The eruption is merely to be regarded as a symptom, and by no means a universal symptom. It is well known that many cases of eruptive fevers are very mild, and require little treatment, while others are extremely severe and fatal; and that a great deal depends upon the eruption, whether it comes out at the usual period, and whether it remains out, or pre- maturely and suddenly recades. The eruption, in point of fact, ought to be regarded as a natural blister, acting as a contra-irritant. It is produced by powers inherent in the constitution, that enable it to remove so much of the diseased action from an internal organ, the functions of which are more immediately necessary to life. In slight cases, I conceive the eruption is in proportion to, if it does not exceed, the amount of the internal disease. This may be stated without reference to the quantity of the eruption, except, perhaps, in small- pox. There can be no doubt that the eruptions are produced by in- flammation of the cutis, which consequently must take off so much of the determination of blood, and so much of the diseased action from internal organs. These circumstances, it appears to me, are clearly proved — 1. By attending to the constitutional commotion and oppression of the whole system, and the morbid changes in the functions of various organs, for many days before the appearance of the eruption. 2. By the relief afforded, in general, after the free development of the eruption. 3. By the increased suffering and danger which exist when the eruption is deficient, or when its repulsion suddenly and prematurely takes place. 4. By the relief which follows proper treatment; and, 5. By the appearances observed on dissection. With respect to the first of these points, it may be stated, that the eruption does not appear in general till the third, fourth, or fifth day of the complaint, and during that time, the patient labours under the combination of symptoms denominated fever, and suffers from the impeded functions of all the organs; all the symptoms denote internal disease. That the respiratory organs suffer very considerably may be discovered by the state of the respiration, the cough, the anxiety and colour of the countenance, but more particularly by auscultation, which will announce bronchitis iu its first stage. In this stage, which is called the eruptive, there are frequently affections of the brain announced by the patient suffering from delirium, lethargy, or even coma; and it is by no means uncommon to see convulsions, or other serious nervous symptoms, come on, at the period when the eruption ought to have been fully developed, but has not yet ap- peared, or has only partially come out. As to the second point, which has been offered in proof, it is to be observed, that the symptomatical physician will not be inclined to *[« Measles and scarlatina begin by gastro-enteritis, and by an acute catarrhal inflammation of the eyes, nose, throat, or bronchia. These phlegmasia constitute the whole danger of these diseases, by becoming violent, and attacking the brain and all the viscera.—Broussais.] ° ERUPTIVE FEVERS. 145 receive it as evidence in favour of the views which I wish to estab- lish. He will say there is no relief; and in so far he will say truly. The eruption being occasioned by extensive inflammation of the skin, produces great irritation, and very often an increase of the febrile symptoms; that is to say, the person will complain more of thirst, restlessness and uneasiness, than previously. But still a pathological eye will discover relief—relief produced by the translation of a part, and perhaps a great part, of the diseased action from internal organs to the surface. The symptomatical physician will point out to us that the respiration is still hurried and short, but we may be able, after an examination of the lungs, to assure him that there is less congestion of the lungs, and less inflammatory action in their mucous membrane, than before; and that the state of the respiration which he has noticed, is now produced principally by the hurried circula- tion through the lungs; so that, pathologically speaking, the patient is relieved. A common blister, when it is sufficiently large, very frequently increases the patient's sufferings, while it has mitigated the disease. The third point of proof is the acknowledged danger which exists when the eruption is deficient, or when its repulsion has taken place. Dr. Gregory, in his lectures, when treating of scarlatina, used to make the following statement: "We find a connection similar to that between the efflorescence and other symptoms in this disease, existing between the eruption and general affection in measles; for there it is not critical, but is accompanied with an alleviation of the symptoms, which is greater or less according to the degree of the eruption; and all the symptoms are very much aggravated by the repulsion of it." Indeed, if the reader will refer to any author who has written upon this subject, he will find, that in the severe forms of the disease, which are commonly described under the terms scar- latina maligna, scarlatina anginosa, and in rubeola putrida also, the eruption is either wanting, or it appears at irregular periods, but is seldom permanent; and it is in these severe cases that we meet with what are called typhoid symptoms, diarrhoea, and haemorrhage from the nose, mouth, or bowels. The first question which it is natural for an inquirer to ask, is, by what cause is the danger pro- duced ? It appears to me, that the reply is very easily made. There has been lately an extensive inflammatory action in the skin, which required a determination of blood to support it. During this time the symptoms were not very severe; but the moment that the blood forsook the surface, it was marked by increased internal distress; the respiration became more laborious, and the patient more or less comatose; perhaps convulsions appeared. Is it not quite natural, therefore, to conclude that these effects are produced by the sudden determination of blood taking place towards internal parts, produc- ing engorgements, and ending in inflammation of one or more organs, if the eruption be not speedily brought back? But it will frequently be that kind of inflammation which has been described as sup- pressed, and which cannot fully develop itself. The external symp- toms will lead a symptomatical physician to stimulate and give tonics, when the pathologist would try the effect of the warm bath, stimu- 13 146 GENERAL PATHOLOGY OF lating frictions, and bleeding by leeches, if he could not open a vein; and he would also apply blisters. The fourth point in the evidence, is the relief afforded by proper treatment. When the eruption is repelled from the surface, we use all the means within our power to recall it: the warm bath and stimulating frictions are first employed. The warm bath, which is the principal means to be depended on, may not be at hand, or we may have tried these remedies and failed ; but we ought not to delay long under any circumstance, to open a vein, if the eruption be not speedily re-produced, particularly if the patient be above two years of age,' and a vein can be found; if not, we must depend upon leeches, warm bath, and blisters. By opening a vein, however, we prevent a great deal of mischief and risk to the patient. If we cannot recall the blood to the surface, we reduce the quantity of it in the whole system, and thereby remove the accumulation from internal organs, alter the determination of blood, and then assist the system in creating reaction, if necessary, by the addition of a stimulant. But all this, to produce benefit, must be done instantly; every moment lost, diminishes the chance of relief. I am entitled to speak strongly, from the great success which has attended the treatment here recom- mended, not only in my own practice, but also in that of many of my pupils. Although many of these cases might be quoted in detail, yet the perusal of the following case, translated from the Clinique M6dicale, by M. Andral, vol. iii. p. 72, will perhaps make a sufficient impression upon the minds of my readers. The case is entitled, "Acute bronchitis; Measles; Premature disappearance of the erup- tion; Fatal dyspnoea." "A baker, aet. 20, of a strong constitution, was affected within the last five or six weeks with slight diarrhoea; presented on the 10th April, all the precursory symptoms of measles, redness of eyes, flow of tears, coryza, hoarseness, cough; and continued in this state for the three following days. On the 14th, the eruption appeared, and the patient took to his bed. On the 15th, his whole body was co- vered, and in the evening he was admitted into the Charit6; when he had a confluent, well-marked eruption; hardness and quickness of the pulse; redness of the tongue and lips; and a strong cough; there was otherwise no alarming symptom. Towards the middle of the night, the patient experienced, all of a sudden, an oppression, which rapidly increased, and on the following morning we found him in a state of partial asphyxia; the eyes prominent; the face of a violet colour; respiration short and very frequent; cough nearly constant; little mucous expectoration. Percussion elicited the natural sound through the whole of the chest, but the mucous rattle was audible, in different points, by means of the stethoscope. There re- mained only a few pale spots of the cutaneous eruption, which were fast dying away. The pulse preserved its frequency and hardness, and the tongue its redness. This train of symptoms seemed to indi- cate the existence of pneumonia; nevertheless, the pathognomic signs of this complaint were completely wanting. "Could a simple bronchitis occasion, by its extreme acuteness or sudden exasperation, so much dyspnoea? and might not this inflam- ERUPTIVE FEVERS. 147 mation, joined to that of the alimentary canal, account for the com- plaint with which the patient had been so violently attacked? Be this as it may, the indications of treatment were clear;—to lessen the internal inflammation,* and to effect a return of that on the skin. With this object, twenty leeches were applied to each side of the chest, and ten to the epigastrium. After the blood had ceased flowing, a blister was applied to each leg, and the skin rubbed all over with liniment of ammonia. Marked relief followed the use of these means; in the evening the respiration was much less impeded, the cough less frequent, and the tongue had lost its redness. The eruption, however, had not returned. " 17^A, The patient presented the symptoms of a severe bronchitis, accompanied with fever; the respiration was only slightly accele- rated. " 18/A, The fever was reduced to almost nothing, and the opaque expectoration announced the speedy termination of the bronchitis. In the evening, the respiration suddenly became very difficult, and twelve ounces of bloodt were abstracted from the arm. The next morning the dyspnoea was still very considerable, and the pulse had become more quick. Two blisters to the thighs. During the whole of the day, the sense of suffocation continued to increase. " 20th, Face extremely livid, violent colour of the lips, orthopncea; from the appearance of the patient, one would have thought that he was dying of aneurism of the heart. " Inspectio cadaveris.—The mucous membrane of the larynx, trachea, and bronchial tubes, and of the smaller ramifications, were of a scarlet red. In a few points at the beginning of the division of the bronchia, there were some white concretions, resembling the false membrane found in croup. " The lungs were sound and crepitated throughout their whole extent; posteriorly they were gorged with blood. Heart natural; clots of blood of a deep black in the right cavities; stomach white, as well as the smaller intestines, which contained a great number of ascarides and lumbrici in the lower portion ; the caecum contained several worms, (tricocephales); its mucous membrane presented a red spot near the valve, from which arose three or four small conical vegetations, three or four lines long. The rest of the large intestine white, and filled with liquid faeces. Liver gorged with blood. Spleen large and firm. A great quantity of serum infiltrated into the sub- arachnoid cellular tissue ; the cerebral substance was not at all in- jected ; the lateral ventricles, especially the right, were distended by much limpid serum." The fifth point of evidence rests upon the appearances found on dissection; and it may be shortly mentioned here, that these consist of all kinds of lesions of the brain and membranes, usually produced by acute and subacute inflammation. The same observation may * Had the distinguished author used the term " congestion" instead of inflamma- tion, and had he employed venesection without delay, instead of applying leeches, he would have altered the determination of blood, and probably relieved the diseased organs. This ought to have been his practice, from the hardness of the pulse. + It is to b* regretted that this was not done two days earlier. 148 SCARLET FEVER. be made respecting the organs in the thorax. Within the abdomen, the chief diseased appearance to be observed is in the mucous mem- brane, particularly of the large intestine, which is inflamed, some- times ulcerated. But in no case does the pulmonary system escape. The appearances in the brain and abdomen are not so universal, and may occasionally depend upon the impeded functions of the lungs, as will be shown hereafter. If these observations be not fallacious, bleeding to a sufficient extent ought not only to relieve the constitutional symptoms during the eruptive fever, but after the eruption has appeared, ought to destroy it. Observations and experiments frequently performed and repeated by myself, and by my pupils, enable me to state, that these are facts which I shall not be afraid to repeat before the highest authorities in the profession, and stake my professional reputation upon the general result of the plan; having already seen recoveries take place, under this treatment, in cases in which such a happy termination was scarcely to be anticipated. It also follows, if these things be true, that even in ordinary cases there are two periods more critical and dangerous to the patient than any other ; these are, the period at which the eruption ought to make its appearance, and that at which it should naturally disappear. In the first case, the internal disease has gradually become extensive and severe, and wants relief by means of the eruption. In the second, the disease which had existed at first, having been relieved by the external irritation, is now in danger of being reproduced by its cessation; and this of all others is the period at which, in the slightest form of the disease, the patient stands most in need of care and vigilant attention to the con- dition of internal organs. This pathological description, if it should appear deficient, is so only, I am convinced, from the want of sufficient illustration, which would require a separate treatise on the subject. It is introduced in this place to prevent repetition, when treating of each of the diseases which fall now to be described. SCARLET FEVER.-Scarlatina. This term is employed to denote a disease attended by a fever, sore throat, and a red rash on the surface ; which rash appears some- time between the second and fifth or sixth days of the disease, first upon the face and neck, and progressively spreads over the body, terminating between the seventh and tenth days. The rash has very much the appearance of the shell of a boiled lobster and fre- quently there are minute vesicles. The inflammation of the throat sometimes runs into ulceration and sloughing. The literary history of this, or of any other disease, is of little im- portance in comparison to an intimate acquaintance with its natho- logy, and proper means of treatment. Therefore, I shall proceed to SCARLET FEVER. 149 describe the phenomena, without caring from whence the disease came, or in what century it first appeared, further than to notice that scarlatina and measles were formerly confounded, from their mutual pathological resemblance. Sydenham appears to have been the first who gave this disease the name of scarlet fever, as well as a distinct description of the affection, pointing out the circumstances, with suf- ficient precision, in which it differs from measles.* The term scarlatina, notwithstanding the philippic of Dr. Mason Good, is quite as good as his term Rosalia; it affords us an example of what is by no means rare, a disease receiving its name from a single symptom. Scarlatina has been divided into three species, viz. Scarlatina simplex. ---------anginosa. ---------maligna; which last includes the disease termed cynan- che maligna. My chief objection to these terms is, that they do not spring from pathological considerations; and it may be said in the lan- guage of Dr. Hamilton, sen., that " it is altogether foreign to my pur- pose to engage in this controversy; and more so, as the distinction begins to lose ground as our knowledge of the disease becomes more comprehensive and accurate. The time may not be far distant, when scarlatina will be received as the generic disease, the full history of which will include the more aggravated symptoms as they appear in scarlatina anginosa, and in cynanche maligna; in the same manner as the history of variola comprehends the varieties of the distinct and confluent small-pox." Scarlet fever is a fatal disease. The plague is scarcely more dreaded at Constantinople than scarlet fever is in Edinburgh; not because the disease is peculiarly severe, but that the notions taught in a dark age still prevail, and that certain individuals have not kept up their knowledge with the improvements since made in pathology. Symptoms.—In eruptive, as well as other fevers, there are two great varieties, which may be named the congestive and the inflam- matory; and subdivisions might be made of different combinations of these two. In the congestive form of scarlatina, the patient complains of op- pression, and so much debility, that he cannot support himself. Rigors more or less severe accompany or precede these symptoms. The face is pale, the features sharp, the eyes hollow, and deprived of their accustomed animation; the surface cool, particularly the ex- tremities, while perhaps considerable heat is felt on the trunk of the body; the breathing is performed with more or less difficulty; the pulse varies, being sometimes soft, and perhaps weak, although it is occasionally strong; the tongue has a whitish and shrunk appearance. If the patient utter complaint, it will be of universal prostration and of headache, or weight on the top of the head, together with oppres- sion at the praecordia, and difficulty in swallowing. On examining * [A. D. J670. It was called Morbilii confluentes, by Dr. Richard Morton and Rubeola rosalia by Hoffmann. The peculiar characteristics of scarlet fever as dis- tinguished from those of measles were first pointed out by Dr. "Withering, towards the elose of the last century.] 13* 150 [SCARLET FEVER] the fauces, the parts may appear somewhat swollen, and of a dark colour; and should there be any ulceration, it will, perhaps, be ash-coloured, and look indolent. It may be stated, and with some plausibility, by that class of practitioners who are led only by symp- toms, that those just described do not denote the existence of scarlatina; to which it may be replied, that one individual of a family will display such symptoms, while others are labouring under the disease in the ordinary form. Similar appearances have also come on in the course of scarlatina, upon the sudden disappearance of the rash, and further, the cessation of the congestive symptoms has been witnessed upon the reproduction of the rash; which phenomena have occurred so often, that I am compelled to receive them as part of the medical evidence. I have had one opportunity only of examining the body after death, in a subject who fell a victim to this form of the complaint. The throat was found to be very slightly ulcerated. There was considerable distension of the veins in the abdomen, the lungs were much congested, and the vessels of the head were re- markably full of dark-coloured blood. [It is the congestive form of scarlatina which is most usually at- tended by convulsions, which constitute one of its most alarming complications. These are generally preceded by coma; but the lat- ter sometimes continues until death, without any spasmodic action. When the convulsions are sudden, however, they are even less to be feared than those spasmodic affections of the extremities which come on insidiously, indicating a lurking affection of the brain, and always giving just cause of apprehension. They are usually preceded by some thickness of the voice and spasmodic flexion of the fingers or toes; and these symptoms may last for days, when they become general and end in paralysis, coma and death. The most malignant varieties of scarlet fever in the United States are often wholly unaccompanied by the characteristic eruption. They commence with vomiting, followed speedily by purging, and both symptoms are often from the first intractable. The skin as- sumes a livid, cadaverous hue, the features shrink, the surface is cold, and the patient dies within ten or twenty-four hours, in a state of restless and muttering delirium. Another very dangerous complication is that of croup, from which I have witnessed but a single recovery. Yet it is also to be observed that these forms of scarlet fever which are mild in their accession, often become slowly but progressively intractable, pervading the whole system like an insidious poison, impairing the function of every organ, and finally exhausting the patient between the fifteenth and thirtieth day from the commencement of the disease. Scarlatina is proverbially a disease of infancy and childhood, and comparatively unfrequent in adults, in whom, however, the symp- toms are commonly of a more aggravated character. Fortunately for the human race, this fearful maiady v^ery rarely attacks the same individual more than once, nor havel eyer met with an unequivocal exception to the rule.] **' The pure congestive disease is rare; but it is very common to see the mixed disease, that is, a combination of the inflammatory with the congestive symptoms. SCARLET FEVER. 151 The inflammatory form of scarlet fever generally makes its attack in the following manner:—rigors, or only slight chilliness, followed by more or less pyrexia, restlessness, want of appetite, thirst,, want of sleep, headache, some degree of nausea, oppression at the prae- cordia; tongue at first slightly loaded, red, with raised papillae; or it may be much loaded with a yellow fur, and intensely red at the tip and round the edges. [The appearance of the tongue is charac- teristic. For the first few days it is usually covered with a white fur, as in ordinary fevers; but this sooner or later gives place to a uniform shining red colour, while the whole surface is studded with the inflamed papillae which appear to take on the eruptive irritation, becoming elevated, sensitive and intensely red. In fact, the tongue, under these circumstances, has been aptly compared to a piece of raw beef. As the eruption declines on the surface, the tongue, in favourable cases, resumes its healthy appearance ; but if the disease should be protracted and typhoid, the tongue becomes dry, brown and cracked or fissured ; or perhaps assumes a smooth, glossy aspect, which is usually indicative of slow convalescence.] Soreness of the throat is complained of, which is sometimes the first cognizable symptom; it is either slightly swollen and much inflamed, or of a dusky hue, without much swelling ; ash-coloured ulcerations may often be discovered, but we must be upon our guard not to mistake exudations of coagulable lymph for ulcerations. In the generality of cases, there are evidences of subacute inflammation in the larynx and bronchi, which is announced by difficulty of breathing, cough, and hoarseness, and more particularly by auscultation; but the in- flammation in the bronchial tubes is not so decidedly marked in all cases of scarlatina, as in measles and small-pox. Sometimes there is delirium, but perhaps during the course of the night only, and sometimes some degree of coma. These symptoms may continue for 2, 3, 4, 5, or 6 days, before the rash makes its appearance. Some- times, indeed, the eruption is the first symptom which announces the complaint, but this happens in the mildest cases only.* In general, the eruption appears on the 4th or 5th day. The eruption is of a scarlet colour, first to be observed on the face and neck, and in the course of twenty-four hours becomes pretty generally diffused, patches appearing here and there more intensely red than the surrounding parts; on pressing with the finger a white mark is left, but the redness returns in a moment afterwards. [The rash begins in points or dots, and from these centres it soon spreads over the surface, first appearing on the face, breast and neck, and subsequently pervading more or less the body and extremi- ties. On the latter, it sometimes causes an obvious elevation of the papillae which feel rough to the touch and present some analogy to the eruption of measles. The rash begins to decline about the fifth day. I have, in some rare cases, observed the eruption to be attended at its very commencement, with an intolerable itching of the skin; and in one instance I was led to pronounce a patient affected with [* I have met with a remarkable exception to this rule in a child, in whom the efflorescence appeared among the earliest symptoms, and yet the disease suddenly assumed a most aggravated form.] 152 SCARLET FEVER. the nettle-rash, who was actually labouring under scarlet fever, which in the end proved to be one of the most violent cases I have ever known to recover. Dr. Rush and others describe another eruption which they have sometimes observed about the fifth day of the ordinary rash, and constituted of semi-globular vesicles, containing a thin pearl-coloured serum, whence, in some of the older nosological works is derived the name of Scarlatina variolosa. I have never seen a case of this pustuloid form of the disease.] After the eruption has existed from three to five days, it begins to decline; the cuticle subsequently separates and peels off. This is a very dangerous stage of the disease, and would be still more so, were it not that the eruption declines gradually, and that the circula- tion on the surface is still actively employed in the formation of new cuticle for the whole surface. [The desquamation in scarlatina is peculiar. On the body, face and scalp it mostly takes place in bran-like scales; but where the epidermis is thicker, as on the hands and feet, the cuticle sometimes comes off entire like the fingers of a glove, leaving the subjacent papillae distinct and sensitive for many days.] Dr. Gregory, in his lectures, used to state, that " a copious efflo- rescence is a favourable symptom: when it is deficient,the symp- toms are more severe; and when it is repelled, it never fails to ag- gravate both the general fever and the topical affection of the throat." "It is not an easy matter," continued he, " to explain the connection which subsists between the efflorescence and the other symptoms; it is not critical, but all the symptoms are much relieved by its com- ing out copiously." Occasionally anasarca, and more rarely ascites, follow in the first or second week, and are attended with constipation, scanty urine highly albuminous, languor, nausea, general uneasiness, and other symptoms which have been denominated secondary fever. [It is also not unusual to see inflammation and suppuration of the glands of the neck, sometimes extending to both sides, and causing great destruction of the parts involved. These glandular enlarge- ments commonly take place subsequent to the inflammation of the throat; the extension of the one being proportionate to the violence of the other. This affection is sometimes very rapid in its develop- ment, the glands becoming hard, isolated and egg-shaped: and when this happens simultaneously on both sides of the neck, the larynx suffers greatly from mechanical compression, even to a fatal degree; the patient dying with all the symptoms of suffocation, owing, how- ever, in part, to the tumefaction of the tonsils. There is another appearance not so often met with, but much more to be dreaded—the hemorrhagic form of scarlet fever. It usually commences by small purpurous spots under the cuticle of the chest and extremities. Some oozing of blood next follows from the mucous membrane of the mouth and nose, which sooner or later becomes profuse, and the patient eventually bleeds to death. If a vein has been opened in the arm, or an abscess lanced in the neck, the incisions become a source of hasmorrhage; and in a case that oc- curred in my practice in the winter of 1834-5, and which was seen SCARLET FEVER. 153 by Drs. J. Rhea Barton and Wood, the abscess in the neck suddenly filled with blood, and the latter making its way through a leech bite, flowed out as if from a divided artery, and destroyed the patient in a few hours.*] Appearances on dissection.—In the dissections which have fallen within my observation, the inflammation and ulceration in the throat have not appeared so extensive and important as had been imagined before death. The most constant diseased appearances have existed in the air passages, presenting inflammation in its different stages; viz., vascularity of the mucous membrane, thickening, and occasionally, ulceration; in two cases I have seen the epiglottis nearly destroyed by ulceration; and also effusion of thick, tenacious matter, filling up the air passages to the bifurcation, and often lining the trachea. Sometimes the substance of the lungs is seen inflamed, and occasion- ally the pleura, but traces of inflammation in these two tissues are not so frequently met with, and are to be regarded more as exam- ples of acute action, extending from one tissue to another by conti- guity, than as forming essential parts of the disease. The lungs are sometimes so much gorged with blood, as to have lost in a great degree their natural appearance and buoyancy. In the brain there is sometimes arborescent vascularity, with turbid effusion between the arachnoid and pia mater, and the ventricles are occasionally filled with serosity. On opening the abdomen, the peritoneal coat of the stomach and bowels generally looks healthy, except in the conges- tive cases, when the smallest blood-vessels will be seen distended with dark-coloured blood. In different parts of the mucous mem- brane, we frequently see considerable vascularity, sometimes ulcera- tion. The liver is often gorged, or soft in texture. " From a cautious survey of the symptoms during life," says Dr. Armstrong, in his work on scarlatina, &c, page 16, " and from the examination of several bodies after death, I am warranted in affirm- ing, that the brain, the liver, the stomach, the intestines, and the lungs, are the parts most often inflamed, and that the inflammation in these parts is generally the cause of death, together with the affec- tion of the throat." Treatment.—In scarlatina, as in other diseases, differences in pathological opinions have of course given rise to dissimilar methods of treatment. Some, considering it a disease of debility, recom- mend bark, and wine, or brandy, with nourishment, and condemn antiphlogistic means as highly dangerous; in this class of symptoma- tical writers stand Underwood and Dr. James Hamilton, jun. It will not surprise my readers, that the first named individual, who did not live long enough to profit by modern pathology, should have taught the doctrines that prevailed in his own time; but considering the account which every author gives of the symptoms and course of this disease, and the appearances on dissection, it is lamentable to reflect that there is one author of the present day, who speaks doubt- fully even of local bleeding in scarlatina, and who recommends cor- dials and nourishment, and even wine itself, in large quantity. But [* See Purpura, vol. 2, Pt. VII, chap. 7.] 154 SCARLET FEVER. all this does Dr. James Hamilton, jun. ;* he goes even the length of quoting a great medical authority, the head master of a boys' school in Yorkshire, in whose practice, among the said boys, " it was found that children under fifteen years of age, affected with this disease, required, within the twenty-four hours, sometimes not only a bot- tle of port-ioine, and another of raisin, but also a proportion of brandy."\—Poor boys! Underwood, in describing the treatment necessary in this disease, makes the following extraordinary statement: " Should the affection of the throat, therefore, be evidently inflammatory, or should a case occur where the fever may seem to be of that kind, (which may be better ascertained by the hardness of the pulse than any other symp- tom,) it will very rarely bear bleeding, even in the beginning of the disease, as symptoms of debility generally attend in some period of the scarlet fever, and will allow only of that middle course of treat- ment hinted at above. In a general way, a cordial plan is required throughout the disease.":}: And yet, on turning to the next page, it will be found he recommends bleeding in the secondary fever; and he also tells us, that a critical bleeding from the nose has saved life, when the patient's state " has appeared very hazardous, and the prostration of strength been considerable." In the slighter forms of scarlatina, very little treatment is necessary, further than confinement, attention to the bowels to keep them free, and the antiphlogistic regimen. In such cases, however, the medical attendant should be careful to watch diseased action, at the period when the eruption naturally declines, for reasons already mentioned. Formerly, I saw many fatal cases of scarlatina, when I practised according to the opinion of the schools, carefully abstaining from blood-letting, and using all the means recommended to support the strength; but I occasionally observed patients snatched from the grave by considerable bleedings from the nose, and at times when it was thought the loss of an ounce of blood would prove destructive. These circumstances, together with the appearances found on dis- section, led me to bleed in many subsequent cases, and I have never had occasion to regret it. Blood has been drawn at all periods of the disease, in cases where the state of the lungs and brain required it; and should the operation be performed during the period of the eruption, it will disappear, if a sufficient quantity of blood be taken. When the inflammation of the throat runs very high, I know no remedy productive of such certain and immediate good effects as general bleeding, but should the patient's strength be already re- duced, leeches are to be preferred. Dr. T. P. Lucas, of the royal artillery, and Dr. Wilson, cannot have forgotten the case of Ann M'Farlane, aged 18, which they treated, when they were my pupils in the year 1824, from whom they took above 3xx of blood, with instant good effect, on the fourth day of the disease, when she had a large sloughing ulcer occupying the * Vide his work on the Diseases of Children, p 380 t Management of Children, p. 381, ed. 1824 t A Treatise on the Diseases of Children, p. 289. [SCARLET FEVER] 155 whole of the right tonsil. She afterwards required no other reme- dies but laxatives, and in a fortnight returned to her usual occupation. A great many other gentlemen, who have been pupils at my dis- pensary, can be appealed to, and I may refer in an especial manner to the testimony of my talented colleague Dr. Robertson, who was opposed to the practice of general bleeding in scarlatina, till he saw the success of it. [The medical profession in the United States is much divided in opinion with respect to venesection. In my own practice, I have resorted to it sooner or later, in every severe case, and thus far I have no disposition to change my plan. What else can we interpose in those violent inflammatory attacks, in which the burning skin, swelled throat, excited brain, and universal distress, call aloud for relief at the hands of the physician ? How yet more imperative does this mode of depletion become, when convulsions are added to the frightful category ? I am far from recommending the free bleedings which are advocated by the author of this work; because they would be unwarrantable in the disease as seen in this city and its vicinity. But moderate venesection at the outset, re- peated, if necessary, has been of all other remedies, that which has produced, in my hands, the most gratifying results. The only two cases of fatal consecutive dropsy which have occurred in my practice, were patients who had not been bled; and I have thought that effu- sion is more liable to occur in those who, having had the inflam- matory form of the disease, were not treated by venesection. Once for allf I would exhort the practitioner to discard any proscriptive rule with respect to bleeding in scarlet fever. In that appalling variety of scarlet fever which is marked, as we have shown, by comatose delirium, a cadaverous skin, and the other evidences of an essentially malignant disease, every mode of treat- ment seems equally unavailing; and I have sometimes been unable to satisfy myself that the use of medicines had even the effect of retarding the progress of disease. When, therefore, malignant con- gestion takes place, our safest course is to apply leeches to the head, to maintain the capillary circulation, and consequent warmth by every available means, and to give internally, but with great cir- cumspection, such medicines as the nature of the case may seem to demand. It is a great point, under such circumstances, to do no harm.'] When general bleeding is either inadmissible, or not thought necessary, or when the child is under two or three years of age, local bleeding by leeches will be found highly serviceable. When the throat is extensively inflamed, although the accompanying symptoms may be mild, 1 always think it right to reduce the inflammation by the application of leeches, followed or not by a blister, according to circumstances. Laxative medicines, frequently repeated, are very necessary. [Yet blisters, especially when applied to the throat, are apt to become gangrenous, and therefore require to be resorted to with caution. The safest plan is to leave the blister on until it merely reddens the skin, (having first covered it with a fine gauze,) then remove it and apply a soft poultice, which will complete the vesicatory process with the least possible irritation.] Sponging the body either with tepid or cold water, produces good effects, by allay- 156 [SCARLET FEVER.] ing restlessness. Cold affusion may do no harm in the slighter forms of scarlet fever ; but in the severe cases which invariably display marks of internal disease, and in which congestion has taken place, its use cannot be defended. [In children, especially, the use of a warm bath is particularly salutary, both in the hot stage of the fever and during the period of desquamation. Warm pediluvia should be frequently resorted to; and when intolerable itching of the skin comes on, it may be greatly allayed by sponging with equal parts of tepid whiskey and water. I have also found this form of irritation to be vastly relieved by the application of any animal oil, and also by combining the latter, as lard for example, with lime-water, so as to form a preparation resembling the cold-cream of the shops.] The tartrate of antimony has been long employed in this country in the treatment of fevers and inflammations, and it has been found very serviceable in this disease, by controlling the action of the heart, and relieving uneasiness. It may be used in the diseases of children, by dissolving a grain in four ounces of water, a teaspoonful for a dose as often as may be thought necessary. [The safest diaphoretic is, perhaps, the citrate of potassa, as recommended in remittent fever, to which a little spirits of nitre may be added. If this, however, should not be admissible, small doses of the bi-carbonate of soda, dissolved in mint water, or some other agreeable fluid, I have found to answer a salutary purpose. All the milder alkaline preparations seem to be peculiarly adapted to scarlet fever ; whence also the use of the chlorate of potassa, as recommended by Dr. Watson and other practitioners. A drachm of the salt should be dissolved in a pint of water, and this quantity may be taken by an adult, as a drink, during the twenty-four hours.*] Gargles may certainly be employed, and those of a stimulating nature are much lauded; but it appears to me that the best gargle is a little warm water; and I particularly caution young practitioners against attempting to syringe the throat of a young child. Inhalation of the vapour of warm water, will be found to ease the throat more than any other gargle. [But after ulceration or sloughing commences stimulating gargles contribute greatly to convalescence. Nothing has been found more efficacious in the United States than Cayenne pepper, either infused in water, or mixed with vinegar, and fre- quently used. Diluted port-wine, the black-oak bark, and common green-tea may also be used with salutary effect. The too early use of such applications, however, is hurtful for obvious reasons. There are other cases in which the application of nitrate of silver has the happiest effects, especially in arresting gangrene. It is often best put on in the solid form; but if a solution is desirable, ten grains to the ounce of water will be sufficiently active, and this should be applied with a camel's hair brush twice or thrice a day.] Opiates * [The following are Dr. Watson's exact directions for preparing this medicine Two drachms of the chlorate of potass are to be dissolved i?ntwo ofnres ShydrS chloric acid, previously diuted with two ounces of distilled water TheSolution must be put immed.ately into a stoppered bottle, and kept in a dark place Two drachms of this solution mixed with a pint of dislilled wafer, constUutethIchlorZ mixture, of which a tablespoonful or two, according to the kee of "he na?ient ma^ be given for a dose, and frequently repeated.] S patient, may [SCARLET FEVER.] 157 are often serviceable in the last stage, and during convalescence, to allay irritability, and procure sleep. [When the glands of the neck become much inflamed and swollen, leeches should be at once applied to them, followed by emollient poultices, and gently stimu- lating liniments. I have often by these means arrested the inflam- mation, but it will sometimes go on to suppuration, and form large abscesses: when there is no haemorrhagic tendency, these should be opened with a lancet, to prevent a scar and circumscribe their ravages.] Since the alteration which 1 have adopted in practice, I rarely see secondary fever or dropsy; but too great care cannot be taken during recovery, and the patient should be cautioned against the risk that he will run from exposure, errors of diet, and neglecling the state of the bowels. Should dropsy take place, it will in general be found to be of the acute kind, with coagulable urine, with a specific gravity of about 1010°, and will sometimes require the lancet, although brisk purgatives, with diuretics, will in general suffice. Dr. Lewins was called to see a little patient of mine, who, after scarlatina, had dropsy with coagulable urine. Convulsions suddenly appeared when he was much debilitated. Dr. Lewins opened a vein, and allowed the blood to flow till the boy (whose age was ten years) was relieved ; the blood weighed two pounds. No debility followed, and the boy from that time made a rapid recovery, and has ever since been healthy. In conclusion, it may be mentioned, that various affections occa- sionally follow scarlatina, as inflammation and swelling of the glands, and perhaps more particularly of the parotid, which must be treated upon ordinary principles. Inflammation often attacks the internal ear, leaving a fetid discharge followed on some occasions by incura- ble deafness, which must also be treated by appropriate means. [Such, for example, as injections of the solution of bicarbonate of soda, or sulphate of zinc ; or, where the discharges are fetid, a weak prepa- ration of creosote water will answer an excellent purpose. A blister behind the ear, repeated from time to time, according to circumstances, will aid much in the radical cure of this troublesome affection, which not uufrequently terminates in incurable deafness. We often, also, see acrid discbarges from the nostrils, which not only inflame the schneiderian membrane so as to cause great distress and pain, but they also excoriate the adjacent surface of the lip, and sometimes con- tinue month after month with various degrees of irritation. The best corrective I have found to be the internal use of iodine and sarsaparilla; with injections into the nostrils of distilled creosote water, largely diluted.] These and other appearances following scarlatina, are commonly known by the term "dregs" of the disease. [Preventive measures. Much has been said and written on bella- donna, as a prophylactic of scarlatina. It was first employed for this purpose by Hahnemann, who was led to its use from observing that in small and repeated doses it produced a slight erytheniatic eruption, some tumefaction of the salivary glands, and dryness of the mouih; whence he inferred, from the resemblance these symptoms bear to those of scarlet fever, that it might counteract the infection of 14 158 MEASLES. that disease. He directed three grains to be dissolved in a fluid ounce of water, of which three drops were to be given to infants under a year old, and to older persons in proportion. The use of this preparation as a preventive is purely hypothetical, nor is there the least reason to place reliance upon it. Had it been employed in the following case, its efficacy would have been, in the opinions of some practitioners, perfectly well established. A young lady was attacked with high fever, which, at the end of the second day, proved to be scarlatina of a severe type. Her parents, seven brothers and sisters, and several servants, became apprehen- sive of the consequences, and inquired into the propriety of a part of them leaving the house for protection against the disease. I gave it as my opinion, that as they had been so much in the same atmo- sphere with the patient, it would be useless to fly; inasmuch as if they were any of them susceptible to contagion they must already have imbibed it. They all, in consequence, resolved to remain at home; and although they communicated freely with the patient, and assisted in nursing her until she recovered, not another member of the family took the disease.] RUBEOLA.—MEASLES. Measles may also be defined to be a disease attended by fever and an eruption, which appears at various periods, but generally at the termination of the fourth, or beginning of the fifth day, and con- tinues for three, four, or five days; after which, some discoloration is left on the surface of the body, and occasionally the cuticle sepa- rates, but not so invariably as in scarlatina. Measles has been divided into four varieties: 1*/, Rubeola vulgaris. 2d, ------sine catarrho. 3d, ------nigra. 4th,------putrida. Pursuing the same pathological plan, which has been adopted when treating of scarlatina, I shall also mention two great varieties of measles, the congestive and the inflammatory. In the first species which has been so well illustrated by Dr. Arm- strong, reaction does not take place; or if it do, it is slight, the erup- tion is trivial; the pulse is feeble and oppressed, perhaps quick; and the surface is free from that redness and heat which give such a striking external character to the pure inflammatory disease. This is, no doubt, one form of the complaint called putrid, and which has been described by Morton, Huxham, and Watson. The same pathology that was maintained in scarlatina, and also in the general statement concerning eruptive fevers, equally applies to this case, and renders it unnecessary to repeat the observations. Capuron, in his treatise on the diseases of children,* makes the * Page 293. MEASLES. 159 following statement:—One of the most dreadful complications of measles, is that with an ataxic or malignant fever. Individuals naturally lively and delicate, as those in infancy, are more subjected to it. It is one of those unlooked for anomalies in the vital proper- ties. The functions of the brain are disturbed; respiration is de- ranged, and becomes extremely constrained; in a word, the patient is quickly reduced to the last extremity, if something be not done for his relief. The most active treatment is here indispensably neces- sary to sustain life, which is shaken to its very foundation." Sub- sequently he states: that "infants naturally weak, or who live under the influence of debilitating causes, are exposed to an adynamic or putrid fever during the course of the measles. One detects this dan- gerous complication by the change in the form and colour of the spots;—from being at first prominent and of a lively red, they become more depressed, pale, and livid ; in which case, we must pre- vent the prostration of strength in good time, and direct the erup- tion back again towards the surface of the body by the use of tonics, such as wine, bark, and camphor; the greatest advantage may be also obtained by epispastics, and above all by blisters." At p. 294, he again observes, "there are infants in whom the progress of the eruption is arrested, the spots disappear, and pains in the chest, more or less severe, manifest themselves; respiration is op- pressed; peripneumony declares itself; suffocation is threatened." Mr. Burns, of Glasgow, in detailing the symptoms of measles, states, that "sometimes the eruption suddenly and prematurely recedes, or never comes fully out. Both of these cases are unfa- vourable ; the fever is high, and the oppression great." It will be seen, by consulting the report of diseases treated at the New Town Dispensary of Edinburgh, during the last six months of the year 1816, published in the 13th vol. of the Edinburgh Medical and Sur- gical Journal, that this form of the disease was very prevalent, and that few children recovered; most of those attacked were of feeble habit, or weakened by previous illness, "but others appeared to have been quite healthy when exposed to the contagion." Those af- fected in this way were chiefly infants, but a few were children from four to seven years of age. They were ill longer than usual, gene- rally five or six days, before any eruption appeared, having the usual catarrhal symptoms, with much debility and drowsiness; frequent vomiting; generally frequent, and sometimes bloody stools; quick pulse, and white tongue, without much heat of skin. When the rash appeared, it was at first less distinctly circumscribed, and afterwards less elevated than usual, of a darker colour, and attended with less heat of skin. After its recession, the patients were more or less dis- tressed with cough or dyspnoea, generally with diarrhoea, and almost always with a frequent ineffectual attempt to vomit. The pulse and breathing became very quick; the tongue, after losing the white crust which had covered it at the beginning of the disease, became dry and hard; the posture indicated much debility; the countenance had the languid, vacant expression of typhus; and a dark-coloured fur usually gathered on the lips and teeth. In all these cases, there 160 MEASLES. was a degree of drowsiness approaching to coma; and in a few, this state appeared to be blended with delirium. In two or three instances, infants exposed to the contagion of measles, became affected with catarrhal symptoms, fever, drowsi- ness, quick and oppressed breathing, and died, without any eruption being observed. In the cases of speedy recession of the rash, if the cough and dyspnoea were urgent after its disappearance, death almost univer- sally ensued from the first to the fourteenth day after that change. But those in whom the pectoral symptoms were less distressing, re- covered from the state above described, under the use of wine and cordials, which, as far as we could judge, were as decidedly bene- ficial in these as in any other cases in which we have seen them used. It should be mentioned, however, that one or two, who could not be prevailed on to take either food or medicines, gradually mended without any crisis being observed. On opening the bodies of those who had died of this form of measles, a considerable accumulation of mucus in the bronchia was always found. In two infants, under a twelvemonth, there were marks of inflammation of the lungs, (which in one of these had pro- ceeded to ulceration,) and a good deal of water was found in the pericardium. In one child, four years of age, there was such a con- gestion of blood in the lungs, that a large portion of them sunk in water. In several cases, in which the eruption had almost or entirely disappeared on the second day, it reappeared that night, after the use of the warm bath, and an opiate, and continued nearly the usual time. An aphthous state of the mouth and tongue occurred pretty fre- quently, but was not confined to the unfavourable cases. The circumstances of the livid colour and rapid recession of the eruption, of the succeeding typhoid state, and the irritability of the stomach attending that state, seem to point out a resemblance be- tween the cases of measles now described, and the worst cases of scarlatina. I scarcely think that such symptoms and morbid appearances sup- port the wine and cordial treatment, which, we are told, was had recourse to in these cases. It has fallen to my lot to treat a consi- derable number of cases of this kind; and the plan which experience has led me to adopt, is first to try the warm bath with stimulating frictions; but if the symptoms be very threatening, such as coma, convulsions, or asphyxia, or an approach to these states, the best practice, if the patient be an adult, or even a child, if a vein can be found, is to bleed at once. Many interesting cases might be detailed, showing the advantage of this plan. The following is a short sketch ot one. A few years ago, I was called suddenly to see a child in measles on the first day of the eruption; every appearance had been so favourable up to the moment of the sudden recession of the rash, that the family had not applied for medical advice. On my arrival, the eruption, which had been extensive, and of the usual colour, was not to be seen, although it still was to be felt. The child was under MEASLES. 161 three years of age, and of good constitution; it had had three or four strong convulsions in the course of rather less than an hour, and was now comatose; one pupil dilated, whrle the other was of the natural size; the hands were clenched. A good-sized vein being found in the arm, was instantly opened, and from eight to ten ounces of blood abstracted when the breathing and every other appearance became more favourable; the pulse, which was under sixty, rose gradually as the bleeding went on; and the child soon became quite sensible. So far from debility following, it was necessary, from the appear- ance of cerebral irritation, to apply leeches next day to the head; the child made a rapid recovery, and was running about in the course of a week. In every respect the treatment must be conducted in the manner detailed in congestive fever, as well as in the congestive form of scarlatina. The inflammatory disease is the form most generally met with; we have the usual eruptive fever, preceded by rigors, depression, and debility, along with the fever; the patient has a dry cough, with hoarseness; frequent fits of sneezing and coryza. He also complains of giddiness and pain in his forehead, as well as in the back; his pulse is various, sometimes frequent and small, or frequent and strong; often it is irregular and oppressed; the bowels are generally confined, and the evacuations fetid. In the course of the second, third, or fourth day of the fever, the symptoms run higher; the eyes are tender, red, watery, and inflamed; the dyspnoea, which was slight at first, is now more severe; the patient complains of tightness of the chest, pain and oppression at the praecordia. The eruption appears first on the face and neck; in twenty-four hours it is found on the breast, and afterwards gradually spreads over the rest of the body ; it consists of small red papulae, slightly elevated, resembling recent flea-bites; these soon form themselves into extensive patches, irregular in shape, their margins having somewhat of a crescentic appearance. [The eruption ' on the face and body is much more elevated than in scarlet fever, and of a darker red colour.] The eruption is sometimes very extensive, at others slight. The throat, when examined, will be observed to be covered with small red patches, occasioning difficult deglutition. Sometimes, immediately before the eruption comes out, the patient is seized with violent sickness and vomiting; sometimes with con- vulsions; but if the eruption subsequently comes out freely, these symptoms abate. In a great majority of cases, the disease is rather slight, and the internal disturbance, which is discovered by the symptoms already described, is generally very much appeased soon after the appearance of the eruption, particularly if it come out freely and plentifully. Occasionally, however, the symptoms are very severe from the be- ginning; the cough is frequent and harsh; there is considerable dyspnoea, with hot skin, thirst, and a quick pulse ; and the child is occasionally so lethargic, that this symptom early attracts our atten- tion. As the embarrassment of the lungs increases, which may happen in any stage, the face becomes discoloured, and sometimes presents 14* 162 MEASLES. a purple appearance, and occasionally the eruption over the whole body assumes a dark colour; this is the state which is called rubeola nigra, and is probably that form of the complaint described by Dr. Watson, under the term putrid measles. After the natural disappearance of the eruption, the fever, dys- pnoea, and cough, in some cases increase, attended or not with considerable gastro-intestinal irritation and diarrhoea: occasionally inflammation of the eyes, and enlargement of the glands of the neck, succeed. Blistered surfaces frequently slough; and it has been re- marked by Dr. Watson, Dr. Ferriar of Manchester, and others, that an ulceration of a particular character attacks the pudendum of girls, from which few recover; four cases have fallen within my observa- tion, three of which proved fatal; and it is my opinion that death is not owing to this ulceration, but to internal disease. Dissection, in two of these cases, displayed extensive disease of the lungs, but more particularly ulceration of the mucous membrane of the intestines, of which the preparations and drawings are in my museum.* Appearances on dissection.—Morgagni notices the following case, which, he says, has been transferred from Ballonius into the Sepulchretum: " On examining the body of a person to whom it was suspected that poison had been given, the stomach was found beset with exanthemata, and the physicians were upon the point of assert- ing that the appearance was owing to poison, when they were in- formed that the person died of measles, which began to appear on the skin, and suddenly vanished." In the examinations at which I have been present, effusions and other marks of inflammatory action have been found in the brain, and sometimes ulceration in the mucous membrane of the bowels; but I have seen no dissection in which the pulmonary system escaped. The lining membrane of the bronchi, trachea, and larynx, has not only been found in a highly vascular state, but it has been thickened, softened, and occasionally ulcerated; the ulcers are small, and gene- rally situated near the bifurcation; the bronchial tubes are more or less filled with a matter like pus or thick mucus, as in bronchitis; the colour of this secretion varies; and it is sometimes tenacious. This condition of the air passages has always existed on both sides of the chest. In many cases, the lungs are found emphysematous: in others inflamed in different degrees; the inflammation rarely affecting both lungs, and it is frequently confined to one lobe. Occasionally there are extensive inflammations of the pleura, indicated by effusion of serum and exudation of coagulating lymph, besides thickening of the pleura and recent adhesions. In cases of longer standing, tuber- cular formations are observed in different degrees of advancement; sometimes even excavations of the lungs are seen. It ought to be noticed, that the inflammatory appearances in the brain and bowels, together with the disease of the substance of the lungs, and the pleuritic effusions, are to be regarded as accidental * 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 onlv two recovered The case of recovery which I have noticed, was under the care of Dr. Moffit, of the 7th Hussars ; the patient was a soldier's child. The disease followed a very slight attack of measles. MEASLES. 163 circumstances; whereas, the inflammation of the bronchial mem- brane 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 exhibition 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 eruption naturally recedes, for reasons already mentioned. In the severe forms of measles, bleeding is often necessary during the eruptive fever, when the pectoral symptoms run high and appear threatening; and also when coma and convul- sions take place, both of which are more likely to happen, but parti- cularly the latter, if the child be suffering from difficult dentition. I was called to see a fine boy of two years of age, who, during the erup- tive 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 afterwards exceed- ingly slight, and he made a rapid recovery. He bore the bleeding without any tendency to syncope, while his brother, a boy of twelve years old, labouring also under the same disease, and who required blood-letting for pectoral symptoms, fainted upon the loss of two ounces. When bleeding is necessary, it ought to be performed in the man- ner already described when treating of inflammatory fever; a suffi- cient 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 question- able remedy, and no doubt often does irreparable mischief, for reasons which will be fully noticed when treating of bronchitis. Leeches are to be employed as directed in scarlatina, and also blisters.* An- timony is also highly serviceable; and opiates in the last stage, when there are restlessness and irritability, 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. During 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 tuber- cles in the lungs: inflammation and ulceration of the mucous mem- brane of the bowels, producing the disease which is called tabes mesenterica; and also glandular affections of the neck, inflammation 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 notion that can well be conceived, viz., that the bad symptoms in measles are not occasioned by inflammation, • 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 fevers. 164 SMALL-POX. but by "torpor of the lymphatics." But as this 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 overlook so obvious a circumstance. The objections to wine and nourishing diet, which it is so often ne- cessary to combat, probably arise from the supposition, that the fre- quency of the pulse and the cough are the effects of inflammation, when in fact they are occasioned by the torpor of the lymphatics /" [Inoculation in measles.—Many experiments have been tried at different periods, for the purpose of testing this important operation; but they have, for the most part, been fruitless and unsatisfactory. It has recently been asserted, however, that Dr. Von Katona, of Borsoder, in Hungary, has succeeded in inoculating 1122 persons by taking the fluid from the vesicles, or a drop of the tears from a pa- tient labouring with the disease. The operation is said to have been performed in the same manner as the inoculation for small-pox. It failed in seven per cent, of those on whom it was tried; but all the others took the disease in a mild form, and not a single death oc- curred. The puncture was immediately surrounded by a red areola, which soon disappeared. On the seventh day the fever set in with the usual premonitory symptoms of measles; on the ninth day the eruption appeared; on the fourteenth, desquamation commenced, with decrease of fever and eruption; and by the seventeenth day the patients were, in general, well again.] SMALL-POX.—VARIOLA. [It is an interesting and remarkable fact, that small-pox does not appear to have been known to the Greeks or Romans, although there is abundant evidence of its having prevailed in China and other parts of Asia from the remotest times. It appears, indeed, to have been introduced from India into Arabia, about the sixth cen- tury of our era, and then spread rapidly into Syria and over the whole of Europe. In later times it has been conveyed by trading vessels and overland caravans to every part of the habitable earth, constituting the most widely spread pestilence to which the human species is subject.] Small-pox is generally divided into three varieties, viz., 1. Distinct; 2. Confluent; 3. Modified. The first obtains that name when the pustules are distinct, and do not run into each other; the second is denominated confluent when the pustules are very numerous, and coalesce; the third variety is so named from the influence of certain SMALL-POX. 165 well-known causes that modify the disease, and render the symptoms less severe, and the cases less dangerous. 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 convulsions during this period. The attack is fre- quently very sudden; vomiting generally occurs; there is pain in the head and back ; and the patient complains very much of oppres- sion at the praecordia, and 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. The eruption first appears on the face, in the form of small red pa- pulae and afterwards extends over the rest of the body. 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 fluid, 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 neighbouring skin is of a red colour, from the extension of the inflammation. 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 colour 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. In the confluent small-pox, all the precursory symptoms are more severe; the eruptive fever runs higher; 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 second- ary fever, and danger from extensive inflammation, ulceration, and sloughing of the skin. In both varieties, but particularly in the confluent, copious saliva- tion sometimes takes place, and soreness of the throat is a marked symptom; upon examining the mouth and fauces, vesicles or pus- tules may be observed on the tongue and as far down the pharynx as the eye can reach. I have seen the same appearance on the mu- cous 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 declines 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 sub- 166 SMALL-POX. stance, as in carbuncle, and this is one cause of what are called pock- marks. In small-pox, as well as in other acute diseases, there is a congest- ive form, in which the system is unable to raise sufficient reaction; there is consequently more oppression ; the surface is pale; the erup- tion flat, and never matures properly; the dyspnoea is very consider- able ; 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. George Gregory, who must be a very good authority upon this subject, to be about one in every six persons who receive the small- pox in the natural way. But during the prevalence of an epidemic, the mortality is sometimes one-half. Indeed, it appears that during a severe epidemic at Ceylon, in 1819, the number of native inhabit- ants taken into hospital at Kandy, amounted to 931 ; of these 525 died. Since the publication 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 vaccinated, (they were infants under one year of age.) All the protected cases recovered. Of the 15 unprotected cases, 10 died. Three only of the 15 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 inflam- mation of the membranes, evinced by a considerable arborescent vascularity on the surface of the brain ; the vessels of the pia mater being greatly loaded with blood, together with effusion under the arachnoid, and into the ventricles. But it becomes 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 remembered 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. It was curious to observe in this patient the appearance of variolous pustules upon the granulations of the dura mater." Although 1 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 SMALL-POX. 167 completely gorged with matter, most frequently of a reddish colour; but in no instance have I been able to discover a pustular appear- ance below the bifurcation ; the substance of the lungs gorged with blood, and in the first and second stages of inflammation ; and in one instance there was pleuritic effusion. On examining the b»dy of a deformed girl, who died under an attack of confluent small-pox, the peritoneum and pleura were studded 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 shown vascularity, and has been covered with a viscid exudation, the follicles being much increased in size, which appearance often extends throughout the whole in- testinal tube. In three or four instances, I have seen ulcers having a pustular appearance, with a depression in the centre, in the jeju- num, 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 withiu 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 stimulants; and the consequence was, that the mortality was immense: but for many years past, patients have been kept cool, and the antiphlogistic regimen recommended, but, I fear, too little practised, from the dread of putridity. Bleeding has been often employed, and strongly recommended, in this disease, particularly during the eruptive fever; but it has as often been condemned, be- cause 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 inflammatory 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 em- ployed, and largely employed, in the eruptive fever, to moderate 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 they sent for me. In a number of instances, blood has been drawn even after the appearance of the eruption, and with decided benefit; but upon the whole, it is, perhaps, best at that period to trust to leeches for relieving local in- flammations. 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 inflammation. Bleedfng 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? 168 [MODIFIED SMALL-POX] does not prevent me from ordering the application of leeches, in cases which require this practice. With respect to other points of treat- ment, 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 insist 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 restore the strength, which, in a great proportion of cases, is the cause of secondary fever. A number of disagreeable circumstances often take place as sequels of small-pox, and the most painful one is the forma- tion of boils on various parts of the body, and sometimes even car- buncles, of which there are successive crops tormenting the patient for weeks. Glandular affections also frequently follow, as well as 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. [It is somewhere suggested that this object may also be attained by keeping the patient in a dark room, a practice which I have not found to produce any sensible effect. A plan I have adopted with great success, is to have the face frequently wet with spirits of hartshorn, which keeps down the in- flammation, and prevents the pustules from becoming either large or irritable. M. Velpeau asserts, and I have confirmed the truth of his statement, that if the pustules of small-pox are cauterized within the first two or three days, or even somewhat later, their duration is abridged, and no marks ensue. The best mode of applying the caustic, is to cut it to a fine point, and pierce it through the centre of each pustule. Other practitioners have recommended the free appli- cation of mercurial ointment to the pustules with a camel's hair brush when they are distinct, or put on with a feather in confluent cases. Dr. Olliffe, of Paris, speaks in the strongest terms of the plaster of vigo, of the French Pharmacopoeia, an article which is composed chiefly of mercury made into a soft plaster with styrax and other ingredients; but notwithstanding the preference ascribed to this preparation, it can have little, if any advantage, over simple mercurial ointment. , Dr. Midaveine has used sulphur for the same purpose with satis- factory results. His formula consists of two drachms of sulphur to an ounce of lard, which ointment is gently applied to the eruption three times a day. Gold leaf is employed by the Arabs and Egyptians to prevent the cicatrices of small-pox; and on the testimony of Baron Larrey it is highly efficacious. The gold leaf is applied on the first appearance of the eruption on the face, hands, neck, &c, and is kept in contact with the skin by means of gum-arabic mucilage. Baron Larrey also derived evident advantage by simply anointing the face freely with olive oil. Some of these articles appear to act simply by excluding the atmospheric air.] Varioloid.—Modified Small-Pox.—There are several circum- stances which are said, in medical language, to modify this horrible disease. The mysterious power of vaccination in preventing small- [VARIOLOID—MODIFIED SMALL-POX] 169 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 experience, I have known upwards of twelve well-authenticated instances. The first attack is generally supposed to modify the second, and to render it milder; hut it is curious, that all my cases of secondary small-pox, with the exception of two, were remarkably severe; whereas, I have rarely seen a severe case of small-pox after vaccination. Previously to the great discovery of Dr. Jenner, respecting the power of vaccination in preventing small-pox, the disease was mo- dified, 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 troublesome. This disease must be treated according to the general principles already laid down. [Varioloid.—The modification of disease, to which this name has been given, has excited a deep interest for many years past; yet,not- withstanding the zeal and talent of the many observers who have turned their attention to it, it remains a disputed question, whether variola and varioloid spring from an identical contagion. For, al- though I am myself convinced of this identity, many distinguished physicians, in all parts of the world, are of a contrary opinion. Let us now examine into the prominent facts connected with this inquiry. The accession of varioloid in persons protected by vaccination, is usually in the form of a mild small-pox. Thus, the fever, though sometimes considerable, is seldom violent, and subsides greatly, or even disappears on the occurrence of the eruption. The latter ap- pears first in a papulous form ; in other words, in small red, conical elevations of the cuticle, with some inflammation at the base. In some cases these papulae fiil rapidly with a inrpid or milky fluid, and are dry and disposed to desquamate by the fourth or fifth dny. Ex- amples of this kind bear a close resemblance to varicella, and have, no doubt, been mistaken for that disease. In other cases, however, the eruption differs little or nothing, in its physical characters, from that of genuine small-pnx: for the lim- pid fluid at first noticed in them, becomes purulent,t the pustules are ♦ A D. 1721. [t Dr. Albert, a German physician, and several other authors assert, that the pus- tules of varioloid never contain pus -a statement too much at variance with common observation to require an argument to disprove it ] 15 170 [VARIOLOID.] large, well defined and flattened, and have a distinct central depres- sion. Although the desquamation is usually completed within the sixth day, it is sometimes extended to the sixteenth. The scabs are thin and diaphanous, of a dark straw or light brown colour; as they fall off, they leave the surface marked by a tubercu- lated elevation, rough to the touch and obvious to the eye; but pits or scars are of extremely rare occurrence. Secondary fever seldom or never occurs; and the patient is usually convalescent from the completion of the eruption. The pustules are almost invariably distinct in their character, nor have I ever met with an approach to the confluent form. They are most numerous on the chest, neck, at the bend of the arm and on the face ; but in many instances the whole eruption has been confined to a very few pustules, and sometimes to one pustule only. The erup- tion, moreover, is apt to assume a mixed character; some of the pustules continuing papulous throughout, and never becoming puru- lent: while others, in the same person, will have all the appearances of true variolous disease. In persons, who have had the genuine small-pox, the varioloid does not differ materially from the form just described. It is remarkable, however, (and the fact constitutes a stumbling- block in the study of this disease,) that varioloid sometimes occurs . in persons who have had neither variola nor vaccine. Dr. Thomson has recorded his experience in several cases of this nature; and later observers have incontestably corroborated his statements. For my own part I have never seen an example of this kind, and shall there- fore quote from Dr. Thomson a few remarks on this particular modi- fication. He observes that in this class, the eruptive fever has in general been severe, though in some cases mild and of short dura- tion ; but usually continuing three days before the eruption came out. The latter was sometimes papulous at first, soon becoming vesicular; but, in a majority of cases, the papulae became distinctly pustular at an early period of the eruption, assuming the characters of distinct small-pox; the pustules, however, varying in the time of their appearance, sometimes coming out simultaneously over the whole body, and in other instances appearing in successive crops. Even in these unprotected constitutions, the disease is much milder than casual small-pox; the fever is of shorter duration; the pustules often want the central depression, and are mostly matured by the sixth day; cicatrices seldom follow the desquamation, and secondary fever is unusual. The preceding facts have led some pathologists, erroneously, we think, to consider variola and varioloid as distinct contagions; but they at least overthrow the familiar postulate, that varioloid is always and only small-pox modified by vaccination; unless from the comparatively small number of cases we assume that the excep- tion proves the rule. It is also said, by some pathologists, that whilst in variola the chorion, or cutis vera, becomes the seat of a phlegmonous inflamma- tion ending in suppuration, and followed by loss of substance, vari- oloid is a lymphatic phlogosis of the most superficial layer of the [COW POX—VACCINATION.] 171 integuments; hence,also,the groundless inference that the two mala- dies are developed under the influence of different contagious agents. The following brief history will serve to illustrate the identity of small-pox and varioloid; and there are, perhaps, few physicians in extensive practice who have not met with analogous examples. I was called to see a black man servant with a violent fever, which soon developed the characteristic small-pox eruption with great severity, and of the mixed, distinct and confluent kind. This man had never been successfully vaccinated. The gentleman of the house, a man of forty, who had been carefully vaccinated in infancy, was next attacked; he had a high fever, followed by a plentiful erup- tion, which, however, was distinct, and the recovery took place at the usual time. There were, also, in the house, three children from five to nine years of age, all of whom had been vaccinated in early infancy by my own hand; they all had an active fever; two of them had about a dozen or twenty abortive pustules, and the third had a solitary pustule on the forehead. In the servant, who was unpro- tected by previous vaccination, the cicatrices left by the small-pox are everywhere abundant. In the gentleman there is no remaining trace of the eruption, nor is there any in the children. All these various modifications of disease were derived from the same conta- gion, influenced solely by vaccination or its absence, and the period of time which had elapsed since its use. What was confluent small- pox in one became a mild disease in another; while in the children, in whom the vaccine was yet active, the disease was so slight, that but for the collateral circumstances, it might never have been identi- fied even as a varioloid infection. The treatment of varioloid is such as would be resorted to in mild small-pox—saline aperients and diaphoretics, and a light, cooling regimen.] [COW-POX.—VACCINATION.] [We owe the discovery of vaccination to Dr. Jenner. He observed that those persons who milked cows affected with the disease called cow-pox, were exempt from the small-pox—whence he inferred that an equal immunity might be derived from the artificial insertion of the virus of the former eruption. Experiments proved the truth of this inference, and vaccination is now justly regarded as one of the greatest benefactions that medical science has bestowed upon the human race. Dr. Jenner's discovery was first published by him in 1798, and vaccination was introduced into the United States the year fol- lowing. It had long been known that a disease called the grease, in horses, was sometimes communicated to the cow by persons employed in dressing the heels of the one, and afterwards in milking the other. 172 [VACCINATION.] Dr. Jenner, in the outset of his inquiry, supposed this disease to be the origin of the small-pox. "This idea he lived to correct; but the prejudices it excited, and the erroneous views to which it gave birth, have unhappily been perpetuated. It is ascertained that the horse is liable to a vesicular disease of a variolous nature as well as the cow, and equally protective. The error consisted in believing that this affection was the grease, and that it required to be transmitted through the cow to give it efficacy."—But it is now well ascertained that the horse, as well as the cow, in different ages and in various countries, has suffered both from the mild and malignant variola; that the latter, when inoculated from the cow, for example, may pro- duce an aggravated disease in man ; that the human small-pox can be communicated to the cow; and that the matter thus obtained pro- duces in man the most perfect form of vaccination. "In other words, the direct inoculation of the cow with human small-pox, has produced a mild and mitigated disease ; and that such disease, repro- duced by inoculation on man, accords entirely, in its character, in its progress, and in its protecting influence, with the varola vaccine as described by Dr. Jenner; thus irresistibly proving his fundamental proposition, that cow-pox and small-pox are not bona fide dissimilar, but identical; and that the vaccine disease is not the preventive of small-pox, but the small-pox itself;—the virulent and contagious disease being a malignant variety."* Dr. Stephen Brown had early, in this discussion, declared it to be his opinion, that the cow-pox is the variola or small-pox of the human system; and that it was originally excited in the cow in the form of cow-pox, and in the horse in the form of grease, by the direct application of small-pox virus to these animals. Such, also, were the matured views of Dr. Jenner himself; and they have been remark- ably sustained by the recent experiments of Mr. Ceely and others. It may be added, as a curious fact in the history of vaccine, that various animals, besides the horse and cow, have been vaccinated with complete success, as the ass, buffalo, sheep, and even poultry'. Vaccine matter is, perhaps, most certainly efficacious when taken before the tenth day of the eruption; but experience has amply proved, that a mature scab is capable of retaining all its virtues for many weeks after its separation from the arm. Whether we use the fluid matter from the pustule, or the dried crust, the best mode of inserting it is on the point of a lancet, about the middle of the arm; care being taken to make five or six oblique punctures into the cutis vera, without drawing blood. These punc- tures should be confined to a very small area, say about two lines in diameter. If the dried scab is used, it must be rubbed to a thin paste with water, and after its insertion, the spot should be allowed to dry without interruption. With these simple precautions, vaccina- tion is performed with almost uniform success, and with the following appearances:— No obvious change is observed until the third day after the in- sertion, when a minute inflamed spot is seen. As the inflammation * Medico-Chirurg. Review, No. 56. [VACCINATION.] 173 proceeds, a small, circular, flattened and slightly elevated tumour is formed. About the sixth day, the pustule begins to assume the vesicular character, the secretion of matter taking place in the centre, and in- creasing until the tenth day, when the perfect vesicle is produced, having the following characters:—It is circular or oval, with a dis- tinct, smooth, turgid margin, and a depression in the centre:—the contained matter being of a uniform pearl colour. After the eighth day, the vesicle is surrounded by a bright-red areola, varying in diameter from less than an inch to two inches, and accompanied by a radiated tumefaction and hardness of the subjacent parts. It is at this period of the disease that the febrile and other consti- tutional symptoms appear, sometimes very slight, and again in a more active form, such as occur in common infantile remittents. It is also at this time, as Dr. Gregory remarks, that the child's body is covered partially or generally with a papular eruption, which con- tinues for two or three days. On or before the twelfth day, the areola begins to decline ; at which time the vesicle becomes discoloured, and of a greater firmness, and in a few days more is converted into a scab of a dark mahogany colour, which becomes blackish as it dries, but retains its smooth surface. This scab separates about the fourteenth day, leaving a cicatrix which is circular and slightly depressed, and presents a num- ber of minute pits or depressions. The constitutional symptoms are usually so slight as to require little or no attention:—they consist in a slight fever about the eighth day, with some tumefaction of the ax- illa, which pass off with the local affection. A drowsiness, which is one of the most common appearances, is often remarked within forty- eight hours after the matter has been inserted. These are the appearances, and the order in which they occur, in unequivocal vaccination. Slight aberrations may take place without lessening confidence in the result; but there are some deceptive ap- pearances against which it is necessary to provide. These, which have been called spurious vaccination are enumerated by Dr. Willan as follows:—merely premising that it is not unusual to see a common conical pustule, having no character of the vaccine, and of course readily distinguished from it. " The first is a single pearl-coloured vesicle, set on a dark-red base, slightly elevated. It is larger and more globate than the pustule above represented, but much less than the genuine vesicle ; its top is flattened, or sometimes a little depressed, but the margin is not rounded or prominent. "The second appears to be cellular, like the genuine vesicle ; but is somewhat smaller, and more sessile, and has a sharp angulated edge. The scab is smaller and less regular than that which succeeds the genuine vesicle; it also fells off much sooner, and when separated, leaves a smaller cicatrix, which is sometimes angulated. " The third irregular appearance is a vesicle without an areola."* [♦ Bateman's Synop. p.206] 15* 174 [VACCINATION.] With respect to the areola, however, it should be remembered, that it may have existed without being noticed by the attendants or the physician: it may have been trivial in Its development, of partial duration, and occurring at night, when it would not be noticed. The mere asserted absence of the areola, all the other characters being perfect, is not conclusive evidence that the disease has been abortive. When-considerable inflammation ensues, at an early period after vaccination, and especially if suppuration takes place, the disease may be reasonably suspected. "Now and then" says Dr. Hooper, "it happens, that after the spurious pustule, or more properly, the phleg- mon, has run its course, which is within, a few days, a vesicle begins to appear, bearing every characteristic of the genuine vaccine disease, and yielding, a limpid and efficient virus. In this case the patient is as perfectly secured from all danger of the small-pox, as if no fester- ng of the puncture had preceded." Inflammation and suppuration will occasionally follow a rupture or other injury of the vesicle, from which cause its characters are ren- dered more or less imperfect and doubtful. In such cases the deve- lopment should be assiduously watched; and if any ambiguity remains, the operation should be repeated. The characteristics of a genuine vaccine pustule soon become fami- liar to the practitioner, and are not easily mistaken.. But in doubtful cases, the safest plan is to re-insert the vaccine virus in a short period after the first operation. - The causes of spurious vaccination are various; the matter used may be itself spurious,or it may have lost its virtue by long keeping. But the most common cause of failure is the presence of cittaneous disease: and again, there are some children of perfectly healthy con- stitutions who are wholly unsusceptible to the vaccine influence. It is not to be denied, that the real small-pox has occasionally oc- curred in persons who have been, to all appearance, perfectly vacci- nated; and the modified disease'has been much-noticed of latter •years. But the former is extremely rare ; and the latter, as has been elsewhere shown, is so much less severe than the variolous conta- gion, as to be a source of little apprehension. Amongst a mass of evidence on this subject, I may adduce the facts set forth in the Report of the English Vaccine Institution, viz: that among several hundred thousand persons who had been vacci- nated, no well-attested case of fatal small-pox had occurred : but on the contrary; that, when the latter disease did appear, it uniformly takes on a mild and manageable form. From these and other facts it has been assumed, that the vaccine disease is a perfect security against death from the small-pox. This axiom in medicine is strikingly supported by the following summary from an authentic report made to the Medical Society of Philadelphia. " We may, without the least want of candour, come to the conclusion, that only one death from small-pox, after vacci- nation has occurred m Philadelphia during the year 1827, among eighty thousand vaccinated persons, and during the prevalence of a r^.^ fh^r\il hm°rtal,,Smal|-p0X; While several individuals have lost their lives by smallpox, after they had already gone once [VACCINATION] tf5 through the disease. It appears, then, clearly, that vaccination ought to lose nothing of the public confidence; and as a protection from the fatal efl'ects of genuine small-pox, it may safely be asserted that it is in every sense to be preferred to inoculation."* Some authors contend that the protection afforded by vaccination does not extend beyond seven, or at most twenty years. In some constitutions this appears to be the case; although it may not be so general a rule as many suppose. I have repeatedly vaccinated per- sons with the most unequivocal success, who had beyond all doubt gone through the same process from fifteen to twenty years before. In one family I saw five persons, the eldest not more than thirty, all of whom had been vaccinated in the most cautious manner in childhood: three of them in succession took the varioloid in a mild form, during which period the remaining two requested to be re-vac- cinated, which was done with entire success; the vesicles passed through their characteristic stages, and the patients escaped the dreaded contagion. Some physicians consider it possible, by repeat- ed vaccination, to saturate the system so as to obtain a perfect im- munity from any form of small-pox. As a rule, this proposition is subject to many exceptions, in proof of which we may cite the fol- lowing statement from a recent medical journal: "Whilst sufficient facts are wanting in favour of the reputed effects of what is termed saturation of the system, to produce a more perfect exemption from varioloid, evidences of the insufficiency of such a practice exist, of which the occurrences on board one of our public vessels, the North Carolina, offer a striking example. In a cruise made by this ship up the Mediterranean, she shipped at Norfolk a crew of 900 men, most of whom had been vaccinated or had the small-pox; but were never- theless twice vaccinated, prior to the ship's sailing, a third time at Gibraltar, and a fourth time at Port Mahon. Dr. Henderson, who repeats these facts, states that, notwithstanding this ultra re-vaccina- tion, under such various circumstances of virus, climate, &c, 157 of the crew had the varioloid."t It is a prevalent opinion, that much of the asserted uncertainty of vaccination has originated from a deterioration of the virus in pass- ing through a long succession of individuals. Experience, how- ever, is adverse to such an hypothesis: and Dr. Thomson observes —" that the establishment of such a point, either by experiment or observation, would present an anomaly in the history of contagious diseases; for I am not aware that any thing analogous to this alleged deterioration, has ever been observed to occur in any of the other contagious diseases that are capable of being communicated, by con- tact or inoculation, from one human being to another. I know, in point of fact, that the vaccine virus, which has been used at the Royal Dispensary here, and in other parts of Scotland, for a series of IS years, still continues to produce, on those who are inoculated with it the very same appearances which it produced on the first trials [* " Report of the Com. of the Philad. Med. Soc. appointed to collect facts in rela- tion to the recent occurrence of small-pox m tiiis city." North Amer. Med. and [t Auiei. Jour. Med. Sci. May, 1836.] 176 CHICKEN-POX. that were made with it; and that these appearances agree exactly with those which have been delineated and described by Dr. Jenner as characteristic of cow-pox: and I know, also, that the appearances of the vaccine vesicle produced by this matter, which must have passed through a succession of at least 900 individuals, agree exactly with those exhibited by vesicles by inoculation with the more re- cent equine matter, with which I have been lately favoured by Dr. Jenner."* Drs. Mitchell and Bell,t in an able investigation of this subject, corroborate the sentiments of Dr. Thomson : and it may be added that vaccine matter, in its most recent state, possesses no more pre- ventive efficacy in reference to varioloid, than that which has been in use since the discovery of vaccination. It would appear that some persons are wholly insusceptible to vaccination; the operation may be repeated over and over again without effect. In other cases the susceptibility is restored or evolved in a short period of time, and the disease goes through all its stages in perfection. The inability to take the vaccine, however, is no guarantee against small-pox; for the latter has occurred, in an aggravated form, in those persons in whom vaccination could never be accomplished: and, moreover, it has been observed, that persons in a variolous atmosphere are very insusceptible to the vaccine dis- ease.] CHICKEN-POX. This disease, known also by the name of Varicella, has been often confounded with small-pox. Those who maintain the identity of the two diseases, and who have figured in the controversy that has been so long carried on, have, nevertheless, completely failed in proving their position with respect to one point, while they have succeeded in another, apparently without being aware of it. Look- ing at the diseases symptomatically, there is no doubt a striking dif- ference. 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 can- not 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 vari- cella, or from varicella small-pox? Extensive experience enables us to answer both ,n the negative, and therefiWthey cannot be identified any more than measles or small-pox.J w"™ " [*On Varioloid, p. 320.] lf £-JAl?f- ^ed- and SurS' Journal, vol. 2. p. 250 1 * Vide Dr. Hennen s paners and wnwimY. 'j^.j ■«, Xiv.p.409. [Dr. ThomsoPn,Pof Ed?nbuS S ^i,*1 a"d S" Journal- vo1" be varieties of the same con la-ion as win hP«*!k small-pox and chicken-pox to on Varioloid. It appears that Dr'. hSden a disun™^ to. h,'-s e,aboral« work -neroen, a distinguished physician of the last MILIARIA—MILIARY FEVER. 177 ["It has been ascertained of the genuine chicken pox, or varicella lymphatica, that it occurs only once to the same person; that it spreads by contagion; that, nevertheless, it is not communicable by inoculation; whereas, the matter of modified small-pox, when en- grafted, produces genuine variola; that it occurs equally among those who have, and those who have not been vaccinated; that the vaccine vesicle and disease proceed with perfect regularity after the occur- rence of chicken-pox; and that it affords no protection against small- pox, while, on the other hand, small-pox affords no protection against it."* The pustules in varicella are mostly prominent and rounded; but, among a great number, a few will be noticed which are flattened on the top. The fluid they contain is at first transparent, becomes gra- dually milky, and then straw-coloured. Many of these pustules burst spontaneously about the third or fourth day, and form rough, dark-coloured scabs, which desquamate without leaving scars.] 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 inflammation 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 examined. MILIARIA—MILIARY FEVER. This disease is characterized by an irregular eruption of exceed- ingly 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 inflam- matory blush. [It is observed by Dr. Schedel, that the only disease with which miliaria can be confounded, is eczema; but in the latter, the vesicles are remarkably confluent, a large number being crowded into a small space, while in the miliaria they are larger and more isolated.] 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 dis- century, entertained the same opinion, and calls the chicken-pox variola pusilla. The water-pox and swine-pox (Varicella globata,) are mere varieties of chicken- pox, which last is the varicella lenticularis of Willan.] * [Watson's Practice of Physic, p 876] 178 ROSEOLA—ROSE-RASH. ease. It is also considered one of the diseases of child-bed. Since women in that state have been treated in a proper manner, by avoid- ing 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 after 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 pre- viously 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 miliary 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 connected 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. Treatment.—If this disease occur in the course of inflammation of the peritoneum, 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 regularly 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.—ROSE-RASH. Roseola is a fever attended by a rose-coloured efflorescence, without wheals or papulae ; [but sometimes in blotches of a quarter of an inch or more in diameter, which continue from one to two, three, or even four days. It is a common disease of infancy, and more particularly in the summer season, when the itching of the URTICARIA—NETTLE-RASH. 179 skin renders it very irritating. Also the eruption assumes a ring-like form, sometimes a consecutive, but followed by little or no des- quamation,] 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 laboured under small-pox, and the result of the case proved that his opinion was correct. This is a disease which may very frequently be traced to indi- gestible 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 consulted; and they would probably be still less frequently called, only that parents 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 distinctions as these and other skin nosologists have drawn.* URTICARIA—NETTLE-RASH. This disease is known to the vulgar by the name of nettle-rash, and is distinguished from other febrile eruptions, by circular eleva- tions of the cuticle, of a red colour, with a white spot in the centre, and is usually termed a wheal; [these wheals, however, are often very irregular, of a mottled character, either whiter or redder than the surrounding skin ;] and here, again, Willan and Bateman have unnecessarily described six varieties. The eruption is generally preceded by marks the most distinct of gastro-intestinal irritation and fever; and the patient is affected with restlessness, oppression, languor, and want of appetite ; his tongue, however foul, will in general be found red at the tip, and round the edges. If the eruption be very general, the patient suffers much distress from the heat and itching of the parts, but the internal disor- der will be found to be relieved. Sometimes the rash appears 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 particular articles of food, [especially, as Dr. Willan has remarked, by shell-fish, lobsters, crabs, shrimps, and the common mytilus or sea muscle. " In a few individuals," he adds, " in con- sequence of a peculiar idiosyncrasy, other substances when eaten, are ♦ It affords me great pleasure to refer to Mr. Plumbe's Practical Treatise on Dis- eases of the Skin. That gentleman has taken correct views of the subject, and treats of all the affections pathologically; therefore he has few subdivisions. It is the best work we possess on the subject. 180 URTICARIA—NETTLE-RASH. followed by the same immediate affection of the skin ; such as mush- rooms, honey, oatmeal, almonds, and the kernels of stone fruit, straw- berries, &c. In some persons the internal use of valerian has produced the nettle-rash. The operation of these substances is almost instanta- neous, and the symptoms are extremly violent for several hours."* Sometimes nettle-rash is attended by the sensation of needles or other sharp points penetrating the skin ; these pains, which are at first limited to a spot or to a limb, extend to other parts, and cause extreme suffering and sometimes even severe cramps. The eruption is variable, and sometimes altogether absent in this form of the disease.] It appears to me, that individuals who are frequently subject to this affection, and others of a smilar nature, during youth, are those who, in after-life, are liable to be affected 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 repro- duced 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 remedies which a physician may prescribe. The pa- tient must find out by experience, 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 sud- denly 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 health. [A case also came under my own care, in which the eruption, from causes unknown, receded early in the disease; it was almost immedi- ately followed by an aphthous condition of the mouth and consequent ulceration of the tongue, which continued with much suffering and constitutional irritation for upwards of two months, and was seem- ingly cured by change of climate.] Besides avoiding every thing that disagrees with a patient, it may be mentioned that gentle laxatives are essential remedies; and that an emetic is highly useful, if an indigestible matter be still in the stomach. [* Synopsis, p. 87.] PESTIS—THE PLAGUE. 181 [I have found the use of small and repeated doses of magnesia to be particularly beneficial in urticaria; and this, with a farinaceous diet and the avoidance of acids, will, in general, meet all the indica- tions. The safest external applications are warm or tepid bathing, either with simple water, or whiskey and water mixed half and half. When the itching is local and very irritating, the application of laudanum affords great relief. I have known this disease to last with severity for several days, and to require free bleeding before the distress became in any degree tolerable.] PESTIS.—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 appears to be, under certain circumstances and seasons, highly contagious; and it would seem, also, to be occasionally epidemic. The accounts we have of the phenomena of this disease are so contradictory, and the histories 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 no doubt,* the symptoms must not only vary in intensity, but they also must have a very wide range of character. The disease must have varieties and shades arising out of one organ being more severely affected than another, as well as from local congestions and inflammations. It 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 opinion of some physicians, that the plague is nothing more than a malignant typhus, and the only peculiar symp- tom 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 expression 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 aspect; in others, the patient's * I have had the pleasure of enjoying several communications with Dr. M'Guffuc, who resided many years in Turkey, and who has had ample opportunities of seeing the disease. It is his decided opinion, that the plague is a fever attended by buboes, &c. 16 18 THE PLAGUE. 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 are insensibility and fierce delirium; occasionally stupor takes place, 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 constipation, 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 suppuration of the glands go on quickly, death soon takes place. Sometimes carbuncles appear, with or without the buboes; but petechias more frequently than carbuncles. Discharges of blood from the stomach and intestines often take place in the last stage. Sometimes the disease is very rapid in its progress, running through its course in thirty hours. It is said, that if the patient sur- vive the fifth day, the bubo being completely formed, he maybe pronounced to be 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., that 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 attributed 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 depart- ment of the army, the latter director-general of the medical depart- ment of the ordnance, should have distinguished themselves in the same field of investigation, having been both employed with our Egyptian army above 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 business, which marked them out as men admirably qualified for the high situations in which they have been subsequently placed, and which they have filled with so much honour to themselves, and benefit to the service. Their statements respecting the plague, will be read with much interest and advan- tage.* Treatment.—Sydenham recommended free and repeated vene- section in this disease, during what may be called the eruptive fever, and it has occasionally been practised since his time: but even Syden- ham 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 individuals condemn * Sir James M'Grigor's Medical Sketches of the Expedition from TnH,a tn i?mnL -Sir John Webb's Narrative, 6th vol. Medical TransaSSons? S7V THE PLAGUE. 183 bleeding entirely. The same difference exists with regard to purg- ing. Cullen condemns both, upon theory, but recommends the vio- lence of reaction 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 promulgated, that we have no means of forming correct opinions. A great number of other remedies have been strongly recommended—as mercury, wine and bark, opium and aether, emetics, diaphoretics, and the cold affu- sion ; 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 opposite effect. For example, if there be violent inflam- mation and congestion of the brain, no one will say that wine, aether, bark, or camphor, are the proper remedies; but in which cold appli- cations 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 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 bark. It is to be feared that the recommendation and condemnation of various im- portant remedies have taken place, without reference to the stage of the disease, the particular organ or organs affected, the peculiarities of the prevailing distemper, as well as the idiosyncrasy of the patient; but it becomes me to speak with diffidence upon a subject respecting which I must acknowledge myself to be profoundly ignorant. The reader who wishes for more minute information, must peruse the various works published on this subject; or a most excellent ab- stract of them, in the third 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. [The following interesting particulars, respecting the plague in Egypt, are from the celebrated Clot Bey, in a letter to Dr. Chevrin, of Marseilles, dated Cairo, March 26, 1835. The plague commenced in Alexandria, in November; for a month it was very fatal, and, altogether, 20,000 persons have died. It be- gan in Cairo, in December, but, during the last fortnight only, has been of a serious type. The first symptoms are pain in the head, nausea and vomiting, injected eyes, staggering walk, as if from drunkenness, stupid expression, white moist tongue,full and frequent pulse. At this period, emetics and diffusible stimuli may be tried, but Clot Bey knows nothing of their effect. On the second or third day, there is mental confusion, sometimes delirium; the tongue is dry in the centre, with red edges; the skin hot; there is often pain in the epigastrium; rarely diarrhoea ; buboes and carbuncles. There is now actually irritation in the digestive canal, brain, and lymphatic glands; and bleeding and cupping are employed, with cauterization to the buboes and carbuncles, to fix the irritation in the skin. On the fifth and sixth days, petechias and blue patches on the skin. Revul- 184 THE PLAGUE. sives to the extremities. This treatment has apparently saved some patients. The corpses have not the hideous aspect which physicians have described and artists painted. The petechiae are particularly on the neck, sides of the chest and limbs; the buboes in the groins and armpits; very rarely in the neck: all the lymphatic glands were enlarged in those who had no buboes; carbuncles in three cases only. No particular tendency to rapid decomposition; subcutane- ous veins not apparent. Heart, and veins in the cavities, gorged with black blood, as well as the liver and spleen; this viscus was generally found doubled in size and softened. Arteries empty; kid- neys of a deep violet, gorged with blood, haemorrhage in their pelves. The stomach always contained a blackish fluid; its mucous mem- brane, much injected, exhibited red patches like petechias, which, sometimes, from the size, might be called ecchymoses; their last degree is ulceration. The intestines were in a similar condition, but less well marked: the lymphatic glands were always engorged, sometimes increased five or six times, softened, and of a colour like lees of wine, and sometimes black. Those of the groin, or armpit, by their agglomeration, formed a homogeneous mass of a colour almost always like lees of wine, with effusion of black blood into the surrounding cellular tissue. A similar change was seen in the chain of glands along the vessels of the abdomen and chest; and, in many cases, the extravasation of blood around them amounted to haemorrhage. Sub-arachnoid veins and the sinuses gorged; paren- chyma of the brain and spinal marrow natural, except in two or three cases, where it was softened."*] [* From the British and Foreign Medical Review, No. 1.] PAET II. DISEASES OF THE ORGANS CONNECTED WITH THE DIGESTIVE SYSTEM. 16* CHAPTER I. DIFFICULT DENTITION. Few children go through the process of dentition without some suffering; and, when teething is difficult, many complaints arise, which fall under the denomination of infantile diseases. These are, fever, determinations to the head, occasioning inflammation of the brain and its membranes, or convulsions, cough, and difficulty of breathing; bowel complaints; cutaneous and glandular affections; inflammation of the eyes, and sores 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 Louis XIV; and Haller has cited a con- siderable 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 com- monly 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, pro- trude, 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 between the cutting of each pair. The formation of each tooth goes on in a membranous and vas- cular 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 dentition. The irritation pro- duced by the pressure of each tooth against the gum, in its advance- ment to the surface, particularly when the child teethes late, and the gums are hard and cartilaginous, also occasions the different phe- nomena which are ranked under the same appellation. A child, in such circumstances, is observed to be restless, fretful, and feverish; 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 188 DIFFICULT DENTITION. crying, apparent suffering when brought into the erect posture, start- ings, slight spasmodic movements of the muscles of the face, and even general convulsions. Many children, whenever they cut a tooth, are teased with a cough, depending on bronchitic irritation or inflammation. This is announced by wheezing. Others suffer from constipation, while many are afflicted with troublesome diarrhoea. Cutaneous and glandular affections are often observed during difficult dentition. The glands of the neck, and the submaxillary, are those generally affected, and they sometimes suppurate. Of the eruptions, the porrigo larvalis, and lichen, are those most commonly seen. Occasionally there is inflammation of the eyes, particularly those forms which are termed ophthalmia purulenta and ophthalmia tarsi; and sores take place behind the ears, which seem to operate bene- ficially. This statement will show the propriety of examining the mouth, when we are called to a child labouring under these or any other affections during the period of dentition ; when the mouth may feel very hot, and on examining the gum over the tooth which we suspect, 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 general, be found to have disappeared. If such appearances present themselves, the tooth may be 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 show itself in a day or two; whereas, if they are previously told 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 scarification. If the operation be effectually performed, it constitutes the principal part of the treatment. Should the gum even heal imme- diately, the bleeding will remove the local inflammation, upon which the febrile symptoms frequently subside. 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 appli- cation 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 down 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 may be subsequently placed in warm water, for the purpose of en- couraging the bleeding ; besides which, the haemorrhage is better under command upon the application of a bandage. Many prac titioners are heard to complain of the great difficulty in stopping the bleeding in young children, but I never experienced any impediment. In the first place, we ought always to point out the situation where DIFFICULT DENTITION. 189 the leeches ought to be placed, 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 bleeding 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 second 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 fric- tions 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 rhu- barb or scammony, together with castor or croton oil and injections ; 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 depends upon any diseased action in the lungs, or merely upon irritation 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 proceed from bronchitis, which may sometimes require the application of leeches or of a blis- ter, or contra-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 servicea- ble ; but the treatment of bronchitis need not be dwelt upon in this place. It is only necessary to state the general principles, with refe- rence 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 chil- dren 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 suffering, 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 febrile symptoms or disorder of the bowels, are liable to erup- tions on the surface, because they act beneficially by removing irri- tation and increased action, on many occasions inflammation itself from internal organs. When these eruptions take place during the course of dentition, it will almost always be found best not to meddle 190 DIFFICULT DENTITION. farther with them than to enjoin cleanliness; indeed, on many occa sions, do what we will, the eruption continues, the child becoming better between the periods of cutting teeth. 1 have frequently seen great mischief done when external applications had the effect of re- pelling the eruption, and, on more than one occasion, death itself. In "porrigo larvalis," when there are great heat, itching and inflam- mation of the part, I have found it answer well to apply leeches to the inflamed surface, and to cover the part with oiled silk. The child's hands should be muffled, to prevent the face from being scratched and disfigured. Glandular affections may be safely let alone, unless they become inflamed and painful, when the practitioner will do well to apply either leeches, fomentations, or a soft warm poultice. If matter form, the sooner it is let out the better, in whatever constitution 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. WTe 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 conjunctiva ; sometimes to the tarsi; there is rarely deep-seated inflammation on 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 frequently creates unnecessary irritation; and, above all, the blistered surface should be carefully examined every day by the medical attendant, till it shows a healing tendency, as it is apt to slough, which the timely application of a linseed poultice 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 unnecessarily irritated. Great uneasiness is often produced by carelessly removing the dressing; this might always be avoided by previously applying tepid fomentations. An occasional opiate is very beneficial; but no medicine of this kind should be left in the way of an 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 mollifying 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 rubbing the gums with the finger. A ns of Diseases of the Lungs and Pleura p 1661 J^\7i uZ^J^l ^^bronchophony to be a "sound like thaPt'of a person [t Diagnosis of Diseases of the Chest, p. 108.] [PHTHISIS PULMONALIS.] 417 the physician to announce a positive diagnosis long before cavities are formed by the elimination of tubercular matter. When the latter condition, however, does take place, the physical signs assume at once a new and decided character, and seldom leave occasion for doubt or difficulty in the diagnosis. If the cavity or abscess is large, the resonance, on percussion, is as sonorous as in the healthy lung, sometimes more so ; but it is uniformly hollow, and if the patient have his mouth open, the sound is not unlike that which is yielded by a cracked earthen vessel. In other instances, in which there is only a small cavity, or, indeed, many small abscesses, the dull sound of the indurated stage is still present, and even in increased degree from the yet further destruction of the vesicular tissue. Auscultation, in this stage of phthisis, yields the following sounds : Cavernous and amphoric respiration, mingled and alternating with various rhonchi; gurgling or bubbling; pectoriloquy; metallic tinkling or echo; certain clicking sounds, and various modifications of the cough itself* It is in the next place requisite to inquire briefly into the individual peculiarity of these morbid sounds. 1. The cavernous is a modification of the blowing respiration, in which the ear receives the impression of air passing into and out of an excavation of moderate size; these sounds, or murmurs, are hol- low, blowing and strongly metallic. 2. The amphoric respiration is also of the blowing kind, and differs only from the simple cavernous variety in yielding the sound as if it were passing into a large, empty cavity, such, for example, as a pitcher. 3. The gargouillement, or gurgling rhonchus, is derived from the presence of pus or other fluid in the cavity of an abscess which com- municates with the bronchia, so that the air passes in and out with a sound like that produced in water when we blow into it through a pipe-stem or other tube. "It may be considered as an exaggera- tion of the mucous rhonchus, and it so nearly resembles that produced in the trachea and large bronchial ramifications, that the symptom must be considered doubtful when heard only near the sternum, or in the axilla, in the upper part of the interscapular regions, as it may here be produced by the air-vessels." A little experience, how- ever, enables the practitioner to distinguish between these two morbid conditions, and the diagnosis is really of great importance. When the cavity becomes emptied of its fluids, the cavernous rhonchus is changed for cavernous respiration, of which we have already spoken. 4. Pectoriloquy.—This phenomenon is marked by a peculiar reso- nance of the voice of the patient, which appears to pass through the stethoscope to the ear of the observer. In its most perfect state the sound is loud, distinct and somewhat metallic. These symptoms are a certain indication of cavities in the lungs, to which the sound of the voice is propagated through the bronchi, and thus to the ste- thoscope. Hence, as Dr. Williams observes, the most unequivocal pectoriloquy is produced from cavities of moderate size situated L* Walshe.—Physical Diagnosis, dec, p. 138.] 418 [PHTHISIS PULMONALIS.] near the surface of the lungs, and fully communicating with a large bronchial tube. 5. Metallic tinkling.—When there is a cavity of some size communicating with the bronchia by a small opening, there is often a sharp ringing sound, like that produced by striking with a pin against the sides of a glass or metallic vessel; this is the metallic tinkling; and when the sound is prolonged and vibrating, the name of metallic echo has been given to it. 6. The Latin word rhonchus, and the French rale, and the English rattle, are synonymous, and apply to a class of unnatural sounds, produced by partial obstructions to the passage of the air through the bronchial tubes. Every one who is the least accustomed to auscultation, is familiar with various modifications of these rhonchi, which, besides being classed as dry and humid, are called, according to the attendant phenomena—whistling, clicking, snoring, rub- bing, cooing, crepitant, crackling, mucous, cavernous, fyc. fyc. We have not space, on the present occasion, to analyze these varied phenomena, or to enter into further explanations; but we feel confident that these few elementary remarks will enable the young practitioner to pursue his observations with advantage, and espe- cially if he avails himself of the instructive explanations contained in any of the treatises on auscultation, to which we have referred. Once for all, we call attention to the importance of examining pulmonary invalids in relation to deformities of the chest, which, in modern pathological language, are called hetero-morphisms. They almost invariably attend or follow pleuritis, pneumonia, phthisis, emphysema, &c. &c, and often so manifestly as to strike the eye of the observer the moment the chest is exposed to view. In other instances, they are best detected by standing behind the patient and looking down from the clavicles, when the scapulae or ribs of one side or the other will be found projecting, or retracted, elevated or depressed, in a manner that at once conveys an important means of diagnosis. These malformations are also discovered, and their pro- gress noticed by measuring with tapes or other contrivances; but this, although satisfactory for comparison, is seldom important in practice.] Appearances on dissection.—Bayle divided phthisis into nearly as many species as there have been diseased appearances found in the lungs; but Laennec and Louis, on the other hand, think there is only one species of phthisis, the tubercular. The latter author states, that he has not examined the body of one subject, without finding as the principal lesion, tubercles or tubercular excavations, or the demi-transparent gray granulations; he joins Laennec, there- fore, in stating, that the existence of tubercles in the lungs is the cause, and constitutes the proper character of phthisis. Before describing the various morbid appearances found in sub- jects who have died of phthisis, I shall seize the opportunity of stating some particulars respecting those accidental formations which are called tubercular. They are bodies of a yellowish, dull, white colour, variable in consistence, which subsequently soften. When situated in the lungs, they are sometimes expectorated by the bronchi, giving PHTHISIS PULMONALIS. 419 rise to excavations more or less extensive. They are always more numerous, larger, and more advanced in their development, towards the superior part of the lungs, than in the lower lobes. Out of one hundred and twenty-three dissections, Louis mentions having seen two exceptions only to this rule; for some years past I have seen one exception only, and in it the superior lobe was quite healthy. Thenard's analysis of tuberculous matter gives 98 parts of animal matter in the 100; the remaining two parts consist of phosphate and carbonate of lime, muriate of soda and oxide of iron. According to Laennec, tuberculous matter may be developed in the lungs under two forms—insulated bodies, and interstitial injection or infiltration. He divides the insulated bodies into four kinds—miliary, crude, granular and encysted ; the second has three varieties—the irregular, the gray, and the yellow. Under any of these forms, the matter presents, in the early stage, a gray semi-transparent substance, which gradually becomes yellow, opaque and dense; it afterwards softens, and gradually becomes converted into a fluid, like thick cream or pus, which, being expelled through the bronchi, leaves cavities in the lungs which were formerly termed ulcers. Miliary and crude tubercles.—This variety of tubercle is the most common. The size varies from a millet to a hemp seed, very irregular in shape, and as firm as cartilage. At first they are dis- tinct, and afterwards become grouped together, and very often run into one another, so as to form one mass. A small yellowish opaque point appears near the centre of each tubercle, which gradually en- larges, till it involves the whole mass; it cuts like cheese, and con- stitutes the crude tubercle. Sometimes the miliary tubercles do not coalesce, but continue to the last distinct, and sometimes acquire con- siderable size. Sometimes distinct masses are seen, which are fre- quently the product of many tubercles united together. Granular tubercles.—These are spherical shaped bodies, inter- spersed, perhaps, through a whole lung; they were first described by Bayle, and were considered by him to be distinct from tubercles. But Laennec and Louis assert that they are nothing more than the ordinary tubercle in its first stage; the former distinctly states, that the only difference between these granulations and the yellow tuber- cles, is that between green and ripe fruit; " besides, (says he, at page 275,) the miliary granulations are never met with, except in lungs in which there exist at the same time other tubercles of a larger size, and sufficiently advanced to render their character no longer matter of question." My observations oblige me to dissent from this state- ment. Within the last six years, I have seen a considerable number of instances, in which granular tubercles pervaded the whole of both lungs; they were all nearly about the same size; the surrounding pulmonary tissue was of a red colour. Several drawings, showing these appearances, are in my portfolio. In these cases, there was little cough, and very slight expectoration; and in one adult, the lungs weighed nine pounds and three quarters. Three cases were children; in two of which, tubercles were found on the arachnoid coat of the brain also; and in one, the membranes, on one of the hemispheres, were ulcerated in a great many points. This kind of 420 [PHTHISIS PULMONALIS.] tubercular formation in the lungs has long engaged my attention, and I feel convinced they are the air-cells distended and enlarged by a diseased deposition, probably the consequence of inflammation of their inner membrane. A similar appearance may be produced by pouring a little quicksilver into the air-passages of a rabbit, if it be allowed to live for some days after the experiment. At one time, I felt disposed to believe, that bronchitis was the cause of almost all tubercular formations in the lungs; which opinion appeared to be so far confirmed by a well-known fact, that the majority of individuals who died of phthisis, attribute their illness to what they call a ne- glected cold; but I have been induced to abandon this opinion. Encysted tubercles are rare. I have seen cases where one, two, or three encysted tubercles were found in the lungs, about the size of a filbert, inclosed in a cyst. Two of the cases died of hooping- cough, and another of the disease called tabes mesenterica. In all these cases, the surrounding substance seemed somewhat firmer and redder in colour than usual, but in other respects, there was no dis- ease in the substance of the lungs. Laennec says they are rare, and Louis declares he has only seen one instance of this formation. On making a section of the tuberculous mass, it appears of a whitish colour, semi-transparent, and of a texture like hard cheese; but for a more minute account, I must refer to the works of the above authors. With respect to the tuberculous infiltration, I have to observe, that it is commonly of a grayish-white colour, sometimes with a rose tint, and is found either surrounding tuberculous excavations; or existing in large masses, occupying the whole lobe of a lung, having no connection with the miliary tubercle; indeed, I have a prepara- tion in which every part but the superior lobe is infiltrated with this matter, and I have an idea that this may be one of the occasional ultimate terminations of the granular tubercle. This opinion is somewhat supported by Laennec's description of the gray tubercu- lous infiltration. According to Laennec, tubercles first show themselves in the sum- mit of the upper lobe, more particularly on the right side; while Louis states, that they are more frequently met with in the left lung. My own experience corroborates Laennec's statement. An important question is still undecided, and perhaps will remain so, as to the cause of this singular formation. Some insist that tubercles are the product of inflammation of a peculiar kind; while others, with as much confidence, allege that they have nothing what- ever to do with inflammation, except inasmuch as they sometimes excite it by mechanical irritation. Many advocate the fluid origin of tubercles, and Dr. Baron maintains that they are primitively hy- datids ; and although he has supported his doctrines with much learning and ingenuity, yet I feel persuaded he has not convinced a single pathologist. [Much observation and reflection devoted to this subject, have led me to adopt the following propositions; but for the full elucidation of I several of these, the profession is mainly indebted to the celebrated Andral: 1. Tubercular matter is a secretion from the blood-vessels. [PHTHISIS PULMONALIS.] 421 2. This secretion is a morbid condition of the albuminous halitus proper to the cellular tissue forming the parenchyma of organs. 3. Inflammation is not necessary to its development, but may be either a cause or consequence. 4. The cellular tissue which envelops and intersects tubercles, sooner or later takes on inflammation, and secretes pus; by which process the tubercular matter is eliminated, and an abscess is formed. 5. The morbid state immediately antecedent to the tubercular se- cretion, and which may be considered its exciting cause, is a san- guineous congestion analogous to that which precedes every secre- tory process. Physiology teaches us that in the healthy living body there is a constant secretion, from the blood, of an albuminous halitus, which is deposited in every part of the system, and in no structure so abun- dantly as the cellular tissue. Whatever deranges this interstitial secretion tends to the production of preternatural substances; hence any irritation may act as an exciting cause; not that it necessarily increases the activity of the secretory process (which in health is very prolific) but because it perverts this important function. Such appears to have been the opinion of the indefatigable Baumes, who, in his work read before the Medical Society of Paris, in 1783, holds the following language: "An organ that has become en- feebled, secretes its peculiar fluid in an imperfect manner; these fluids no longer possess the degree of vitality necessary to stimulate and support the solids; they become from day to day more unnatural, until at length they cease to have any analogy with healthy structure."* Analysis has proved tubercular matter to consist almost entirely of albumen, showing its affinity, in this respect, to the healthy interstitial secretion, from which it mainly differs in certain physical characters. The reason why the tubercular secretion is so much more common and abundant in the lungs than in other structures, is that the former are composed of a most delicate series of tissues, which are pre-emi- nently exposed to the many vicissitudes arising from atmospheric changes, inordinate physical exertions and direct mechanical irritation. Tubercular disease is by many considered to be invariably a pro- duct of inflammation :t but although the latter often accompanies it, and always in its second stage, it appears to me by no means essen- tial to its secretion, any more than to the deposit of osseous particles in the coats of an artery, or in the substance of a cartilage. Tubercles are often found in great numbers in the lungs after death, without their having been even suspected during life; and if these tubercles have not passed into the crude state, the parenchyma around them is often found perfectly healthy, presenting, in fact, no trace of pneumonia. Could the pulmonary tissues maintain this in- tegrity if each tubercle was a centre of inflammatory action? It ap- pears to me that inflammation is much oftener a consequence than a cause of tubercles; the latter forming independently of it, and sub- [♦ De la Phthisie, tome i. p. 135] ft" 1 have never seen tubercles of the lungs without a preceding inflammation. Those, even, which are found in children at birth, do not appear to me to be independ- ent of this phenomenon."—Broussais. Exaraen des Doctrines Medicates.] 36 422 PHTHISIS PULMONALIS. sequently inducing phlogosis like any other extraneous bodies. Thus it is that tubercles induce pneumonia; while, on the other hand, pneumonia is a cause of tubercles; for I conceive it to be inconsist- ent with analogy as well as with fact, to restrict this secretory pro- cess to an inflammatory state of the vessels, and vice versd. This exclusive doctrine (to which I was at one time strongly biased), has given rise, among pathologists, to those conflicting views, which can only be reconciled by a concession like that here admitted, and which is founded on the known phenomena of diseased action. The theory of the lymphatic origin of tubercles, which is now so generally received, is at least as old as Sylvius, (1761,) who supposed the lungs to contain an infinite number of minute conglobate glands, analogous to those of the mesentery. This opinion has been ampli- fied with great ingenuity byM. Broussais, who attributes tubercular matter to an inflammation of the lymphatic glands and vessels con- sequent to inflammation of the sanguiferous capillaries; in fact, a double inflammation, beginning in one set of vessels and thence propagated to another. Without entering into a discussion of this question, I will merely observe, that if tubercles originate solely in lymphatic glands and vessels, ought we not more frequently to meet with them where these structures are most abundantly distributed, as in the axilla and groin, the mesentery, neck, &c? Yet it often happens that in per- sons who have died of phthisis, we see the bronchial, axillary, and inguinal glands greatly tumefied and diseased, without being at all tuberculous; while, on the other hand, we find the same hypertrophy and disease of the bronchial glands in those pulmonary affections in which tubercles have had no part. This hypothesis presupposes the existence of innumerable minute glands in the lungs; but anatomy, even aided by the microscope, has never detected them: moreover, a true tubercle has not the ana- tomical characters of a gland, for it is closely attached to the sur- rounding parenchyma; whereas all glands,especially when enlarged by disease, possess their proper capsules, which enable them to be dissected out with facility.] The body of a person who has fallen a victim to this very dread- ful disease, is found greatly emaciated, sometimes to the last degree, and the chest looks contracted on itself, which may, however, be a deception produced by the general emaciation. Laennec thinks the contraction of the chest is real, and is to be attributed to two causes. 1st. To the existence of pleurisies, to which phthisical patients are ex- tremely liable. 2dly. To the attempts made by nature to cure phthisis. On opening the thorax, the heart is sometimes observed to be small; Laennec says it is almost always remarkably so. The lungs are sometimes found adhering throughout their whole extent to the ribs, and the left lung is frequently attached to the pericardium, which is occasionally distended with serum. Sometimes one side of* the tho- rax contains a puriform matter, with a considerable quantity of air, the result of a vomica bursting into the cavity, leaving a communi- cation open with the bronchial tubes; when this is discovered, the person is said to be affected with pneumothorax, which may be PHTHISIS PULMONALIS. 423 ascertained by the splashing noise which is heard, when the patient's body is shaken by the shoulders; the stethoscope communicates a peculiar sound, called the metallic tinkling. The powers of the constitution, however, employed to prevent this accident, are gene- rally successful, by effusion of lymph, and the agglutination of parts. These adhesions are mostly found to affect the superior lobes, and sometimes are so dense, that it is impossible to separate them with the fingers, without tearing the lung itself. On removing the lungs from the body, they are found to be much heavier than natural; one case I have already mentioned, in which they weighed nine pounds and three quarters. Notwithstanding the assertion of Laennec to the contrary, I have several times seen the marks of the ribs left upon the posterior and lateral parts of the lungs, when they were very heavy.* It was seen in two cases in which the lungs were extremely dense and large, the effect of long- protracted chronic peripneumony. On making a longitudinal section of the lungs, which will usually be found " to cry under the knife," we sometimes find one excava- tion only, which may be full, none of the contents having yet found their way into the bronchial tubes; and when solitary, it is almost always in the superior lobe. In general, however, many cavities are found, containing more or less softened tuberculous matter, and the most striking difference will be observed in the progress of the tubercles in different situations, being commonly farthest advanced in the superior parts; occasionally they present the appearance of fresh crops. Sometimes the lung is found studded with miliary tubercles, affecting the pleura also, and most commonly some of the bronchial glands will be found enlarged and hard, sometimes mela- notic. I have met with this condition of the lungs only twice or thrice; the subjects were children. I have seen several dissections in which the tubercles, called granular by Bayle, were found in immense numbers, dispersed with great regularity throughout the whole substance of the lungs, with intervening spaces of a red colour, having the appearance of the roe of a salmon. Occasionally we find a chain of excavations extending through- out the whole lung, communicating with each other; the tubercles having become successively softened, and then discharged. In these excavations bands are seen stretching in every direction, like the fleshy columns in the ventricles of the heart, which seem to be com- posed of condensed pulmonary tissue, coated over with tuberculous matter, or, as it has occasionally appeared to me, coagulable lymph; these bands sometimes contain blood-vessels. Bayle makes the same remark, which is questioned, however, by Laennec, who states that he has " never even found a vessel of any consequence included within the substance of these bands;" but I have had several oppor- tunities of demonstrating it to my class. Indeed, on one occasion, a large blood-vessel in one of these bands gave way, and the child quickly died. This is the case previously noticed and in which the blood found its way from the cavern by a fistulous opening into [* I have also met with a solitary example of this kind.] 424 PHTHISIS PULMONALIS. the oesophagus, as high up in the neck as to correspond to the in- ferior margin of the thyroid gland, and from thence passed into the stomach. It will be remarked that Laennec's expression is qualified, and I am ready to grant, that it is rare to find vessels of " any con- sequence" in these bands, because they must be compressed and diminished in size, in proportion to the condensation of the pulmo- nary tissue in which they are involved. Laennec supposes that the tubercles, during their increase, separate the blood-vessels, and press them to one side, which would no doubt hold good, if there were only one mass; but it is not a satisfactory explanation of the situa- tion of the blood-vessels, when the lungs are completely studded with tubercles. On one occasion, I found a blood-vessel passing through a cavern, in one of the bands already described, which had become obliterated by a plug of coagulable lymph. The ramifications of the bronchi seem to be obliterated; they are frequently found to open into a cavern, but I have never seen a trace of them in the tuberculous matter. In proportion as the tubercle becomes softened and discharged, the walls of the excavation are found more or less thickly covered with something like a membrane, which can be scraped off with the knife. According to Laennec, this membrane presents, in different parts of its surface, projecting points. Sometimes there is an appearance of two membranes, but occasionally the walls of the cavity are formed by the natural tissue of the lung itself, condensed, red, and charged with tuberculous mat- ter. Sometimes the walls of the caverns appear to be lined by a membrane of fibro-cartilaginous consistence, occasionally filling up a small cavern entirely, presenting an appearance of cicatrization; in this way, it is supposed that phthisis is sometimes cured. The mucous membrane of the bronchial tubes is generally red and thickened; that portion.of it which lines the trachea and larynx is occasionally red, thickened, and pulpy, with ulcerations here and there. Ulcerations are sometimes seen as far down the tubes as the third and fourth division. Occasionally the epiglottis and larynx are also covered with numerous ulcerations, sometimes having the ap- pearance of chancres. The stomach occasionally presents diseased appearances, its mu- cous membrane being red, thickened and velvety, with dark streaks, as if seared with a red-hot iron. In other cases, a great portion of the mucous membrane is found entirely removed, generally from the splenic extremity, leaving the naked vessels exposed; the rest of the membrane being thickened, soft and reddish, with a great num- ber of redder spots in the neighbourhood of the parts already de- stroyed, as if a pen full of red ink had been spattered over the surface. Sometimes large red vessels are seen arborescing in the mucous membrane, which displays appearances here and there as if portions had been removed by passing the nails roughly over the surface of the stomach. In one case, all the coats of the stomach, except the peritoneal, were destroyed over a space about the size of a shilling. In very few cases have I observed tubercles in the mucous mem- brane of the stomach ; they are frequently seen in that of the intes- tines, particularly in the caput caecum, ascending colon, and termina- PHTHISIS PULMONALIS. 425 tion of the ileum: they are sometimes situated in the mucous coat, and at others in the sub-mucous tissue. It is precisely in the situa- tion above described that ulcerations are most frequently found, occasionally involving the whole of the colon down to the sigmoid flexure, which is much thickened in its texure, in some cases feeling contracted and hard like a small rope. The state of the mucous membrane has been often described in this work; but I must here state, that I have never seen ulcerations undergoing the healing pro- cess in the disease now under consideration; nor the mucous surface in that dark, livid, fleshy, and thickened state, which it frequently shows in dysentery. The peritoneum is sometimes found inflamed, thickened, and covered with flakes of lymph, which may be traced to points of the intestines, at which the ulcerations have extended through the other tissues, till it attacked the peritoneum itself; occa- sionally, indeed, a small perforation is found, which has admitted the passage of feculent matter into the cavity of the abdomen. The peritoneal is frequently the seat of tubercles. They first appear, per- haps, in the miliary form, and afterwards become crude. I had lately an opportunity of seeing tubercles formed on the peritoneal surface of the stomach of a child, who died of chronic peritonitis, occasioned by ulceration of the bowels. They did not extend deeper than the sub-serous coat. The mesenteric glands are always found enlarged and altered in structure in phthisis when the bowels are affected. The liver is sometimes found diseased, more frequently, perhaps, in women than in men; it is generally softened, enlarged, and of a whitish or yel- lowish colour, feeling greasy to the touch. This is the fatty liver; I have seen it so large as to fill the iliac region, the right lobe extend- ing down to the brim of the pelvis. The spleen is sometimes found tuberculated both in its substance and its capsule. The omentum is occasionally diseased in phthisical subjects. It is found thickened ; fatty, like the liver, and tuberculated. The brain is found in various states; sometimes there is effusion between the arachnoid and pia mater, or into the ventricles, the effect, in all probability, of impeded circulation. Tubercles are also ob- served in various situations in the brain, and in different stages, either solitary in some part of the cerebral substance, or spread generally over the arachnoid membrane, where I have frequently seen them in the miliary form, as well as in a crude state. It has never been satisfactorily explained why ulcerations should be found so frequently in the mucous membrane of the bowels, in phthisis. It may, perhaps, be partly attributed to the obstructed state of the circulation, producing considerable vascular distension in its vessels, which at last become inflamed and ulcerated. There may be also something in the diseased condition of the blood itself, which cannot be perfectly decarbonized. I have little doubt that the mu- cous surface of the bowels, in the ordinary state of the system, assists the lungs in depriving the blood of carbon. After the lungs have been impeded by the tubercular state of the pulmonary substance, perhaps the mucous surface of the bowels becomes more active, thereby causing inflammation and ulceration. There is no doubt 36* 426 [PHTHISIS PULMONALIS.] that ulcerations in the intestines are sometimes owing to the irrita- tion of tubercles in that part, but this speaks for itself. For further particulars, relating to the morbid appearances found in this disease, the reader is referred to the work of M. Louis. [Causes.—Consumption is a remarkable instance of hereditary disease: thus, when the parents have died of constitutional phthisis, the children are almost sure to suffer. This predisposition, or tuber- culous diathesis, is not confined to any period of life, but is most apt to show itself between the ages of eighteen and thirty-five years. Some authors have endeavoured to identify it with the scrofulous habit, from which, however, it appears to be entirely distinct; scro- fula is most active in the juvenile state, while phthisis is a disease of adult age. I have twice seen the scrofulous diathesis developed in the spine, even to deformity, and accompanied by chronic pulmonary disease, without exciting a tubercle in either lung. The physical characteristics of scrofula and phthisis are not the same; for two- thirds of the consumptive patients who have come under my care have had dark hair, dark or sallow complexions, and dark eyes. It seems, indeed, extremely difficult to detect the tuberculous constitu- tion by any physical appearances of even general application ; and still more difficult to identify it with the scrofulous diathesis. If the predisposition to phthisis exists, various slight causes are sufficient to excite it into action. Thus bronchitis, pneumonia, hae- morrhages, the depressing passions and exhausting indulgences, bad diet, sedentary occupations, and a hundred other means by which the healthy functions of the system become perverted, may be ad- duced as exciting causes.] Treatment.—Although Laennec states that phthisis is curable, still such a happy event is scarcely to be expected after the disease is formed. The only case which I conceive to be capable of a spon- taneous cure, is that in which a solitary tubercle has existed, without any other disease of structure in the lungs. In examining the bodies of cholera subjects, we frequently observe puckered marks and cica- trices, with corresponding pulmonary indurations, sometimes to a considerable extent. These were evidently the situation of tubercu- lous degenerations, from which the individuals had quite recovered. Professor Lizars has, in his collection^ very valuable specimen of a lung entirely excavated, nothing being left but an empty sac. The history of the case is quite complete; the man recovered, and was able to exist and support himself by manual labour, and died ulti- mately of typhus fever, unconnected with any pulmonary complaint. Much may be done in warding off the disease for many years, and retarding its progress after it is formed, bv care in the management in an individual—by attending to his diet," which should be nourish- ing and moderate—to his clothing, which should be warm and light —and to his exercise, which should never be carried the length of producing fatigue. Constipation should be avoided, and such an individual should remove to a steady climate if he can afford it. After the disease is somewhat advanced, a great deal of expense and trouble may be spared by keeping the patient at home, because, at this period, change of climate can do no good; on the contrary I [PHTHISIS PULMONALIS.] 427 have known it frequently to hasten the fatal termination, from fatigue and accidental exposure to cold during the journey.* [When I meet with a case of incipient phthisis, when the disease is confined to one lung, and is circumscribed in extent, and the pa- tient's general health not yet impaired, I pursue the following plan. I at once establish an issue of caustic potash over the diseased part, and keep it discharging by means of basilicon, savin, and mezereon, and by washing it with soap and water. The cough should be con- trolled through the day by demulcent and acidulated drinks; but at bed-time, if it continue troublesome, I direct as much anodyne as will secure the patient a night's rest. In this manner the cough will be chiefly confined to the early part of the day, when the patient is best able to bear it. If there be febricula, with a frequent pulse, I am partial to the use of digitalis, which sometimes has a most happy effect in reducing the wearing excitement of the blood-vessels. To this simple treatment I add the internal use of the preparations of iodine—the most powerful alterative, with the exception of mercury, with which we are acquainted. As bronchitis is often the precursor and cause of consumption, and especially as it may coexist for a considerable period with tubercles, without any positive evidence that these are present, it is well to regard every cough with distrust, and treat it accordingly. How much more is this course necessary, when we know that tubercles are already formed, and forming in the lungs? Of all the counter- acting agents for these bodies and for bronchitis, or catarrh, no one medicine has, in my hands, proved so efficacious as the preparations of iodine. Whether they be used in form of the iodides of potassa or iron, or of the former combined with pure iodine, the effect is generally prompt and salutary. We should give them freely; not less than two or three grains of either iodide, three or four times a day; while the combination with pure iodine, for reasons I cannot explain, must be administered more sparingly.! I have resorted, also, with great advantage, to iodine inhalation. Sir Charles Scudamore was, if I mistake not, the first to propose a systematic plan for this purpose, or at least to combine conium with iodine, and his formula is as follows: R.—Iodinii puri, Iodidi potassii, 5a gr. vj. Aquae destillatse, 3v. 3yj. Alcoholis, 3J. Fiat mistura. "1 always prefer," observes the author, " to add the conium at the time of mixing the iodine solution with the water; and it should be a saturated tincture, prepared with the genuine dried leaves. In the commencement of the treatment, I advise very small proportions of the iodine mixture; for example, only from half a drachm to a drachm for an inhaling of eight or ten minutes, to be repeated two or three times a day. Of the soothing tincture, (conium), I direct * For much valuable information on this subject, I must refer my readers to Dr. James Clarke's excellent work on Pulmonary Consumption, &c. &c", 1835. [t See Prescription, No. 35, Appendix.] 428 [PHTHISIS PULMONALIS.] half a drachm, which I usually find sufficient; but it may be in- creased, if the cough be very troublesome. I soon augment the quantity of the iodine, and progressively from 3j to 3iv; but also then prolonging the time of inhaling, I divide the iodine dose, put- ting two-thirds at first, and the rest after the expiration of seven or eight minutes. During the process (of inhalation) the inhaler should be immersed in a jug containing water of rather a higher tempera- ture than 120°."* I have thought best to give the author's directions in his own words, because I think it probable that some, and perhaps all the difficulties complained of in this formula, have arisen from some in- advertence in its preparation. That great care is requisite will be obvious to any one; but of the efficacy of the plan, when fairly tried, there can be no question. Dr. Pearson, of London, many years ago recommended an inha- lation of ether, saturated with cicuta leaves; a drachm of the latter being kept in an ounce of the former, for about a week, at the end of which time, the vapour of one drachm of this tincture is to be inhaled thrice per diem. Having repeatedly tried this plan with advantage, it occurred to me to add the iodine to the cicuta and ether, in the following manner: R.—Iodinae purae, gr. iv. Foliorum cicutae, gr. viij. Etheris sulphurici, ^i. These ingredients are to be mixed for forty-eight hours, or a week, at option. I direct a teaspoonful of this ethereal tincture of iodine and cicuta to be poured into a wineglass, which is to be grasped in the warm hand, and the vapour to be inhaled as it rises. In ten or fifteen minutes the evaporation is complete ; and in this short period, the inhalation is completed without the inconveniences which attend upon the more complicated process which has been described above. Sometimes the ether causes cough. Every species of inhalation will sometimes do the same. To obviate it in the present formula, let the wineglass be held a few inches from the nostrils; and if the vapour causes some dizziness, (which, however, can only be tempo- rary,) the patient may begin with half a drachm. 1 need hardly add, that this, and every other use of iodine is inadmissible, when active fever is present. The patient's diet should be light but nutritious; he should use freely the farinaceous articles, and avoid every indigestible article of food. Conjoined with these means, I direct daily free exercise in the open air by walking, riding or driving, and by protracted journeys, when these can be resorted to without undue fatigue or exposure. As an interlude I am extremely partial to a change of climate, of which more will be said in the sequel. It is by a persistence in this plan of treatment, that I have now the satisfaction of seeing a considerable number of patients pursuing their daily avocations, and enjoying a good degree of general health, who, I am confident, never would have [* London Medical Gazette, 1840.] [PHTHISIS PULMONALIS.] 429 survived, for three months, the old practice of close confinement, low diet, antiphlogistics and mercurials. I do not pretend that in all such cases the tubercular disease is eradicated, or that the abscesses have cicatrized; but I know that the malady may sometimes be kept at bay, and rendered comparatively inert, until at length it ceases to molest the patient. The obliteration of abscesses by cicatrices is a very common oc- currence, but most unfortunately, these cavities are seldom single or isolated, but, on the contrary, succeed each other at uncertain inter- vals, and thus keep up an exhausting drain on the constitution. But the existence of abscess does not prevent my pursuing the practice above mentioned, provided the general strength of the pa- tient continues in a reasonable degree unimpaired. Abscesses may continue for years, occasioning no pain, and little inconvenience be- yond debility, more or less cough, and occasional febricula. Such instances, however, are exceptions to a rule; for where suppura- tion has taken place we have little to hope for.] Much may also be done to retard the advancement of the disease, to mitigate the patient's sufferings, and to smooth his passage into the vale of death by avoiding every cause which can hurry the cir- culation and respiration, and preventing exposure in bad or change- able weather. Phthisical patients suffer occasionally very severely from pains in the chest, produced by pleuritic inflammation, traces of which are almost always seen on dissection. Small bleedings, leeching and contra-irritation, should therefore be occasionally em- ployed. Profuse perspirations are to be discouraged, as is also the exhibition of acids, which are so often given to prevent them.* The bowels are to be assiduously watched to prevent constipation, and the necessity of having recourse to strong purgatives, particularly when the disease is of long standing. When a laxative is necessary, it should be of the mildest description, and united, perhaps, with the extract of hyoscyamus. [This condition of the bowels may be, in a great measure, prevented by diet: thus, instead of bread made of wheat flour, the patient should be restricted to bran bread, conjoined with the free use of cream. Sound ripe fruits, and the dried fruits stewed, subserve the same purpose.] Whenever a patient has more than the usual number of stools, particularly if they are watery, dark-coloured and fetid, and when he begins to feel even slight un- easiness in the belly before going to stool, a few leeches should be applied to the abdomen, followed or not, according to circumstances, by the application of tartar-emetic ointment to produce irritation. It * [I confess I cannot join in the author's objections to mineral acids. The nightly recurrence of profuse sweats is so debilitating, and at the same time sodistressing to ihe patient, that a physician is sometimes compelled to resort to some measure that will afford relief, even though it be merely temporary. Thus I have many times seen eight or ten drops of elixir of vitriol, given in a little cold water or bitter infu- sion at bed-time, produce the happiest effects. A similar result may be obtained from a solution of alum in spirits, with which the limbs should be freely sponged. The infusion of sage may be taken internally for the same purpose. I use these means to check colliquative perspiration, on the same principle that 1 would check a haemorrhage: either is exhausting to the patient; and where our curative means end, our palliative ones must begin. The same remarks will apply to the diarrhoea of phthisis.] 430 [PHTHISIS PULMONALIS.] is wonderful, in many cases, to observe the good effects which fol- low the application of leeches in subduing the inflammation of the mucous membrane, thereby controlling the diarrhoea, and preventing the formation of ulcerations. Indeed, I have seen the best effects follow the application of leeches, even after a large extent of the mucous surface was ulcerated ; but superficial irritation, produced sometimes by a mustard plaster, sometimes by hot spirits of turpen- tine, or by antimonial ointment, will be often found of essential ser- vice, when the patient is too weak to bear bleeding. [The Moors of Africa, among whom consumption is common, have a practice of controlling diarrhoea by means of two grains and a half of alum, with an equal portion of sulphate of iron, given in a powder. Having mentioned this plan to Dr. Pitcher, of the United States army, he subsequently informed me, that he put it in practice on two soldiers who appeared to be dying with diarrhoea consequent to phthisis, and that both men were so greatly relieved, as to be able in a short time to resume their duties in the garrison. I mention these facts with the more satisfaction, because 1 believe patients are sometimes allowed to die of diarrhoea, from an impression that it is a mere sequel of the pulmonary affection, and therefore incurable. 1 am decidedly of opinion that we should combat the diarrhoea with every available means, both internal and external, to the last hour of life. It is now upwards of two years and a half since I had in charge a middle-aged man with an abscess in his left lung, which was soon followed by an exhausting diarrhoea; the latter was happily checked by strong opiate and astringent medicines, at the very time when the case appeared hopeless: the diarrhoea subsequently recurred twice, and was, in like manner, subdued, after which the patient's general health began to improve, and he is at the present time able to take daily exercise in the open air, although he still labours under his pulmonary disease, and is occasionally confined with relapses of various kinds.] Peritonitis is sometimes occasioned by an extension of the ulcera- tion to the peritoneum; therefore leeches and contra-irritation are sometimes advisable. An occasional opiate is also serviceable; and I have seen the best effects produced by the exhibition of one-twelfth of a grain of strychnine, when the bowel-complaint was very trouble- some. [Change of climate.—One of the most powerful means of eradi- cating or alleviating disease is change of climate. This remark is especially applicable to pulmonary affections. Phthisical patients are often improved by mere changes, even though it be from a clear atmosphere to^one damp and unhealthy, from warm to cold, from cold to hot. Thus we send our consumptives to a southern climate, Florida or the West Indies, to escape the winter : while in the latter islands physicians frequently send their consumptives beyond the tro- pics, to England, Denmark, and the United States, to pass not only the summer but the winter also. It is in fact evident, that both ex- tremes of temperature are sometimes salutary; and that great changes, by acting powerfully on the constitution, are capable of breaking [PHTHISIS PULMONALIS.] 431 those chains of morbid action which constitute the most inveterate maladies to which man is subject. In phthisis, however, a clear, dry atmosphere, of an equable tem- perature, is most adapted to the majority of patients, especially if the exercise of travelling is precluded. Travel itself is highly beneficial nor is there any means more invigorating, provided it be not carried to excess and consequent exhaustion. The chief reason why so few people are benefited by the climate of Italy is to be attributed less to any fault of the climate itself, than to their own imprudence. Inva- lids must see every thing; they persist in ascending mountains, climb- ing to the dome of St. Peters, the tower of Pisa, and the cathedral of Milan ; travelling from place to place in all kinds of weather, and exposing themselves to the sun, as if the mere circumstance of their breathing the air of Italy was a guarantee against fatigue, exposure and dissipation itself. I have considered this interesting subject at considerable length in another work,* and shall now merely indicate, in the briefest manner, certain winter resorts in the United States and West Indies, which have been found most salubrious under the circumstances in question. St. Augustine, in East Florida, is our principal winter resort for pulmonary invalids. It certainly possesses one of the most equable climates of the United States, yet is subject to no small vicissitudes of temperature; while the inadequate provision the inhabitants make for cold weather renders a severe winter very exposing to the sick. From a letter of Dr. Porcher, contained in Dr. Dunglison's admirable work on HygiSne, I have gleaned the following facts: 1. The thermometer, in a solitary instance, fell 37° in 24 hours. "2. Changes of 20° or 25° occur frequently every winter; in some instances even in a few hours." These changes, however, are be- tween 65° and 45° or 40°. 3. The thermometer does not fall to 35° more than five or six times in a winter, nor does it remain so low more than a few hours. 4. The lowest degree to which the mercury is known to have fallen, is 20° of Fahrenheit; nor has it been observed to remain for 24 hours so low as 32°. 5. Cold weather seldom lasts beyond two or three days, and is generally followed by a " long succession of days with an atmosphere the most bland and delightful." It would, therefore, seem, that while St. Augustine presents an equable climate, it is liable to serious objections: at the same time, it is well known that many pulmonary invalids annually derive import- ant benefit from passing the winter there. Cape Florida may yet prove more salubrious than St. Augustine. The Passa Christiana, on the Gulf of Mexico, has also been much extolled as a winter re- treat. Texas, too, possesses a most genial climate. During the summer season, the Red Sulphur Springs, in Virginia, and the Pine region, in the vicinity of Pemberton, in New Jersey, are resorted to with great advantage by many. [* Illustrations of Pulmonary Consumption, 2d edition J 432 PHTHISIS PULMONALIS. Of the West Indies, the islands of Barbadoes, Cuba and Santa Cruz offer the strongest inducements to the sick ; but particularly the last named island, in which the thermometer scarcely varies 10 de- grees the year round. An almost constant sea breeze, a clear elastic atmosphere, and a profusion of fruits render this island one of the most delightful in the world. Every person, however, who visits the West India islands, must expect to feel the enervating influence of so warm a climate. Lan- guor of body and listlessnessof mind are inevitable consequences, and indispose alike to physical and mental exertion. The West Indies should not be visited earlier than December nor later than March.] The duration of phthisis is very various: few survive above a year; indeed, the generality of patients sink in about nine or ten months, and I have often observed that women die quicker than men. One case terminated fatally in about twenty days, where there was no other perceptible organic lesion, except the granular tuber- cles which affected every part of both lungs. Louis says he has seen a case fatal in twenty-four days, but that the general period in acute phthisis is about fifty days. It was formerly mentioned, that Bayle divided phthisis into as many species as there have been diseased appearances found in the lungs. He has, therefore, treated of calculous concretions under this title; together with the condition which has been called melanotic; and that which has been so well described by Laennec, under the term "medullary cancer." It appears to me that Bayle was so far right, because when the lungs are thus affected, the individuals fre- quently emaciate, cough, and breathe in the same manner as in the tubercular disease. The following account of the more rare varieties of structural de- rangement found in the lungs, is compiled from Laennec's work: 1*/. Bodies of a cartilaginous, osseous, calculous, and creta- ceous nature.—Sometimes cartilaginous cysts are seen, containing bony or chalky concretions. Laennec states that the bony matter is not perfect, containing a greater quantity of calcareous phosphate, and much less gelatine than true bone, and hence these bodies re- semble a piece of stone more than bone. In some cases, he says they contain no gelatine, and resemble moistened chalk. There are also found points of ossification in various parts of the lungs. I have nevej- seen them provided with cysts, which Laennec states are very rare indeed; the non-encysted ossifications are those to which 1 now allude. They are sometimes very numerous; they feel rough and pointed, and are generally adherent to the pulmonary tissue, which is sometimes of a cartilaginous hardness. Lately I dissected a lung studded over with this kind of production; each was surrounded with a melanotic mass, which, when situated on the surface of the lung, adhered to the pleura in such a manner as to prevent a sepa- ration. Sometimes they are observed in the bronchial glands. The chalky concretions are found in two states, one resembling soft chalk, the other like common mortar. In general, these are en- cysted. Sometimes calculous bodies, of the shape and size of small PHTHISIS PULMONALIS. 433 peas, are not only found on the surface of the lungs, but are also oc- casionally expectorated, which leads many to suspect that they are formed in the bronchial tubes; it is more probable they are formed in the substance of the lungs, and find their way into the air-passages by ulceration or absorption. When meeting with these large bodies on dissection, I have always seen considerable disease in the surround- ing pulmonary tissue, sometimes in the state of recent inflammation, at others of gray or red hardening. I cannot sanction the opinion that these concreiions are the product of powdery substances taken into the lungs, suspended in the air we breathe; but bronchitis is often produced in this manner. Laennec supports the same opinion, and his reasoning appears to be quite conclusive. He believes that these concretions are consequent to tuberculous affections that have been cured; but I see no reason for agreeing with him. 2d. Melanosis of the lungs.—These productions, in their early or crude state, " possess a consistence equal to that of the lymphatic glands, and a homogeneous and somewhat humid composition ; they are opaque, and in structure very much resemble the bronchial glands in the adult. When they begin to soften, a minute portion of fluid can be expressed from them, of a thin reddish character, intermixed with small blackish portions of a substance which is sometimes firm, sometimes friable, but which, even when friable, conveys to the touch an impression of flaccidity. In a more advanced stage, these portions first, and subsequently the whole mass in which they are contained, become quite friable, and are soon converted into a black paste. Melanotic matter is found in four different forms, encysted, non-encysted, generally infiltrated into the natural texture, and deposited on the surface of organs."* Encysted melanosis.—" The cysts inclosing this species are very regularly rounded, and vary in size from that of a small hazelnut to that of a walnut. They have a very regular and equal thickness, which is never greater than half a line. Cellular substance appears to be the only tissue that enters into their composition. They adhere by means of a very fine cellular membrane to the substance of the organ in which they are situated, and from which they can be readily separated by dissection. Their interior surface is rather smooth, but adheres to the morbid matter which it surrounds. The medium of this adhesion appears to be a very fine imperfect cellular tissue, though it cannot always be distinguished. I have hitherto (says he) only found this variety of melanosis in the liver and lungs; and in the latter organ I have only as yet met with a single mass of it."t Unencysted melanosis.—" This variety is much less rare than the preceding. I have met with it (he says) in the lungs, the liver, the pituitary gland, and the nerves; but it has been since found in almost every organ. The volume of masses of this kind is quite indeter- minate, varying from that of a millet seed to that of an egg, or more. They are also quite irregular in figure. They commonly adhere very closely to the parts in which they are situated; sometimes, however, they are united to these by a very fine, though sufficiently » Forbes's Laennec, p. 383. t Laennec, p. 383. 37 434 PHTHISIS PULMONALIS. visible, cellular tissue, which permits their removal without any lace- ration. In this last case they are commonly of a rounded shape."* Melanotic matter generally infiltrated into the natural texture. —" It frequently happens that this morbid matter, in place of being segregated in distinct masses, is disseminated throughout the organs in which it is found, and deposited between the particles or molecules of the natural tissue. The appearance and colour of parts affected in this manner present a good many varieties, according to the tex- ture of the organ, the quantity of matter deposited, and the particular condition of this matter. When the infiltration is recent, and in moderate quantity, the appearance of the affected part merely differs from the natural condition, in being intermixed with small black dots or striae, the intermediate portions being quite of a healthy character. As the disease increases, the dots and striae enlarge in number and volume, until the whole of the natural tissue of the part is lost in the morbid degeneration. It is usually only at this period of its progress that the melanosed matter begins to soften ; but if the softening takes place before the complete removal of the natural tissue of the part, it frequently happens that this softens also, and intermingles with the morbid matter, the colour of which is thereby changed to brownish, yellowish, or grayish." There are various preparations in my museum, which illustrate these very excellent descriptions of M. Laennec. There is one, showing the last variety of this affection, which was found in the stomach of a dram-drinker. I have also the portion of a lung, the whole of which was affected with the disease, and which looks like a sponge filled with very black ink. There is also a rare specimen of melanosis affecting the pleura pulmonalis. A case, rapidly fatal, occurred to me in 1825. The subject was a middle-aged man, who began to complain on the 15th July, but did not take medical advice till the 19th, when he was found to complain of severe pain and weight in his head, some ringing in his ears, but no intolerance of light; the pain was increased by motion and cough- ing; his breathing somewhat accelerated, respiration 24 in a minute; but he had neither pain, cough, nor expectoration; complained of uneasiness in the abdomen, which was not increased on pressure; tongue whitish in the centre, and at the edges red; skin hot and dry; pulse 90, full and strong. Twenty ounces of blood were taken without any decided relief, and in five hours afterwards, twelve ounces more, which removed the headache. On the 20th, he was so much better as to be able to leave his bed, but became worse again towards evening. 21st. Again somewhat improved. By the stethoscope, the respiration was noisy and blowy, which led to a suspicion of the existence of crude tubercles, surrounded by healthy structure; respiration 30; pulse 112; tongue not improved; face somewhat flushed; skin hot and dry. He died next morning in what his friends called " a fit," which appeared to be asphyxia. The lungs were found completely infiltrated with melanotic mat- * Laennec, p. 384. PHTHISIS PULMONALIS. 435 ter, but still crepitating; and they floated when placed in water • the spleen was affected in the same manner.* 3d. Medullary sarcoma.— According to Laennec, "medullary sarcoma may exist under three different forms, viz.: 1st, encysted* 2d, in irregular masses without a cyst; and 3d, diffused iri the tissue of an organ. In whichever of these forms it exists, it presents, in its progress, three different and distinct stages, viz. 1st, the incipient or crude state; 2d, its perfect state, in which it exhibits the resem- blance to brain, which forms its special characteristic; and 3d, its soft or dissolved state. " I shall first describe it as it is observed in the second or perfect state, as this is the condition in which the three varieties most nearly resemble each other, there being much difference between them in the first and last stages. In its perfect state it is homogeneous, of a milky whiteness, and very like the substance of the brain. In differ- ent parts it has commonly a slight rose tint. It is opaque when ex- amined in mass, but in thin slices it is in a slight degree semi-trans- parent. Its consistence is like that of the human brain; but it is commonly less coherent, being more easily broken and comminuted by the finger. According to its degrees of density, it resembles one part of the brain more than another; but it is more commonly like the medullary substance of a brain that is more ordinarily soft (or like that of a child's) than the healthy brain. When existing in any considerable extent, this species of cancer is, in general, supplied by a great many blood-vessels, the trunks of which ramify on the exterior of the tumours, or between their lobes only, while the mi- nuter branches penetrate their substance. The coats of these vessels are very fine, and readily ruptured ; and this accident gives rise to clots of extravasated blood in the interior of the tumours, sometimes of considerable size, which bear occasionally a striking resemblance to those found in the brain of subjects dead of apoplexy. Extrava- sations of this kind may sometimes be so considerable as to supplant almost the whole of the brain-like matter, so that the true nature of the tumour can only be ascertained by some small points, still remaining of the Original growth. This change occurring in super- ficial tumours of this kind, and being productive of much hsemor- hage, appears to me to have given rise to the name of Fungus he- matodes, applied to certain cancers by modern surgeons. Under this name, however, I am also convinced that they have confounded tu- mours of different kinds, especially those commonly called varicose, which are composed of an accidental tissue, very analogous to that of the corpus cavernosum penis. I have never observed any lym- phatics in tumours of*this sort, but it is probable that the circulating [♦ In the splendid work of Dr. CarswelL " Illustrations of the elementary forms of disease," the reader will find an admirable view of every form and variety of mela- nosis. On the present occasion I shall merely quote one or two facts respecting the chemical charactersof true melanosis, which Dr. Carswell, however, calls melanoma. Melanotic matter is essentially composed of the colouring matter of the blood, unit- ed with fibrine, (both of them in a particular state,) three kinds of fatty matter, and a considerable quantity of phosphate of lime and iron. • I am inclined to believe that melanosis is of less frequent occurrence in the United States than in Europe. In my dissections it has occurred with extreme rarity,] 436 PHTHISIS PULMONALIS. system is complete in them, as I have seen their substance deeply tinged with yellow in cases of icterus. The matter of encephaloid does not continue long in the state just described; it tends incessantly towards a softer condition, and, in a short space, its consistence scarcely equals that of a thickish paste. Then begins the last stage: the process of softening becomes more rapid, until the morbid mat- ter becomes as liquid as thick pus, still, however, retaining its whit- ish or rosy white tint. Sometimes, at this period, or a little earlier, the blood extravasated from the vessels contained in the tumour, be- comes intermixed with the morbid matter, so as to give it a dark red colour, and the resemblance of clots of pure blood. In a short time the extravasated blood is decomposed; the fibrine concretes, and, to gether with the colouring matter, unites with the brain-like matter of the tumour; and the serum is absorbed. In this condition the mor- bid growth retains no resemblance to brain ; it is of a reddish or blackish colour, and of a consistence like that of paste, somewhat dry and friable. Sometimes the change of structure and appearance is so complete, that one would be led to consider the tumours as of a dif- ferent kind, but for the existence in them of portions of the original matter still unchanged. In some cases, contemporaneously with tu- mours that have changed in this manner, there will be found others retaining the original cerebral character; so that, in all cases, we are able, with a little practice, to discover the true nature of the tumour in all its stages."* " Such are the characters which this species of cancer presents in its two latter stages, and equally in all the three varieties. I shall now describe the characters of each of these varieties in the first or crude state. " I. Encysted medullary sarcoma.—The size of this species is very various. I have seen the tumours as small as a hazelnut, and larger than a middle-sized apple. I have found them as large as this in the lungs. The cysts are of pretty equable thickness; and this is never more than half a line. They are of a grayish-white, silvery, or milky colour, and have a semi-transparency, more or less, according to their thickness. Their texture is altogether cartilagi- nous, and rarely fibrous; but it is much softer,and less easily broken by bending, than cartilage; on this account they must be ranged among the imperfect cartilages. The medullary matter contained in these cysts can be easily detached from their inner coat. It is commonly divided into several lobes, by a very fine cellular tissue, which may be compared with the pia mater, and the more so from the great number of blood-vessels which traverse it. The fineness and brittleness of these have been already noticed, and also their penetration of the cerebriform matter itself, to which they give a rose tint here and there. It is their rupture that gives rise to the clots of blood formerly mentioned. Sometimes, also, the trunks of these vessels are ruptured in the interstices of the lobules; and the blood being injected beneath the fine cellular substance which accompanies them, gives this the appearance of a distinct membrane. It is com- * Forbes's Laennec, p. 393. PHTHISIS PULMONALIS. 437 monly in their early or crude stage that these tumours are divided into distinct lobes. These are especially observable on their surfaces, and have sometimes considerable resemblance to the convolutions of the brain. The cyst does not at all enter between these convolutions, nor does it even indicate on its surface their place or configuration. In this stage the medullary matter is pretty firm, often firmer than the fat of bacon. It is of a dull white, pearl gray, or even yellowish colour, and, in thin slices, has a slight degree of semi-transparency. When cut into, it appears subdivided interiorly into lobules, much smaller than those seen on its surface. These lobules are in such close contact as to leave no interval whatever; and their separation is merely indicated by the reddish lines traced by the vascular cellular tissue by which the separation is effected. These lines rarely cross each other, butexhibit many irregular curves and convolutions. When these tumours pass into the second stage, their texture becomes more homogeneous, and all distinction of the small interior lobules is quite lost; the distinction, however, of the larger exterior lobes still con- tinues. The blood-vessels, which run between these lobes, and in the cellular tissue immediately investing the tumour, are much more developed than in the early stages of the disease, and it is only at this second stage, or as it approaches the third, that the extravasa- tions of blood take place. The third stage begins, as I have already mentioned, when the medullary matter has acquired a consistence like pap or paste, or like that of a brain softened by commencing putrefaction. In this state, it has still much resemblance to cerebral substance. I have never found that the morbid growth ever softens still more, or that it is absorbed or evacuated, so as to leave an empty cyst or cavity like tubercles; consequently, it is not probable that we shall ever find pectoriloquism as a sign of this affection. Hitherto I have only found these encysted medullary tumours in the lungs, liver and cellular substance of the mediastinum."* "2. Unencysted medullary sarcoma. — Medullary tumours of this species are very frequently met with. Their size is very variable. I have seen them from the size of the head of a full-grown foetus to that of a hemp-seed. Their shape is commonly spheroid, but occa- sionally flattened, ovoid, or altogether irregular. Their external surface is lobulated, but the divisions are less regular than in the encysted species; their internal structure, in the two last stages, is precisely the same. The cellular membrane, which invests them, is more or less marked, according as they are placed in a loose cellular tissue, or in the substance of a viscus of firm texture: in the latter case, their investing membrane is thinner and less distinct. In their first or crude stage, their semi-transparency is greater than after- wards; they are almost colourless, or have a very slight bluish tint in ocellated patches; they are pretty hard, and divided into numerous lobes. Their substance is then fatty, like lard; but when incised, it does not at all grease the scalpel, and it coagulates by heat, without showing a particle of fat. The transition from the first to the second stage takes place in the * Forbes's Laennec, p. 395. 37* 438 PHTHISIS PULMONALIS. following manner:—The substance of the tumour becomes more opa- que, softer, whiter ; and its inner distinction into lobules, for the most part, disappears. The original texture is observed longest in the neighbourhood of the external interlobular fissures. In this situa- tion, 1 have found portions still in a state of induration, after the mass of the tumours had passed into the third stage. I am led to conclude that the encysted tumour follows precisely the same pro- gress as that just described. The non-encysted medullary tumours may exist in any part of the body; but they are most frequently met with in the loose and abundant cellular tissue of the limbs, and in the larger internal cavities. I have met with them in the cellular mem- brane of the forearm, thigh, neck and mediastinum; they are still more frequently found in the cellular substance around the kidneys, and the anterior part of the spine ; and in these situations they often have a very large size. Although they are frequently found in the viscera, they are, however, much rarer there than in the cellular sub- stance." * In my collection there are several fine specimens of all these varie- ties of medullary sarcoma, and others unnoticed by any author, but which it would be tedious to describe. * Forbes's Laennec, p. 397. CHAPTER VII. ASTHMA. This term was formerly used to express every species of difficulty of breathing. Latterly it has been employed to signify a specific intermittent dyspnasa, independent of organic lesion; but I shall show how erroneous such views of this disease are when I come to treat of its pathology. This disease is observed most frequently in people beyond the middle age, rarely in youth; it affects men oftener than women, and those of full habit of body more frequently than the spare; and it would seem to be occasionally hereditary. Phenomena.—Attacks of asthma sometimes appear towards the afternoon, or at the moment the patient is going to bed, but more fre- quently they occur during the night; occasionally/indeed, the patient is seized during a sound sleep, and awakes with a sense of suffoca- tion. In describing the disease, I shall confine myself to a few of the leading symptoms, because, depending upon so many morbid conditions of the lungs, heart, and perhaps the brain, the symptoms which may take place, have too wide a range of. character to be taken into a short general sketch. Upon the approach of a paroxysm, the patient usually feels a sense of coldness over the surface of the body, indeed sometimes severe rigors take place; a sense of constric- tion is experienced in the chest and difficulty of breathing, both of which are increased in the recumbent posture. He"sits up, because he can then breathe more easily; he demands more air to be admitted into the apartment; he employs all his efforts to dilate the chest, and then to empty the lungs. There is restlessness; occasional cough, which the patient makes efforts to perform, thinking to force some- thing out of the lungs which impedes his breathing. Expiration is performed with, a peculiar whistling sound, and sometimes it is sonorous. The face is either pale or livid. The eyes have an anxi- ous expression. The extremities are frequently cold, even the nose and the ears; and the face and breast are covered with a cold dew. The pulse is in various states—full and quick—small and quick— sometimes oppressed—and it occasionally intermits. The skin is frequently discoloured; and there are often a troublesome flatulency and sense of fulness in the abdomen. These symptoms continue with more or less violence for some hours or days till expectoration takes place, which generally precedes a remission. The expectoration is sometimes scanty, at others copious. This is a short description of 440 ASTHMA. the symptoms as they generally occur. In slight cases, however, a sense of constriction in the chest only is complained of, which is sometimes relieved by the expectoration of a whitish mucus; but in more severe instances, the symptoms are much more violent and alarming, not only to the patient, but to the bystanders; instant suffo- cation being threatened, he solicits relief in the most urgent manner. A remission sometimes takes place immediately after the occurrence of profuse perspiration, and occasionally after a copious discharge of urine. An individual may have an attack for three or four successive nights, and not be again affected for months; sometimes it returns every month for a number of years, and then disappears for a con- siderable time. Women are generally attacked immediately pre- ceding the catamenia. The duration of each paroxysm is very various, from two or three days to three or four hours. One attack leads to another, and the paroxysms generally become more and more frequent and severe. In describing this disease, authors have mentioned two varieties —the humid and the dry. The first commences more gradually, and becomes slowly worse; the cough is frequently severe, attended with early and copious expectoration, which produces relief; the mucous rale is heard almost from the beginning. The dry asthma commences suddenly, and becomes quickly severe, but does not con- tinue long. The cough is slight; the expectoration very scanty,and observed at the close of the paroxysm only; the mucous rale is not heard till towards the conclusion of the attack—even then it is very slight and, perhaps, partial. Causes.—Asthma is liable to return occasionally during the whole period of a man's life. The subsequent attacks depend on different circumstances in different constitutions. Some are affected by ex- ternal heat, others by external cold; many by eating indigestible substances, or by overloading the stomach ; and almost all asthmatics are affected by hurried exercise, and by any other cause that increases the rapidity of the circulation. It will generally be observed, that those who are predisposed to it, dread cold, moist weather, and stormy seasons. Individuals who follow particular occupations, would seem to be more subject to this affection than others, particu- larly those who are exposed to irritating vapours, and breathing an atmosphere in which different substances, in very fine powder, are suspended. Causes particularly affecting the nervous system, would also seem to be capable of producing paroxysms, such as passions of the mind, &c. Pathology. — It is generally admitted, that that kind of dyspnoea which is now under consideration, and which is commonly known by the name of asthma, is produced by various diseased states of the lungs and heart. Chronic bronchitis, emphysema and congestion are the three conditions of the lungs which most frequently produce asthma; and I believe it is likewise occasioned by some kind of nervous irritation, the nature of which is yet unknown. It is, per- haps, from this view, that the doctrine of a spasmodic structure in the air-tubes has arisen. ASTHMA. 441 Having already treated of chronic bronchitis, it is unnecessary to say more upon the subject in this place ; I shall therefore proceed to describe Emphysema of the lungs, of which there are, according to Laennec, two kinds : 1st. That which consists in the simple dilatation of the air-cells, which he calls pulmonary or vesicular emphysema; and 2d. That which is characterized by infiltration of air between the lobules of the lungs, which he terms interlobular emphysema. In the first, the size of the vesicles is much increased, and also less uniform ; the greater number equal or exceed the size of a millet- seed, while some attain the magnitude of cherry-stones, or even French beans. The largest are, in all probability, produced by the union of several of the air-cells, in consequence of the rupture of the intermediate partitions; sometimes, however, they appear to arise from the simple enlargement of a single vesicle. The bronchial tubes, especially the small ramifications, are sometimes very evi- dently dilated in those portions of the lung where the emphysema exists. The interlobular emphysema, according to the same author, is characterized by infiltration of air between the lobules of the lung, and must be considered as necessarily depending on a rupture of some of the air-cells in the first place, and the consequent extravasa- tion of the air contained in them. When the extravasation exists near the root of the lungs, it sometimes extends to the mediastinum, thence crosses to the neck, and occasionally spreads over the whole subcutaneous and inter-muscular cellular substance of the body. The pathognomonic signs of the pulmonary emphysema, says Laennec, "are furnished by a comparison of the indications derived from percussion and mediate auscultation. The respiratory sound is inaudible over the greater part of the chest, and is very feeble in the points where it is audible; at the same time, a very clear sound is produced by percussion. From time to time, also, we perceive, while exploring the respiration or cough, a slight sibilous rattle, or sound of the valve, as in the dry catarrh, occasioned by the displace- ment of the pearly sputa." When existing in a high degree it may be recognized by a sign which is altogether pathognomonic, which Laennec calls the crepitous rattle with large bubbles. '• In this case, the sound, during inspiration or coughing, is like that which would be produced by blowing into half-dried cellular substance."* In the interlobular emphysema, Laennec assures us, "there is one sign completely pathognomonic, viz.: the dry crepitous rattle with large bubbles, when very distinct and continuous, or nearly so. To- gether with this sign, (continues he,) we usually perceive, during inspiration and expiration, a sound or sensation as of one or more bodies rising and falling, and rubbing against the ribs." Emphysema of the lungs is a common disease in horses, and is the great cause of what is called broken-wind; and is more common in man than is generally imagined. It is produced by various causes, as lifting a heavy weight: it occurs during the act of bearing down in labour; but more frequency it is a consequence of violent cough- * Forbes's Translation, p. 158. 442 ASTHMA. ing in cases of bronchitic inflammation; indeed, I have scarcely ever witnessed a dissection of a person who died of bronchitis or hooping- cough, without seeing pulmonary emphysema. For a more particular account of these morbid states, the reader is referred to the work of Laennec. There cannot be a doubt that the nervous system has a powerful influence on the functions of the lungs, when labouring under dis- ease, as well as in health; and I imagine no one can deny that asth- ma may be produced, either in consequence of some diseased action in the brain, or in the nerves themselves which supply the lungs. It has been attempted to be shown by Reisseissen and Laennec that the bronchial tubes possess a muscular structure, through the agency of which the air-vessels contract, when under the influence of spasm; but this is not a new idea on the part of Reisseissen or Laennec, for Cullen makes the following statement:—"From the whole of the history of asthma, now delivered, I think it will readily appear, that the proximate cause of this disease is a preternatural, and, in some measure, a spasmodic constriction of the muscular fibres of the bron- chiae, which not only prevents the dilatation of the branchiae neces- sary to a free and full inspiration, but gives also a rigidity which prevents a full and free expiration."—(Par. 1834.) But neither is this an original idea of Cullen's, for it was entertained long before his time by Hoffman and Willis. It is foreign to the object of this work to enter into anatomical controversy, and unnecessary in this instance, for even Laennec states that he had " met with only a very small number of asthmatics in whom there was evidence of pul- monary spasm, without any attendant catarrhal affection; but some few I have met with. On the other hand, I have known a great number of patients, in whom the catarrh, whether dry, pituitous, or mucous, was too slight in degree, or too small in extent, to be consi- dered as the real cause of this asthma."—(Page 412.) Because, perhaps, there might be, in these cases, some organic lesion of the heart and large vessels, or the coexistence of cerebral irritation. These observations lead me to remark, that there is almost always something more in this disease than the original organic lesion in the lungs themselves ; this experience has frequently led me to trace to sudden congestion of the lungs, which flattens the air-vessels, and prevents them from dilating. Various diseases of the heart produce asthma; the most frequent are dilatations of its cavities, diseases of its valves; and aneurism of the aorta, of which more hereafter. Treatment.—From want of attention to the pathological condition of the body, the treatment of asthma has hitherto been uncertain and empirical. Some highly extol one remedy, and some another; some always use the lancet, and others invariably condemn it. Although an advocate for occasional bleeding in asthma, yet I am convinced that no remedy, except the indiscriminate use of opium, has done more mischief. There are two circumstances only in which bleed- ing should be had recourse to: 1st. Where we have evidence of acute action in any tissue of the lungs, superadded to any of the organic lesions already mentioned; 2d. When there is much venous engorge- ASTHMA. 443 ment of the lungs. In old chronic cases, it must always be a doubt- ful, and occasionally, a dangerous remedy. Dr. Bree assures us, that he repeatedly tried bleeding, but does not think the paroxysm was ever shortened an hour by the remedy; and in old people he found it injurious. It maybe mentioned, that Dr. Bree was himself an asthmatic, and after paying much practical attention to the disease, he wrote a treatise upon the subject, which is worthy of perusal. Bleeding must be employed early in the paroxysm, or not at all, un- less the patient is threatened with suffocation. The pediluvium is to be instantly had recourse to, which I have known to arrest a paroxysm; as well as inhaling the vapour of hot water. The apart- ment is to be freely ventilated, and too many people are not to remain in the room. Laxatives are always necessary, as confined bowels aggravate the complaint. Vomiting is a favourite remedy with many, and is useful principally in two cases — when there is evidence of a load of food being in the stomach — and when we know that the disease depends upon chronic bronchitis. In the last case, vomiting will assist in clearing the air-passages of superabundant mucus. In almost all cases, contra-irritation is useful, whether produced by mustard plasters, stimulating embrocations or blisters. Strong col- fee was formerly recommended by Sir John Floyer, from the relief he experienced in his own person, and it has since been highly lauded by his fellow-sufferer, Dr. Bree. With respect to opium, very oppo- site opinions have been maintained. Laennec speaks strongly in favour of the whole class of narcotics, with a view of producing sleep, upon the theory of bringing patients so affected as nearly as pos- sible to the level of bats, and other animals, which hybernate, and consume nearly a hundred times less air when in a state of torpidity- He seems to have been influenced by an idea of producing relaxa- tion of the muscular fibres of the air-tubes, thereby overcoming the spasm of the lungs. The following narcotics are recommended by Laennec—opium, belladonna, stramonium, phellandrium aquaticum, aconitum napellus, colchicum, tobacco smoked or taken internally, cicuta, dulcamara, hyoscyamus. With respect to tobacco, it may be mentioned, upon the authority of Dr. Ferriar, that Baglivi used the "Julapum tabaci," in cases of asthma.* If the disease generally depended on spasm, opium should be use- ful in a great number of cases; but I am convinced, from what I have seen in practice, that it is the most dangerous of all the reme- dies which have hitherto been recommended. Dr. Bree tells us that four grains nearly sent him into the next world. In truth, it is a remedy which must very often interfere with the efforts of the con- stitution for relieving the patient; more particularly in that form of the disease produced by chronic bronchitis, when opium, by allaying the cough, promotes a collection of mucus in the air-passages: hence the common observation, that opiates dry up the expectoration. I have seen some individuals very much relieved by smoking tobacco, and some by smoking stramonium. As the disease is frequently observed to terminate by expectora- ♦ Reflections, p. 204. 444 ASTHMA. tion, the class of medicines called expectorants has been much em- ployed. In fact, if routine practitioners were asked what should be done for a patient in a fit of asthma, they will be found either to order bleeding, or to give an expectorant. 1 have seen them often tried, but very seldom with any good effect. Of this class, squills is much in use, together with the foetid gums. [I have been much pleased with the use of the infusion of vale- rian; and when an expectorant is necessary, liquorice root may be added. Of all anodynes, that which has had the happiest effect in my experience is pure Hoffman's anodyne, given in full doses. In cases attended with a dry cough and great oppression, I have found signal relief to follow the application to the chest of a large poultice of flaxseed and hops, or bran and flaxseed. These ingredients should be mixed with hot water or hot vinegar, until the mass attains a proper consistence, when it should be enveloped in gauze or thin muslin, applied as warm as it can be borne, and renewed every three hours.] After the termination of the paroxysm, tonics are frequently re- commended. Dr. Bree speaks much in praise of a remedy com- posed of nitric acid, hyoscyamus and squills. Some tell us to avoid warm bathing, and to use the cold bath as a tonic during the inter- vals ; the cold bath agrees with some better than the warm, and I have seen both do much mischief. [I have known great benefit to be derived from frequently bathing the feet in hot salt and water; but to, be serviceable during the paroxysm, the bath should be pro- tracted for at least half an hour.] Issues, setons and cauteries have all been used as contra-irritants, and it is worthy of remark, that many fits of asthma have taken place immediately after the disappearance of a cutaneous eruption. I have myself witnessed examples of this kind, and I have been acquainted with asthmatics who were occasionally affected with cutaneous eruptions, and who, although they complained of much distress from the itching and tingling of the skin, were yet contented with their lot, and invariably expressed themselves as being certain of an attack of asthma if the eruptions were repelled. The obser- vation of such circumstances has led me to insist much on the pro- priety of employing contra-irritation in all diseases of the chest, but particularly in those of a chronic nature. The subcarbonate of iron has been recommended, but I cannot speak from experience of its effects. A very dangerous complication of asthma with anasarca occa- sionally takes place; the routine practitioner amuses himself and distresses his patient, by " pumping out the water." But I cannot too strongly condemn this as a general practice, because the reme- dies weaken, sometimes hasten the fate of the patient, and do not reach the root of the evil. Galvanism is another remedy which has been much lauded, not only in this country, but on the continent. Dr. Wilson Philip, to whose exertions in endeavouring to improve the science of medicine, the profession stands deeply indebted, directed his attention to this subject. He made many experiments on animals, in conducting an ASTHMA. 445 inquiry into the laws of the vital functions; and among others, he divided the pneumogastric nerves, in order to diminish the nervous influence in the lungs and stomach; the digestive powers were found to be thereby much impaired or suspended, and dyspnoea was pro- duced. He then directed galvanic influence towards the lungs and stomach, and he observed that the animal could be made to breathe easily, and digest its food. After these experiments had been re- peated and confirmed, Dr. Wilson Philip was naturally led to inquire what diseases depended on a failure of the nervous influence. Judging from analogy and observation, he thought it probable that indigestion and asthma were two, at least, of the number. This is a short view of the circumstances which led Dr. Wilson Philip to expect relief from galvanism in habitual asthma; which name he has given to that form of the disease, in which the breathing is constantly op- pressed—better and worse at different times, but never free—and often continues to get worse in spite of every means we can employ. He states that he used galvanism in many cases, and almost uni- formly with relief, applying as much of the galvanic influence as patients could easily bear. The period varied from five to fifteen minutes before relief was experienced ; and he generally found, that the stronger the sensation excited, the more speedy the relief; he found from eight to fifteen four-inch plates of zinc and copper suffi- cient ; the fluid used, was one part of muriatic acid to one hundred and twenty of water. Some people required more than sixteen plates, and a few could not bear eight. It is a curious fact, that on the first application of galvanism, a person may experience little sen- sation from the operation of twenty-five or thirty plates, yet after- wards he may not be able to bear more than six or eight. He ap- plied it in the following manner:—he placed two thin plates of metal dipped in water, one on the nape of the neck, the other on the lower part of the epigastric region. The wires from the different ends of the trough were brought in contact with the plates; in this way the galvanic influence was sent through the lungs, as much as possible in the direction of the nerves. The operation was discontinued as soon as the patient said his breathing was easy, any further application being found quite unnecessary. We are assured that this means afforded relief to those who had laboured under oppressed breathing for ten or twenty years, as readily as in more recent cases; therefore, we must join Dr. Wilson Philip in taking this as a proof, that no or- ganic lesion existed in the lungs. For further information on this interesting topic, the reader is referred to his work, entitled " Inquiry into the Laws of the Vital Functions."* Whatever differences of opinion exist respecting the nature and seat of asthma, and the treatment proper to be pursued during a paroxysm, all agree in recommending, that the diet of an asfhematic should be light, sufficiently nourishing, and easy of digestion; his clothing warm; and that he should avoid exposure in cold, damp weather, particularly when the wind is in the east. The bowels [* Another and a simpler mode of applying the galvanic fluid will be mentioned under the head of Epilepsy.] 38 446 [PULMONARY C3DEMA.] should be kept easy; but it is proper to mention, that I have known a paroxysm brought on by hypercatharsis as well as constipation. [M. Aboussohn, in a recent memoir, has shown that worms some- times infest the air-passages, giving rise to extreme distress, and to death itself. The worm,ln every instance, has been found to be the ascaris lumbricoides, which, no doubt, passes from the oesophagus into the trachea. The above author cites six cases, and adds, " that there were five in which the accident happened to children between eight and nine years of age, four of whom were girls; the sixth case, however, proved that it may happen in advanced years, (the patient having been 52 years old) when circumstances are favourable to the development of worms. The symptoms differ according to the situation of the worm: when it was in the larynx, the violent pa- roxysms of cough threatened suffocation; when in the trachea, the cough was less intense; there were rather dyspnoea with paroxysms of orthopnoea, and great agitation, vomiting, and incontinence of urine. Death was preceded by convulsions in one case, and in ano- ther was sudden, as if the lung, fatigued by the struggle, was deprived of all nervous influence. The impression of the patient, that a fixed and local obstacle prevents his respiration, is a valuable diagnostic sign. The means to be employed would be, 1. Immediately to pass the finger into the throat to examine if a worm can be felt, and to remove it. 2. Vomiting should be excited. 3. As a last resource, tracheotomy should be performed."*] [PULMONARY CEDEMA. CEDEMA PULMONUM.] [This is an effusion into the cellular tissue of the lungs; when cut into, these organs pour out a frothy serum, are heavier than natural, and pit under the finger. This form of dropsy often accompaniesgeneral anasarca, and especially when the latter is a sequel of scarlet fever. The symptoms are cough, dyspnoea and serous or other mucous ex- pectoration; but there is no mode of diagnosis, not even that derived from auscultation, which is not liable to some fallacy; because the effu- sion is usually a mere consequence and concomitaut of other morbid states which mark this particular condition. The sound on percus- sion is, of course, more or less diminished in clearness and duration; while the respiration, as heard by the stethoscope, is harsh, bronchial, blowing and unequal or circumscribed. The heart's sounds are transmitted with undue intensity.t The treatment of this form of dropsy must depend on its cause and the attendant circumstances; but should the dyspnoea be urgent and sudden, immediate cupping between the shoulders and blistering to the chest in front, with a hot, saline pediluvium, will constitute the most available treatment.] [* Brit, and For. Med. Rev., No. 3, 1836.1 [t Walshe. Physical Diagnosis, p. 133.] PAET IV. DISEASES OF THE CIRCULATING SYSTEM. CHAPTER I. GENERAL REMARKS ON DISEASES OF THE CIRCU- LATING SYSTEM. Diseases of the heart, from their frequency, and the extreme seve- rity of their symptoms, constitute a very important branch of practi- cal medicine. Till the conclusion of the last century, the generality of the profession were very imperfectly acquainted with them, and even now, when so much has been done by the labours of Corvisart, Laennec, Bertin and others, very erroneous notions prevail both with regard to their diagnosis and treatment. On this subject, our common systematic works are particularly deficient, and with the exception of the imperfect Treatise of the late Mr. Burns, no original work exists in English on this interesting and important class of dis- eases ; but it behoves me to mention, that the "original cases" of Dr. Forbes are particularly deserving of attentive perusal; and many valuable papers and cases are scattered through our periodical works, and the transactions of different societies. The utilities of the discovery of mediate auscultation by Laennec, in diseases of the lungs, have been already as fully discussed as the plan of the work will allow. Great advantage may also be derived from the employment of the stethoscope in diseases of the heart. Percussion affords us some assistance, but much less than in many of the affections of the lungs. Some physicians inform us, that the stethoscope is entirely useless in affections of the heart, because, according to their account, we cannot distinguish between organic disease and nervous palpitation, which we confess we cannot always do by the stethoscope alone. These gentlemen seem to forget, how- ever, the impossibility of forming an accurate diagnosis by the com- mon signs or symptoms; and 1 may observe, that they might as well be required to give up the exercise of their profession altogether, as reject the important assistance which we derive by mediate auscult- ation, because it does not in all cases afford an absolute certainty. A common prejudice prevails, that as diseases of the heart are in their nature irremediable, therefore an accurate diagnosis would only lead to despondency and inertness of practice. Slethoscopists deny both the premises and the conclusion; and we insist, that the more accurately we are acquainted with the nature and seat of a disease, the more appropriate will be our practice. I can state, from experi- ence, that much may be done by judicious treatment, not only in alleviating, but in some cases in curing, diseases of the heart. We 38* 450 GENERAL REMARKS ON DISEASES have seen patients labouring under disease of the heart, pronounced to be far advanced in consumption; and others, with disease of the valves, treated for indigestion and gastric irritation; and we have also seen patients labouring under enormous dilatation of the heart, in its last stage, who were laughed at, and treated for nervous or dyspeptic complaints, and recommended to avoid vegetables, and eat beef-stakes; who were urged to use exercise, when the very effort brought on severejlyspnoea, and a sense of suffocation. I shall content myself, at present, by stating one additional circumstance— that it is of the greatest consequence to be able to distinguish simple hypertrophy from dilatation of the heart, because I feel convinced the former is as capable of being cured as almost any other disease to which the animal frame is liable; so that, if there were no other circumstances to uphold us, in making use of the stethoscope, as an additional means of diagnosis in diseases of the heart, this alone should induce every professional man of common feeling and ho- nesty, earnestly to set about acquiring the power of employing the instrument. I blush to confess, that I was formerly one of those who ridiculed mediate auscultation, merely because, on applying the stethoscope once or twice I could hear nothing; but after putting myself under the direction of Dr. Scott, I was able, in the course of a very short time, to discriminate between the sound produced by respiration in a healthy state of the lungs, and that in disease. The contractions of the heart give rise to very distinct sounds, which enable us to study with ultimate success the actions of that organ, and to detect any irregularity or deviation from its natural condition. Before describing the organic changes which the heart undergoes, it is necessary to give a very brief analysis of its natural action as heard and felt with the stethoscope. If we apply this in- strument to the region of the heart, and place a finger on the radial artery, a moment previously to the arterial pulse, the ear is sensible of a slight impulse, accompanied by a somewhat dull, but very dis- tinct sound. Immediately, and without any interval, a clear sound is perceived, resembling that of a valve, or whip, or the lapping of a dog. After this, there is a short but well-marked period of re- pose. In a healthy person, with a well-proportioned heart, and carrying a moderate quantity of flesh, the shock or impulse of the heart can be felt over, or very near, the cardiac region only. In persons who are thin, and the thorax narrow, the impulse is more extended, and may be felt over the whole of the sternum, and occasionally over the left side of the thorax. The sound can generally be heard over the left side, anteriorly, and under the clavicles, but more faintly as we recede progressively from the cardiac region. When more extended, it is heard suc- cessively in the following places: —1. Leftside anteriorly—2. Right side anteriorly—3. Left side posteriorly—4. Right side posteriorly. The intensity of sound is progressively less in the order above mentioned ; but it must be recollected, that a condensed, or strongly compressed lung, transmits the sound better than a healthy one; and when there is much wheezing, the sound of the heart is obscured. OF THE CIRCULATING SYSTEM. 451 Therefore, in estimating the heart's action, we must always take into account the state of the lungs. When the heart can be heard in all the points stated, we may suspect that it is larger than natural, and that it is dilated; for if may be stated generally, that a great extent of sound is a mark of thin parietes; and that a strong impulse, with a confined range of sound, coincides with hypertrophy, or increased thickness in the walls of the heart. By the shock or impulse, we mean the'sensation of percussion which is communicated to the ear on applying it immediately to the chest, over the region of the heart, or through the medium of the cylinder of wood. The degree of impulse is inversely as the extent of the sound, and directly as the thickness of the walls of the heart; when these walls are very thick, the shock is often so great as to elevate the ear of the observer, and may be often perceived even through the garments. When the walls are very thin, no impulse is communicated, even when the sound is very loud. A strong impulse, then, is to be con- sidered as a characteristic of simple hypertrophy;—the absence of impulse, with increase of sound, as an indication of simple dilatation; —sound and impulse conjoined, point out the combination of hyper- trophy and dilatation. It has been stated, that the action of the heart is accompanied by two distinct sounds, and one impulse ; that the first sound is dull and prolonged, and that the second, which immediately succeeds the other, is sharp and clear; after which there is an evident interval. Accompanying the first sound, there is a shock or impulse felt by placing the hand over the region of the heart, which is not synchro- nous with the pulse at the wrist. Much diversity of opinion exists, and considerable discussion has lately taken place, as to the causes of the impulse and sounds, as well as respecting the rhythm or order of contraction of the different cavities of the heart; and it appears that the opinions of Laennec upon these physiological points are erroneous, and must be abandoned. Laennec supposed that the first sound is produced by the contraction of the ventricles, the second by that of the auricles; but Mr. Turner has shown, in a paper published in the 3d vol. of the Ed. Med. Chirur. Transactions, that the con- traction of the auricles always precedes that of the ventricles; thus reversing the almost universally received opinion of the order of the contraction of the different cavities of the heart. Mr. Turner states that the contraction of the auricles is so immediately succeeded by that of the ventricles, that he found it very difficult, if not impossible, to distinguish any interval between them. He thinks, therefore, that the first sound is occasioned by the almost simultaneous contraction of both sets of cavities. Cause of the first sound and impulse.—It is proper to mention, in this place, that the sounds produced by the heart's aciion are not dependent on the contraction or relaxation of the muscular fibres of that organ, but are occasioned by the motion of the blood on the un- even surface of the cavities of the heart; the intensity of the sound being increased by the rapidity of the motion, the roughness of the 452 GENERAL REMARKS ON DISEASES surface over which the blood passes, and the thinness of the muscu- lar structure of the heart. On this point Dr. William Stokes, of Dub- lin, and Mr. Spittal are agreed. After a careful review of all the writings on this subject, and frequent examinations of the action of the heart by auscultation, I believe Dr. W. Stokes's view to be correct, that the first sound and its accompanying impulse, are produced by the motion of the blood propelled into the ventricles by the contrac- tion of the auricles. M. Magendie states, that the two sounds of the heart are owing to the successive impulsation of the apex and side of the heart against the thorax, and that they are quite unconnected with the motion of the blood, or condition of the valves. He further states, that in hypertrophy of the heart to such a degree as to leave no space between the heart and ribs, there is no impulse, and no sounds. These views are erroneous, and have been ably refuted by M. Pigeaux, who has adopted opinions corroborative of those of Dr. William Stokes. Cause of the second sound.—Mr. Turner supposes the second sound to depend on the flapping of the pericardium on the heart. Dr. Williams considers it to be the effect of the flapping of the mitral and tricuspid valves against the walls of the heart. Mr. Spittal is rather inclined to attribute it to the rushing of blood into the ventri- cles, during their elastic dilatation. Mr. Spittal has erred, after ably and successfully refuting the theories of M. Laennec, Mr. Turner, and Drs. Barry and Williams. That he should not have formed a correct opinion as to the second of the consecutive sounds, is not to be wondered at, when we consider that he was misled with respect to the first. But it is with pleasure I seize this opportunity to ex- press the high sense I entertain of Mr. Spittal's talents and zeal in the cause of medical science, and his superior acuteness in ausculta- tion, of which I have several times availed myself in practice. Dr. W. Stokes performed some vivisections in August, 1829, to ascertain whether there is a want of synchronism between the impulse of the heart and pulse at the wrist, at the suggestion of Dr. M'Donnel, of Belfast, who had many reasons for doubting the correctness of Laen- nec's statements concerning the heart, wherein he describes the im- pulse felt at the side as the effect of the contraction of the ventricles. These experiments were performed in company with Mr. Hart, and in the presence of many pupils; the results were immediately made public by both these gentlemen, in their lectures and in private con- versation. They were well known in Dublin many months before the appearance of any other researches on the subject. In the course of these experiments, Dr. Stokes became convinced that the cause of the second sound is the motion of the blood during the contraction of the ventricles, and the dilatation of the auricles; for there appears to be no doubt that the dilatation of one set of cavities takes place at the same moment with the contraction of the other, a fact which was stated some time before by Dr. Barry. I entirely coincide with Dr. Stokes as to the second sound, and his researches will remove many of my doubts as to the possibility of determining disease of the valves and other parts on either side of the heart. If his opin- ion be correct, the sounds produced by disease affecting the auriculo- OF THE CIRCULATING SYSTEM. 453 ventricular valves should be synchronous with the first sound, while those occasioned by disease of the aortic valves should be synchro- nous with the second. The subjects of Dr. Stokes's and Mr. Hart's vivisections were the rabbit and goat. These gentlemen arrived at the following conclusions: « 1st. The process of contraction begins at the auricular, and ter- minates at the ventricular portions of the heart. "2d. The contraction of the auricle in the goat was evidently preceded by that of the sinuses of the vena cava. " 3d. The impulse at the side is produced by the dilatation of the ventricle. " 4th. After the expulsion of the contents of the ventricle, an in- terval of apparent rest occurs, during which, however, the auricles are filling." Having arrived at these conclusions, they next turned their atten- tion to the action of the arterial system. They found, " 1*/. That in the state of health, the impulse of the heart pre- cedes the pulse at the wrist, by an appreciable interval. " 2d. That this interval is more perceptible in proportion to the slowness of the heart's action. " 3d. That the length of the interval is directly as the distance of the vessel examined from the heart. " 4th. That hence the wave of blood at each pulse is progressive through the arterial system, and not an instantaneous impulse, as has been supposed." (Ed. Med. and Surg. Journal, October, 1830.) Certain remarkable sounds, which accompany the action of the heart and arteries, require a few observations in this place. l.y/. The blowing or bellows sound, {bruit de soufflet,) as it is called by Laennec, from its resemblance to the sound produced by that instrument when blowing the fire. This sound, when present in the greatest degree, entirely masks the natural sounds produced by the action of the heart. It is sometimes heard in the subclavian and carotid arteries. 2d. The sound of the saw or file (bruit de rdpe) is another phe- nomenon, occasionally presented by the action of the heart. Both this and the blowing sound were formerly considered as invariably indicating disease of the valves of the heart; and although often present in such circumstances, yet are by no means to be considered as pathognomonic, as they may exist in a slight degree without any organic lesion of the;valves. Laennec states, that the only disorder which appeared to him constantly, or almost so, to accompany the bellows and file sound, was a state of nervous agitation, which, how- ever, was more or less marked by other symptoms. These sounds are not unfrequently met with in young persons of a nervous tem- perament; and, in most cases, we can make ourselves pretty certain that they are owing merely to a nervous affection; for if we examine such patients in a state of repose, no particular sound will be heard; but after violent exercise, or during a state of agitation, they become instantly perceptible: whereas, if they proceed from disease, they will never be entirely absent, although they may be increased by every cause which tends to hurry the circulation, and may be heard 454 [GENERAL REMARKS ON DISEASES at all times in severe cases, even on the back. It appears probable, that even in the pure nervous affections, sounds, resembling those produced by disease of the valves, may hereafter be found to depend upon a congenital disproportion between the heart and the orifices through which the blood passes, and which produces the effect only when the circulation is hurried. Since writing the first edition, I have seen several dissections, which proved that both the bruit de soufflet and the bruit de rdpe, but particularly the former, occasionally depended on hypertrophy, with dilatation of the cavities of the heart, as well as on disease of the valves. Examinations after death have convinced me, that both sounds may likewise be occasioned by disease of the aorta.* Dr. Scott, to whom I am indebted not only for the little knowledge I possess in the use of the stethoscope, but for much valuable assist- ance in writing this part of the work, informs me, that he has ob- served a very peculiar sound during the action of the heart in nervous persons;—it is a slight click or jingle, sometimes resembling the splashing of water in a metallic vessel. The first time he met with this sound, was in a very young woman, in a state of insensibility, where the sound gave the distinct idea of a fluid in the pericardium, agitated by the heart. I have noticed this remarkable phenomenon, also, but am more inclined to attribute it to small quantities of fluid and flatus moving from one part of the stomach or bowels to another. 3d. The purring or whizzing vibration—the cat-purr, may also be briefly mentioned. It is a peculiar sensation communicated to the hand placed on the cardiac region, and which Corvisart consi- dered a sign of ossification of the valves, more particularly the mitral. This vibration is in general confined to the left side of the chest, and though it is no doubt met with in almost every case of considerable contraction of the valves, yet it is sometimes perceived in a slight degree when no organic lesion exists. * [The great interest which has, of latter years, been excited in the * [M. Andral has recently instituted some experiments in relation to these sounds, which afford additional evidence that they often exist wholly independent of a dis- organization or alteration of structure, and that they are consequent to certain changes in the relative proportion of the elements of the blood. He takes, as we shall hereafter see, the proportion of red globules in healthy blood, to be as 127 in 1000 parts, and then states that the causes capable of producing the bruit de soufflet, or bellows sound, are the following:— First, when the globules have diminished sufficiently to be below the cipher 80, the bruit de soufflet exists in the arteries in a constant manner. I have never found a single exception to this law. Second, when the globules have remained above the cipher of 80, the bruit it soufflet can again show itself, but it is no longer constant; we continue to hear it often enough when the cipher of the globules oscillates between 80 and 100; it is met with again, but much seldomer, according as the cipher of the globules passes 100, and finally, it is no longer observed when the cipher of the globules is raised above the physiological mean. Moreover, whatever is otherwise the nature of the disease in which these diminu- tions of the globules exist, the bruit de soufflet of the carotids does not show itself the less; I have proved its existence in the most different cases, putrid fevers, eruptive fevers, pneumonias, acute articular rheumatism, and in a great number of chronic diseases. But in all these cases it only took place with the ciphers of the globules marked above. The bruit de soufflet is often present in women with child, which is in relation with the frequent diminution which the globules undergo in them.—AniJral.—Bama- tologie Pathologique.] OF THE CIRCULATING SYSTEM.] 455 medical profession, in relation to the action of the heart, is familiar to everyone; and the admirable epitome which has been given of the present state of the question, needs little, if any addition beyond the following results of a series of experiments performed by Drs. Pen- nock and Moore of this city. Without attempting to analyze the memoir, published by these gentlemen, I shall merely place before the reader the conclusions to which they arrived, after a most ardu- ous and elaborate investigation: " 1st. The impulse is synchronous with, and caused by, the ven- tricular contraction,—and when felt externally, arises from the strik- ing of the apex of the heart against the thorax. "2d. The expulsion of the blood from the ventricles is effected by an approximation of the sides of the heart only, and not by a con- traction of the apex towards the base; during the systole, the heart performs a spiral movement, and becomes elongated. " 3d. The ventricle contracts, and the auricle dilates at the same time, occupying about one-half of the whole time required for con- traction, diastole and repose. Immediately at the termination of the systole of the ventricle, its diastole succeeds, occupying about one- fourth of the whole time, synchronous with which the auricle dimi- nishes, by emptying a portion of its blood in the ventricle, unaccom- panied with muscular contraction. The remaining fourth is devoted to the repose of the ventricles, near the termination of which the auricle contracts actively, with a short, quick motion, thus distending the ventricles with an additional quantity of blood: this motion is propagated immediately to the ventricles, and their systole takes place, rendering their contractions almost continuous. " 4th. From the termination of their diastole to the commence- ment of their systole, the ventricles are in a state of perfect repose, their cavities remaining full, but not distended, while those of the auricles are partially so, during the whole time. " 5th. The sounds are produced by the motions of the heart or its contents, and not by striking against the thorax, as proved in all the experiments; being much louder when the stethoscope was applied directly to the heart than when to the chest, or with the lungs inter- posed. " 6th. The sounds are more distinct when the muscle is thin, and contracts quickly. Hence the clear, flapping character of the first sound over the right ventricle, as compared with the left. " 1th. The first sound, the impulse, and the ventricular systole, are synchronous. This sound may be a combination of that caused by the contraction of the auricles, the flapping of the auriculo-ventri- cular valves, the rush of blood from the ventricles, and the sound of muscular contraction. When the heart was removed from the body, the ventricles cut open and emptied of their contents, the auriculo- ventricular valves elevated, and a sound, resembling the first, still heard, it may be chiefly attributed to the muscular contraction. That these valves aid but slightly in its production, may also be inferred from experiment 16. " 8th. The second sound is caused exclusively by the closure of the semilunar valves from the reaction of the arterial columns of 456 [GENERAL REMARKS ON DISEASES blood upon them, in its tendency to regurgitate through the aortic and pulmonary orifices. This is proved by the greater intensity of this sound over the aorta than elsewhere, the blood having a strong tendency to return through the valvular opening; by the greater feebleness of the sound over the pulmonary artery, which is short, and soon distributes its blood through the lungs, thus producing but slight impulse upon the valves in the attempt to regurgitate ; by the disappearance of the sound, when the heart becomes congested and contracts feebly; and, finally, on account of its entire extinction when the valve of the aorta was elevated. " 9th. The second sound is synchronous with the diastole of the ventricle."*] Symptoms produced by diseases of the heart and large blood- vessels.—Before describing the different diseases of the heart, a brief enumeration may be given of the general symptoms which accompany these affections. In the early stages, it is of the utmost consequence to form an accurate diagnosis; but the general symp- toms are very nearly similar in all. These are, habitually short and difficult respiration ; palpitation, and a feeling of oppression about the heart on any sudden or violent exertion, as in running or walking up an ascent. The late Dr. Monro was so well aware of this, that before examining a patient suspected to labour under disease of the heart, he was in the habit of desiring him to ascend a flight of stairs quickly. Emotions of the mind frequently induce paroxysms of panting and dyspnoea. Sleep is often disturbed by sudden starl- ings and fearful dreams; there is an anxious cast of countenance, and a marked degree of irritability of temper and restlessness; deter- minations of blood to the head take place; and very generally a disordered state of the digestive functions is observed, indicated by impaired appetite, flatulent distension, irregularity of the bowels, &c, which invariably aggravate the feeling of uneasiness about the heart. Sometimes the patient suffers most violent paroxysms of pain, which are occasionally attended with great vascular action and palpitation, at others with diminished vascular action, and a tendency to syncope. In the last stages, diseases of the heart can in general be recog- nized at a single glance ; the patient is unable to lie down; he there- fore requires to be propped up in a chair or bed ; the face is puffed; the lips are swollen, and display the different shades of colour pro- duced by impeded circulation through the lungs; the legs and scrotum become cedematous, and dropsical effusions often take place into the [* Medical Examiner, No. 44. M. Cruveilhier has yet more recently published some observations on an infant born with its heart completely exposed, and protrud- ing through an aperture in the thorax. It lived twenty-four hours after birth. He found only two conditions of the heart,—contraction and dilatation; that of repose generally mentioned by authors, was completely wanting. During their systole, the parietes of the ventricles became pale, and their surface rugged, and in folds. " The two sounds of the heart," says he, " have their seat at the origin of the pulmonary and aortic arteries, and their cause is the flapping {claquemenl) of the sigmoid valves. The first sound, which coincides with the ventricular systole, and with the dilatation of the arteries, is the result of the replacing (redressement) of the sigmoid valves, probably lowered. The second sound, which coincides with the ventricular systole, and with the contraction of the arteries, is the result of the lowering of the sigmoid valves, pushed down by the reflux of the retrograde blood."— Gazette MedicaU, quoted in Braithwaite s Retrospect, Part 4.] OF THE CIRCULATING SYSTEM.] 457 cavities of the thorax, pericardium, and abdomen. Haemorrhage from the lungs is not uncommon ; and the case sometimes terminates in apoplexy: indeed, diseases of the heart frequently terminate in sudden death. The pulse varies much, according to the particular disorganization: in hypertrophy, for example, it is hard, full, and bounding; in dilatation, feeble, compressible, and irregular in point of strength; in valvular disease, small, and easily rendered intermit- ting by exertion, and by mental emotions. Some of these symptoms are, however, common to other diseases; and those of the earlier stages may depend on disorder of the digestive organs, or may ac- company affections usually termed nervous. It is of extreme con- sequence that these cases should be distinguished, if it were only to save the reputation of the medical attendant, as patients so affected generally die suddenly, at a time when the physician has given a favourable opinion, or, perhaps, lightly estimated the complaints of the patient. With the assistance of the stethoscope and percussion, combined with an accurate study of the individual characters of the case and the constitution of the patient, we shall be able to form a more correct diagnosis than those who trust solely to the ordinary means of investigation. In making our examinations with the stethoscope, we should be particularly careful that the patient is free from agitation, and has been in a state of perfect quietude for some time. Causes of diseases of the heart.—The causes of diseases of the heart are imperfectly known; affections of the lungs, which give rise to long-continued and severe dyspnoea, are, no doubt, among the most frequent causes; they are considered by Laennec as the best ascertained. We know, perhaps, with more certainty, that diseases of the heart give rise to various affections of the lungs, more particu- larly haemoptysis, and pulmonary apoplexy. A disproportion between the diameter of the aorta and size of the heart, was considered, by Corvisart, as a constant cause of dilatation; and it is probable that a congenital disproportion is a frequent cause of hypertrophy. Affections of the mind have been considered as the most usual causes of diseases of the heart; thus, we are told, that during the French Revolution, these affections became much more common than at any previous period. The influence of depressing and exciting passions, in predisposing to disorders of this kind, can scarcely be questioned; but it must be borne in mind, that about the period above alluded to, greater attention began to be directed to this branch of pathology, and in point of fact, these diseases became better un- derstood, and more frequently recognized. Every cause which dis- turbs the balance of the circulation, producing an overload of blood about the heart and lungs, excites this class of affections; hence I have been able to trace it to long-continued intermittent fevers. It would appear that rheumatism is a frequent cause of enlargement of the heart: it is well known, by practical men, that pericarditis some- times comes on during an attack of acute rheumatism. We find that those who have suffered repeatedly from acute rheumatism, not un- frequently fall victims to enlargement or other diseases of the heart. 39 458 [GENERAL REMARKS ON DISEASES In what relation these diseases stand to each other cannot at present be discussed. Gastric irritation is a very common source of disor- dered action of the heart, and, it is probable, often lays the founda- tion of structural disease in that organ. In conclusion, it may be confidently stated, that no subject con- nected with the exercise of the medical profession, deserves more attentive investigation, or presents more extensive views of deep practical interest and importance. [ON THE MORBID CONDITIONS OF THE BLOOD.] [Every practitioner is accustomed to notice certain familiar changes which the blood undergoes in various diseases; and, although obser- vations of this kind are as old as the oldest medical records, we have not, until lately, been made acquainted with the precise nature of these changes, and the pathological conditions on which they depend. Among the most laborious and successful inquirers into the varia- tions which the blood undergoes in diseases, is M. Andral, whose name is honourably blended with every department of pathological research. He has published the result of his observations in a volume which has just been very ably translated into the English language, by two gentlemen of this city;* and from this instructive volume I shall take the liberty of collecting and arranging the more important facts, and, especially, those that have a practical bearing. The first requisite, in this inquiry, is to bear in mind the relative proportions of the three grand constituents of the blood in its healthy state,—febrine, red globules, and serum. The average proportion of fibrine is found to be only three parts in a thousand; but M. Andral states that the quantity may, and does vary from 25 to 35 in the healthy state. The proportion of red globules is as 127 to 1000; the maximum may be stated at 140; the minimum at 110; but the former is asso- ciated with plethora, which, in the progress of development, becomes a strictly morbid condition. The mean of the solid materials of the serum, which are composed almost entirely of albumen, is 80 in the 1000 parts of blood. One of the pathological conditions of the blood is a change in the relative proportion of its three parts. " The normal elements of the blood," observes M. Andral, " in which the present state of our knowledge enables us to trace these changes of proportion, are the globules, the fibrine, the albumen of the serum, the different or- ganic materials, other than the albumen, and which are found in the serum, (fatty matter and others,) then the inorganic principles con- tained in the blood, and, in particular, the free alkali, its different salts, and its water, "t [* Pathological Hematology.—An Essay on the Blood in Disease. By G. Andral. Translated from the French, by J. F. Meigs, and Alfred Still*, M. D. Philadelphia, [t Page 37.] OF THE CIRCULATING SYSTEM.] 459 Again, independently of this change of proportions, the principles of the blood may become modified in relation to their size and phy- sical properties. Lastly, new principles are sometimes developed in the blood, which, though foreign to its healthy condition, have their analogies- in other parts of the organization; such are pus, milk, &c, which are sometimes found in the blood. With these few preliminary re- marks, we proceed to inquire into the condition of the blood in dif- ferent diseases, without attempting to introduce those numerical statements and experimental operations, which give so much value to M. Andral's researches, and for which the reader is necessarily referred to the work itself. OF THE BLOOD IN PLETHORA. The proportion of fibrine is not appreciably increased in plethora, nor is there any remarkable change in the organic materials of the serum; but the peculiar character of plethora is derived from the augmented proportion of the globules of the blood, and the much smaller quantity of water that it contains; whence its high colour, the large and moderately firm clot, and the absence of the buffy coat; or rather the latter depends upon the small proportion of fibrine relatively to the globules. This condition modifies the healthy action of the organs ; all the functions are more active; digestion is rapid; respiration is favoured by the great development of the cavity of the thorax; the heart beats forcibly, and the circulation is rapid. Plethoric individuals are subject, as every one knows, to certain symptoms, as vertigo, tinnitus aurium, preternatural heat in the head, &c, which M. Andral explains to arise not from congestion of blood in the brain, but from the passage of an excessive quantity of the globules of the blood through the vessels of that organ. OF THE BLOOD IN ANEMIA. The fundamental character of anaemia is a diminution, in various degrees, of the globular element of the blood; for the fibrine and solid matter of the serum present their natural proportions. This remark holds good both in respect to spontaneous anaemia, and that which results from haemorrhages; so, also, in pregnant women who become anaemic, the globules alone diminish. Again, men are some- times attacked with spontaneous anaemia, which presents all the cha- racteristics of the chlorosis of women, but the blood assumes the same proportions we have already mentioned. It is a curious fact, that the clot of blood is not unfrequently seen buffed in chlorotic patients and in persons of both sexes who are subject to anaemia; whence M. Andral and others have inferred that the buffy coat is not always an evidence of the presence of inflammation. When the blood is deprived of a certain proportion of its globules, the patient suffers with extreme prostration, various nervous symp- 460 [GENERAL REMARK8 ON DISEASES toms, and impaired digestion, respiration, and circulation. More- over, it is not uncommon to meet with persons of a florid complexion and seemingly plethoric habit, who have, nevertheless, a deficiency of red globules. " Observe, in effect, such individuals a little more closely, and you will be struck with their feebleness; they will have, as in the most advanced anasmia, vertigo, dyspncea, and palpitations upon the slight- est effort; they will bear with difficulty any kind of exertion, and still worse venesection, which, far from diminishing, will increase their symptoms."* We must not, then, forget, adds the author, that at the commence- ment of every disease, the blood may present two great modifications in its globules, one of which belongs to plethora, the other to anaemia. It is upon a variation of increase or diminution in the cipher of the globules that depend the peculiar symptoms then observed, and which are superadded to those of the disease. OF THE BLOOD IN FEVERS. In the entire class of pyrexia, the fibrine never augments in quan- tity, provided they are not complicated with strictly inflammatory affections ; and, in fact, it sometimes diminishes to a point unknown in any other acute disease. It is not even augmented by the pre- sence of the variolous eruption, nor by the dothinenteritis of typhoid fever. There are some fevers which naturally tend towards a favourable termination; while there are others which, from their very com- mencement, are attended by symptoms indicative of extreme irregu- larity of the entire organism, and which threaten dissolution itself; under these circumstances, the blood has been observed to present a peculiar appearance, verging to decomposition; whence the terms putrid, adynamic and typhoid fever. The true typhoid fever is thus characterized more or less from its commencement, and in its severer forms is a proverbial illustration of this pathological state. This alteration of the blood consists of a diminution of t he fibrine ; and is therefore the reverse of what takes place in the phlegmasia?. The blood, when drawn, presents the following appearances : the serum and the clot are imperfectly separated from each other, whence it happens that there seems to be but little serum in proportion to the clot. The latter is voluminous, often filling the whole breadth of the containing vessel. "Its consistence is always slight; it is torn and broken with the greatest facility; and there are some cases where even by the slightest pressure, it may be reduced to a true condition of diffluence; it ceases then to form a single mass, and is divided into a number of grumous portions, which mix with the serum and colour it of a more or less deep red."t The network that kept the globules together and which, by its power of contrac- tion, squeezed out the serum, remains only in an imperfect state; [* Page 49.] [+ Page 5i> 55j OF THE CIRCULATING SYSTEM.] 461 whence also the great size of the clot, which is found to be in an in- verse proportion to its density. It is manifest, moreover, that the size of the clot is in part due to the larger proportion of globules it contains, for these, in place of diminishing like the fibrine, are some- times become remarkably increased in quantity. Another peculiar- ity of the blood, in idiopathic fevers, is the absence of the buffy coat; and M. Andral avers that he has never met with this appearance in inflammatory fever, in typhoid fever, whether of a mild or a severe form, in measles, scarlatina or in small-pox, unless there was some phlegmasial complication. In fact, the specific cause of pure pyrexial diseases " acts on the blood in such a way that it tends to destroy its spontaneously coagulable matter, while the cause which produces the phlegmasia} tends, on the contrary, to create in that fluid a fresh proportion of that matter." Finally, in reference to the pyrexiae, we shall merely observe the curious fact that the diminu- tion of the red globules does not lower the temperature of the human body; which is also true in those cases wherein the blood loses a portion of its fibrine. So far is the temperature from falling under these circumstances, that it may experience an augmentation of several degrees. THE BLOOD IN INFLAMMATION. In the true phlegmasie, observes M. Andral, there is an excess of fibrine relatively to the globules, which is the reverse of what takes place in typhus. The clot is smaller, dense, and of greater consistence, and, if properly drawn, presents a buffy coat of variable thickness ; a character which uniformly, except only in cases of anae- mia, is indicative of the presence of inflammation; for, while, in the phlegmasia?, the proportion of globules is unaltered, the fibrine becomes redundant, and the buffy coat reaches its full develop- ment. This phenomenon will result in every inflammation which is attended by fever, and notwithstanding the constitution may have been exhausted by chronic disease, or a more or less complete state of anaemia has been established, the fibrine will, nevertheless, be augmented under the influence of whatever inflammation may supervene; and this result follows whether the subjects of acute in- flammation are strong or feeble, of a sanguine or of a lymphatic temperament.* The fibrine will thus increase to a point between 6 and 8 in the 1000 parts of blood; it will less frequently augment to 8 and 9, and in rare instances has reached 10h, which M. Andral regards as the maximum; while the minimum is a point between 4 and 5. Even the stomatitis, which follows the free use of mercury, presents no exception to the preceding law. If any part of the mucous mem- brane of the digestive apparatus, from the fauces to the end of the colon, is attacked with a sufficient degree of inflammation to excite to fever, the fibrine is increased to 5, 6 and 7, but never higher; while [* Page 65.] 39* 462 [GENERAL REMARKS ON DISEASES we have already adverted to the highly interesting fact, that this increase does not occur when the inflammation, seated in the follicles, exists only as one of the elements of a general disease,—typhoid fever.* THE BLOOD IN HAEMORRHAGE. Every haemorrhage diminishes the proportion of globules in the blood, but unless very prolonged or copious, it has no appreciable influence on the fibrine; in other words, the blood does not differ from that observed in the pyrexiae, and never presents the buffy coat unless attended by some local inflammation. THE BLOOD IN DROPSIES. In simple dropsy the unvarying rule is that the effused serosity, even while it retains the same materials as the serum of the blood, contains a greater proportion of water, and much less of the organic principles, and especially of albumen. Thus in sixteen cases report- ed by M. Andral, he found the maximum of albumen to be 48, the minimum 4; so that this principle of the blood in no instance equaled the proportion that belongs to true serum. When the effusion of se- rosity has been excited by an inflammatory process, as in the drawing of a blister, the proportion of albumen is greatly increased. On the other hand the fluid, which is sometimes effused in hydatids of the liver, is as limpid as pure water, and shows no trace of albumen, even by the most delicate tests. THE BLOOD IN ORGANIC DISEASES. The mere secretion of tubercles, cancer and encephaloid matter, and the development of hydatids, do not augment the fibrine. So long as tubercle and cancer are unconnected with inflammation, the fibrine remains unaltered. " But as the softening of these hard masses ad- vances, and a process of elimination analogous to inflammation is set up around them, the blood becomes more and more charged with fibrine ; so that the excessive formation of this principle is not due to the development of the accidental production, but wholly to the inflammation excited by the latter at certain stages of its existence. This is a new proof to be added to the many others which show that the process engendering the different accidental productions, such as tubercle, cancer, melanosis, hydatid, &c, is not of an inflammatory nature."t The blood in incipient phthisis always presents a diminution of red globules, varying from 122 as the maximum, to 99 as the mini- mum; so that such persons are in a state of commencing anaemia, [* Page 71.] [t Page 119.] OF THE CIRCULATING SYSTEM.] 463 their blood having the character which results from repeated bleed- ings. In the advanced stages of phthisis the globules become less and less in proportion, until they frequently fall as low as 80; and M. Andral mentions a solitary example at 72. Is it not strange, he in- quires, that in chlorosis, without any appreciable alterations of the lungs, or other solid, the globules should even fall lower than 30, while their minimum is at 72 in a disease which it should seem that the state of the lungs could hardly permit the formation of the blood at all ? And yet not only do the globules not diminish as much as might be expected, but, when even a large part of the lung is de- stroyed, the fibrine increases, and the temperature of the body may rise, just as in typhoid fever, or acute pneumonia."* OF THE BLOOD IN THE NEUROSES. Clinical observation has long since demonstrated that one of the most frequent causes of nervous diseases is a certain feebleness of constitution; whence the scantiness of the globules in these affections. "Now it is well known that the increase or decrease of the globules of the blood indicates the vigour or feebleness of the constitution. If the globules be diminished, either by depletion or by insufficient nourishment, the nervous disorder will'certainly be aggravated ; but if the opposite course be pursued, in all probability the nervous af- fection will be mitigated. In this way may be explained the happy influence which the ferruginous preparations and substantial and nutritious food exert upon the termination of certain neuroses: and it is because the globules are inevitably diminished by depletion and diet, that we so often see such disturbance of the nervous functions follow great loss of blood, and a too prolonged abstinence from food."t In conclusion, I may repeat, that this abstract, while it may serve to show the practical importance of the work of M. Andral, should not be allowed to supersede the work itself, which is worthy of the careful perusal and study of every member of the medical profession.] [* Page 123.] [t Page 129.] CHAPTER II. PALPITATION, AND ANGINA PECTORIS. PALPITATION. By this term I mean the occurrence of an unusually strong and frequent pulsation of the heart, without any organic lesion; the pal- pitations produced by disease of the heart itself are to be considered afterwards.* The affection now under consideration is to be regard- ed as purely nervous, occasioned by excessive indulgence in various passions, by mental emotions, and very frequently, by a disordered state of the stomach and bowels. Stimulants of all kinds, violent exercise, excessive depletion, occasionally produce it. Palpitation is more readily excited in persons of a nervous and sanguine tempera- ment; when first observed, the affection is generally slight and tran- sient, but by frequent repetition, the organ at last becomes so irritable that the least circumstance reproduces it. Nervous palpitations are frequently very distressing, even when the body is in a perfect state of repose ; particularly during the first part of the night, and often prevent sleep for many hours. The ac- tion of the heart is not only accelerated, but increased in impulse and sound; sometimes the action is tumultuous, and occasionally so strong, that the person affected feels it painfully. There is some- times a sensation of internal agitation, particularly in the head and abdomen, and, as happens in hysteria, the urine is copious and lim- pid. [The pulse is extremely irregular, and often intermittent. In the language of Dr. Abercrombie, there is a series of quick, weak, flut- tering, irregular beats, with slight anxiety, acceleration of respira- tion, and a grieving sensation in the epigastrium, all which may con- tinue from a few minutes to an hour, or several hours, recurring at long intervals, or they may be of constant repetition throughout the day. A yet greater degree of the affection amounts to a fit of palpi- tation, consisting in increased impulse, sound and frequency of the beats, sometimes with irregularity, and generally with more or less [* Mr. Teale calls this affection Neuralgia of the Heart; but adds, that he uses the term neuralgia in an extended signification, so as to embrace not only those condi- tions which are accompanied with pain, but various other morbid stales of the func- tions of nerves.— On Neuralgic Diseases, fyc, p. 42.] [PALPITATION.] 465 anxiety and dyspnoea; there may also be pain in the region of the heart, with constriction of the chest, and flatulent eructations.] Nervous palpitations are not to be neglected, as by frequent repe- tition they may lead to disease of structure, either in the heart itself, or in some other organ. Laennec says, that he has never seen any proof of the accuracy of this opinion, but I think I have. According to Laennec, in nervous palpitation, the first impression conveyed by the stethoscope is, that the heart is not enlarged. The sound, though clear, is not heard loudly over a great extent, but this very much depends upon the thickness of the parietes of the chest. In thin people, I hear the sound during palpitation, in every spot on the anterior part of the chest; and when the heart is acting very vio- lently, I have perceived it in the back also. With respect to the im- pulse, Laennec states, that in the nervous affection, the head of the observer is never sensibly elevated. This, he says, is the most im- portant and certain of any sign, when taken in conjunction with the frequency of the pulsations, which are always quicker than natural, most frequently from 84 to 96 in the minute. 1 have seen and felt the impulse of the heart in nervous palpitation, not only elevate the head of the observer, but raise the bed-clothes. Dr. Ferriar, one of the most accurate of observers, in detailing a.case of violent palpita- tion of the heart, states, (p. 205, vol. 1st,) "Every stroke of the pul- sation raised her clothes, so as to be visible at some distance;" under the use of castor, with attention to her clothing and diet, she reco- vered "in the course of a few weeks." In this affection, there are rarely any signs of determination of blood to the head or chest. It is rare that palpitations, produced by functional derangement of the heart, continue long at any time: they are in general transient, and are perhaps less troublesome when the patient is taking exercise in the open air than at other times. When of long continuance, and without intermission, they will, for the most part, be found to depend on some organic lesion. I have paid great attention, for the past few years, to what are called nervous palpitations, and have been astonished at their extreme frequency. I have made it a rule to interrogate every patient on this subject, and am satisfied that at least one fourth of the whole num- ber suffers with irregular action of the heart. It is even common in infancy; and although the patient may be too young to describe his feelings, the intermittent pulse detects the irregularity of the heart's action. It is more frequent, however, in latter life, in women than in men, in the old than in the young, in those of a relaxed and irri- table habit than in the robust. It is familiar to dyspeptic persons, in whom I have known it to be very.harassing when the stomach was empty, for example, just before dinner: under such circumstances, moderate eating relieves the palpitation; but if the patient continues to eat to repletion, or indulges in stimulants, so as to render diges- tion laborious, the palpitation not only returns but is greatly aggra- vated. Mr. Teale refers this disease to a morbid state of the cervical gan- glia of the sympathetic nerve. He also remarks, and I think with great truth, that " palpitations purely nervous are principally distin- 466 [PALPITATION.] guished from palpitations dependent upon organic disease of the heart, by the absence of other symptoms which denote a change of structure in that organ. In hypertrophy the pulsations of the heart are more vehement and more uniform: in dilatation they are felt over an unnatural extent of the chest; when there is obstruction to the circulation from contracted orifices, from loss of function in the valves, or from morbid alterations of the muscular structure, there are generally, in a greater or less degree, blueness, oedema, &c."* Dr. Hope has pointed out several varieties of inorganic palpita- tion, which are the more important, because the treatment is differ- ent, and even opposite. 1. Palpitation dependent on dyspepsia, hypochondriasis, hysteria, latent gout, mental perturbations of all kinds, and depressing ex- cesses, constitutes the first variety, and embraces a very large class. This affection may be readily distinguished from that which occurs in disease of the heart, by the occasional nature of the palpitation; by its being relieved, instead of excited, by active exertion ; its ap- pearance while the patient is at rest; by a fluttering sensation in the epigastrium ; by the general prevalence of nervous symptoms, which aggravate the palpitation; by the regularity of the pulse in the in- terval between the paroxysms; and by the absence of valvular and aortic murmurs, and of undue impulse. 2. Palpitation from anemia,—a term which is now adopted for a peculiar condition of both sexes, but which was formerly restricted to the female constitution, under the name of chlorosis. This part of the inquiry we shall postpone for consideration in a future part of the work. 3. Palpitation from too stimulant diet. Dr. Hope has particularly remarked this condition in young men who abandon active exercise in the country, where they have indulged a full diet, and come to reside in large cities, and to follow sedentary pursuits, without adapting their diet to the change in their habits. A febrile excite- ment takes place, with an accelerated pulse, whitish tongue, consti- pation, flushed face, with throbbing in the head, and sometimes of the whole body. Palpitation is induced on slight exertion, mental emotions, &c. This is, perhaps, the most manageable of the several forms of this malady. 4. Palpitation from plethora. This condition is closely analogous to the one just described. It occurs in persons of a plethoric habit, who continue to live full, without the use of active exercise. In fact, the symptoms proceed from an engorged condition of the heart and whole vascular system. Treatment.—If we have careful reference to the several varieties of this affection, we shall find it necessary to vary the treatment according to the characters of each. When it arises from too stimu- lant a diet, or from any other irregularity of living, the treatment is too obvious to require further explanation than is contained in the chapter on dyspepsia. So, also, when it occurs in persons of a full habit.] [* Treatise on Neuralgic Diseases, p. 44.] ANGINA PECTORIS. 467 Venesection, or the application of leeches, is sometimes advisa- ble, particularly in young plethoric individuals, who are affected at the same time with some febrile movement. French practitioners recommend the application of leeches to the anus in nervous palpi- tations. Laxatives, cold or warm bathing, moderate exercise in the open air, light nourishing diet, early hours, and avoiding the excit- ing cause, will usually be found successful, especially in those cases which present a divided nervous or anaemic character. When the affection, however, resists these remedies, various antispasmodics have been recommended, as opium, ether, musk, castor, and vale- rian; of all these, perhaps the best is the volatile tincture of valerian. [I have somewhere seen it asserted that twelve grains of camphor, given in divided doses through the day, will quiet the most tumul- tuous inorganic action of the heart. When palpitation can be traced to spinal irritation, Mr. Teale's plan of applying the remedies to the spine itself should not be omit- ted. It must, however, be acknowledged, that although leeching, cupping and blistering to the spine will sometimes relieve, and even remove the palpitations for a time, yet they are very liable to recur; and most persons seem rather disposed to bear them than to submit to the frequent repetition or long continuance of active counter-irri- tation. I am convinced that long travel, and active occupation of body and mind, avoiding, of course, excessive fatigue and over-ex- citement, are the most certain means of counteracting nervous pal- pitations. In one instance considerable relief was obtained by wear- ing a broad belt, so as to compress and support the lower part of the abdomen.] ANGINA PECTORIS.—NEURALGIA OF THE HEART. This dreadful disease generally makes its attack in the following manner: It is commonly first felt when an individual is walking up hill; he is suddenly and unexpectedly seized with an agonizing sen- sation in his breast, a little to the left of the sternum; he experiences a sense of constriction and suffocation, which obliges him to stop. After a little rest, these symptoms disappear, and he flatters himself that it is nothing more than a common stitch in the side, from walk- ing too quickly. I have known a person fall down in a state of temporary asphyxia, even in the first attack; those affected in this manner fancy that they have merely fainted from excessive pain. Several such attacks may take place in the course of a few years, or even a few months, the paroxysms continuing only for one or two minutes, and the person thinks nothing further of them. In the course of time, however, they return more frequently ; the pain be- comes more and more excruciating, and the paroxysms continue longer. In the early part of the disease, exercise seems to be re- quired to bring on a paroxysm, but when more advanced, every little excitement or exertion of mind or body, or eating an indigestible article of food, produces an attack ; at last, the paroxvsm comes on without any assignable cause, even when in bed, and during sleep. 468 ANGINA PECTORIS. •At the first onset of the disease, the pain is usually confined to the breast, in the region of the heart; afterwards it extends towards the shoulders, and frequently affects the superior extremities down to the wrists. I had a gentleman under my care, who complained of the pain extending from the breast to the arms, stopping exactly at the insertion of the deltoid muscle on each side. In severe cases, the patient is pale, perhaps quite ghastly—his features contracted — his eyes hollow—his countenance expressive of the most dreadful suffering;—his body perhaps cold, and covered with a cold clammy sweat;—his respiration is quick, but free; that is to say, the patient can, if you desire him, occasionally take in a deep inspiration. In such cases, the pulse is in general slow, and so contracted and weak as scarcely to be perceptible; but this varies much, for in other in- stances, particularly when the skin is warm, and the face flushed, the pulse is quick, strong and irregular. I have seen cases in which it was perfectly natural in strength and number of pulsations during a paroxysm. In slight cases, the whole paroxysm is sometimes over in half an hour; in others, in an hour; and it ceases often with a discharge of flatus from the stomach and bowels. Sometimes it disappears sud- denly leaving no sense of uneasiness behind; at others, considerable soreness remains in the chest for several hours or days. In the most dreadful cases, the patient never feels entirely free from uneasiness and constriction in the chest, and he dreads making the least exertion. In the year 1826, I was requested, by one of my pupils, to see a gentleman who had had several attacks of this disease, and was then labouring under one of the most severe paroxysms I have ever wit- nessed, which had continued for several days before my visit. It was most afflicting to see a strong and a brave man weeping like a child, and imploring relief in the most impassioned strain. An interesting case of angina pectoris occurred in my dispensary practice in the year 1828. The patient was carefully attended by the late Dr. T. Briggs,* formerly of Liverpool, from whose notes the following particulars are taken :—James Terry, aet. 38, a remarkably tall and athletic man, by trade a sawyer, habits temperate. Has been ill three years; his complaints began with occasional fits of palpitation, and severe pain in the region of the heart; but he was able to continue at his work for the first three months. He was then obliged to relinquish his occupation from the frequency and violence of the paroxysms, which were most severe when walking, or making any unusual exertion. He found relief by pressing a walking stick strongly against the breast during the fit. His symptoms have be- come progressively worse: he has been under the care of many medi- cal gentlemen, and has been put under the influence of almost every * Dr. Briggs'benevolent and enterprising spirit led him to join the late expedition to Africa, where he fell a victim to disease ; and I regret to learn, that an effort has been made to tarnish his reputation by some one connected with the enterprise, by way of accounting for its failure. But it has not produced the desired effect. His aged parents may rest assured, that notwithstanding the wicked attempt to throw odium upon their son, his memory will be long cherished by all who had the pleas- ure of knowing him. ANGINA PECTORIS. 469 known remedy. Mr. Liston ordered him to be bled twice, and blis- tered many times, without relief. In the infirmary of Edinburgh, under Dr. Alison's care, he was bled again, and took mercurial medi- cine till the mouth was made sore, with temporary benefit. But in a fortnight he became as bad as ever he had been, and Dr. Alison advised him to go to the country. In continuing the history of the case, he stated that a gentleman punctured " the bag of his heart" and blew air into it; "but 1 understand," says Dr. Briggs, "that the air was injected from a bladder into the cavity of the left pleu- ra, and was taken out next day." Terry is now (13th Nov. 1828) seldom free from violent pain in the chest, which he compares to that produced by boiling water ap- plied to the body. The pain shoots down the arms to the wrists ; it is always brought on by any muscular exertion, during the act of eating or drinking, and voiding stools or urine, and by lying down in a recumbent posture. He is always worse during the night. The violence and extent of the pain can be diminished by taking a deep inspiration, and keeping the lungs distended, and by pressing the chest with considerable force against the back of a heavy old-fash- ioned arm chair which he keeps for the purpose, and in this posi- tion he generally spends the night. The inferior extremities are cedematous, and greatly enlarged. Appetite good ; but he eats very little, and that slowly, in consequence of the exacerbation of pain during the act of swallowing. Digestion appears to be perfect, and the state of the bowels regular. The heart's impulse is very great —it shakes the whole frame, and when the patient leans over the chair, the pulsations may be counted by the violent motion of the heart against the posterior part of the thorax. Over every part of the thorax there is a sound like the rushing of water, corresponding to the contractions of the heart. This sound masks all other sounds, even that of respiration; and a similar sound is perceived by apply- ing the ear over any considerable artery. The pulse is strong and full—it vibrates against the finger, imparting a sensation as if the artery were ready to burst. The pulse, which is sometimes stronger in one arm than the other, generally beats 60 in a minute—now and then there is a double beat, as if an additional pulsation were inter- posed; during a paroxysm the pulse is suddenly quickened so as to beat 120. At this period the patient's sufferings were occasionally mitigated by large doses of the wine of colchicum, and tincture of hyoscyamus; but he soon gave up these remedies, from the languor and drowsi- ness they occasioned. Death took place early in the morning of the 9th December, having complained for some time previously of severe pain in the right thigh and knee, which were intensely swol- len from effusion in the cellular substance. Before his death, he talked calmly of the event which was to terminate the most severe bodily suffering I have ever had the misfortune to witness; and he desired his wife to allow me to take away any part of his body that might be found diseased on dissection. The examination of the body took place on the following dav 10th December, 36 hours after death. 40 470 ANGINA PECTORIS Putrefaction had already made great progress; the cuticle was everywhere loose, and the body crepitous from air in the subcu- taneous cellular tissue. The lower extremities and scrotum were tense from cedema. The thorax capacious and well formed, only it was deeply indented by the constant pressure on the chair. On opening the thorax, the pericardium, containing a heart of enormous size, seemed to fill the chest, and concealed the other con- tents. It lay obliquely across, occupying a space of about fourteen inches, extending from the 7th left rib to the 1st on the opposite side. In size it resembled a large ox's bladder fully distended. The right lung, compressed into a narrow space, adhered firmly to the sur- rounding parietes everywhere, except in the antero-superior part. It was greatly engorged with blood, but upon minute examination, was found healthy in structure. The left lung, free from adhesions, was found compressed into a small space also. The heart was then carefully removed, when the fore part of the bodies of five or six of the dorsal vertebrae were observed to be partially absorbed by the pressure of the heart. On opening the pericardium, it was found to contain a small quantity of serous fluid, and some bubbles of air; its coats presented a natural appearance, and there were no adhesions with the heart. The heart appeared to all present to be about the size of that of an ox—it was enlarged in every part, and the left auricle and ventricle were fully distended with blood. Both auricles and ventricles were in a state of hypertrophy, and greatly dilated; the left ventricle contained more than twelve ounces of blood. The orifices were all remarkably dilated also, but the valvular apparatus was found in a sound state. The size of the aorta was not much, if at all, increased from the arch; its internal surface was vividly red, as were the mucous membranes in every situation. The heart and pericardium, forming two dried preparations, are preserved in my museum. Angina pectoris rarely attacks people under forty ; gouty subjects, and those who are corpulent, seem to be more liable to it than others. It appears to attack men more than women; and I believe that sedentary habits create a predisposition to it, as well as long-con- tinued and very violent bodily exertion. Appearances on dissection, and pathological remarks. —This dis- ease has attracted considerable attention on the part of pathologists to ascertain its nature and seat, since it was first noticed by Dr. Heberden, in 1768, in a paper contained in the 2d vol. of the " Trans- actions of the College of Physicians" of London. Subsequent writers have committed a great error by attributing angina pectoris to one particular disorganization : thus, one has attri- buted it to ossification of the cartilaginous extremities of the ribs, a second, to ossification of the valves of the heart; a third, to fat accu- mulated about the heart; a fourth to dilatation and hypertrophy of the heart. Dr. Parry supposed that it depended on ossification of the coronary arteries;—Dr. Haygarth, on inflammation of the medi- astinum;—Dr. Hooper, on diseases of the pericardium;—and there are many who think it is produced by asthma. Dr. Hosack, an American physician, is of opinion that it most frequently arises from ANGINA PECTORIS. 471 general plethora, more particularly "from a disproportionate accu- mulation of blood in the heart and large vessels." I have seen each of these morbid appearances on dissection, in subjects who were never affected with angina pectoris; and it has been alleged, that patients have died suddenly from this affection, in whose bodies not the slightest trace of disease of any kind was perceptible, which has led some to assert that it depends upon scrofula, syphilis, a nervous temperament, or a peculiar affection of the par vagum. Dr. Parry's opinion seems still to have great weight with many in the profession; but it may be mentioned, that I have seen two cases in which the coronary arteries were extensively ossified, and a third, in which they were completely so, and yet none of the patients had symptoms of this disease. A remarkable case of the same kind, which hap- pened many years ago, is detailed in the 1st vol. of the "Medical Communications," by Mr. Watson. In justice, however, to the memory of Dr. Parry, it ought to be stated, that he did not attribute the disease to the effects of ossification of the coronary arteries alone, for he distinctly states, that the symptoms show that an accumulation of blood takes place about the heart and large vessels. This state- ment goes so far to confirm the opinion of Dr. Hosack, which Dr. Forbes assures us is more in accordance with his own observation than any of the other opinions; but he adds, that "in persons sub- ject to this complaint, in whom no severe organic disease of the heart existed, I have generally found, by auscultation, that the organ was possessed of thin parietes and feeble powers."* In my work on "Puerperal Fever," which was published in the year 1822, a case of angina pectoris is recorded, which was evidently produced by an accumulation of blood in the heart and large vessels. The life of the individual appears to have been saved by timely blood-letting; thir- teen years have now elapsed, and there has been no tendency to a return of the disease. [Angina pectoris is now regarded, in accordance with the views of Laennec, as a neuralgia of the nerves of the heart, mostly connected with some organic lesion of that organ, and certainly always aggra- vated by such lesions. But here again pathologists differ as to the nerves involved in the affection, Desportes referring it to the pneumo- gastric nerve, and Laennec to the filaments which the heart derives from the sympathetic. M. Bouillaud thinks the pain is seated in the phrenic and intercostal nerves. There is no reason why it may not be sometimes in one of these nerves, sometimes in all; and be propa- gated to others, as Dr. Hope remarks, by sympathy or anastomosis, viz: "to the superficial cervical plexus and its anterior thoracic branches, whence proceeds the pain in the neck, and on the surface of the chest; to the branches of the brachial plexus, especially the ulnar, whence arises the pain descending to the elbow, and some- times to the fingers; finally to the branches of the lumbar and sacral plexus, whence the pain and numbness felt in the thighs and legs, and even in the spermatic cord and testicles."t] Treatment.—The symptoms of angina pectoris occasionally ac- * Trans, of Laennec, p. 692. [t Hope. Diseases of the Heart, p. 465.] 472 ANGINA PECTORIS. company such a variety of organic lesions, and take place from what, to all appearance, may be considered a neuralgic affection, that it is scarcely to be wondered at that so many remedies have been re- commended, and so few found serviceable. If there be marks of general plethora, with or without an organic affection of the heart, blood is to be taken from a vein, particularly if there be signs of an accumulation of blood either in the heart or lungs; at the same time, we must be careful to restore the heat of the body, if it be below the natural standard. 1 have so frequently seen a neglected state of the stomach and bowels precede an attack of an- gina pectoris, that I consider it of the greatest importance to clear out the primae viae as speedily as possible. Should the attack come on soon after a meal, an emetic is to be prescribed; if not, purgatives are to be had recourse to, and repeated at short intervals. I have seen leeches serviceable, as well as the application of a large mus- tard plaster over the praecordial region. Long-continued contra-irrita- tion on the chest, with tartar-emetic ointment, is to be persevered in for a considerable time, and repeated at intervals, upon the least un- pleasant sensation in the chest. It is a great matter to be able to say, whether or not there be any organic disease of the heart; and although the stethoscope is said not to be so useful in diseases of the heart as of the lungs, yet, in a majority of cases, taken along with other symptoms, we shall be able to determine this point with sufficient accuracy. If there be no dis- ease of the heart, very large opiates, united with colchicum, will be occasionally found singularly beneficial; even in Terry's case, (p. 17,) this treatment was serviceable. If the bowels are in a bad state, a pill may be exhibited every second or third hour, composed of five grains of calomel, the same quantity of opium, and three or four drops of oil of croton. Many object to the use of opium in such cases, but without sufficient grounds. The celebrated John Hunter took opium, it is alleged, with an aggravation of the disease ; but the small doses he used were quite inadequate in such a severe disease. It is stated by Sir Everard Home, that John Hunter was advised to take wine, which he did accordingly, but found the paroxysms more readily brought on after it. Laennec speaks highly of magnetism in such cases, and although too much cried up at one time by medical men. he thinks it is loo much neglected at present. He used it in the following manner:—" I apply," says he, " two strongly magnetized steel plates, of a line in thickness, of an oval shape, and bent so as to fit the part—one to the left praecordial region, and another exactly opposite on the back, in such a manner, that the magnetic current shall traverse the. affected part. This method is not infallible, any more than others employed in nervous cases; but 1 may say that it has succeeded better in my hands, in the case of angina, than any other, as well in relieving the paroxysm, as in keeping it off." And he subsequently assures us, that when the magnet affords little relief, a good effect has followed the application of a small blister under the anterior plate. Should our remedies unfortunately fail in producing relief during a paroxysm of angina pectoris, we have the consolation to know, that ANGINA PECTORIS. 473 much may be done to prevent a return of the complaint if there be no organic disease of the heart. Fatigue and violent exercise, to- gether with all excesses, are to be carefully avoided, as also stimu- lants and the application of cold. The diet of a patient so circum- stanced must be light, and easy of digestion, and he should limit him- self to a certain quantity of food by weight: and he should not drink more than is necessary for the purposes of digestion. Assiduous attention must be paid to the state of the bowels, to prevent constipa- tion; and the patient should regulate himself by medicine, or other means, that he shall have one or two stools daily. 40* CHAPTER III. PERICARDITIS AND CARDITIS. PERICARDITIS. This is a disease, which is seldom so well marked in its external characters, as the importance of the organ affected would lead us to expect. It is sometimes so insidious as to produce considerable disorganization before severe symptoms appear to attract our atten- tion ; at others, it creates constitutional disturbance, which indicates a disease of great severity; but our attention becomes fixed, perhaps, upon some local pain, at a distance from the seat of the disease, to relieve which, our best efforts are directed. In truth, as Laennec observes—" There are few diseases attended by more variable symp- toms, or of more difficult diagnosis than this." And he assures us that it is as frequently mistaken as recognized:—"This is the result (says he) of my own experience up to the present time; and to mine I may add that of many of my medical brethren, and among others, M. Recamier." Cullen confesses that he knew little upon this sub- ject—so little, that he has not devoted more than twenty-seven lines, in his work on the practice of physic, to the consideration of carditis and pericarditis; and his concluding words are—" There is, therefore, upon the whole, no room for our treating more particularly of inflam- mation of the heart or pericardium." Nevertheless, he has given the following definition:—"Pyrexia; pain in the region of the heart; anxiety; difficult respiration; cough; unequal pulse; palpitation; syncope. All the systematic authors seem unfortunately to have fol- lowed this definition, in the descriptions which they have given of this disease, instead of copying from nature. By pericarditis, I mean an inflammation of an acute, subacute, or chronic nature, of the serous membrane which lines the pericardium, and also that which gives an external covering to the heart itself, and the roots of the great vessels. In describing the phenomena of this disease, it must be kept in recollection, that in this, as well as in other inflammatory affections, a great number of varieties occur, giv- ing rise to symptoms more or less urgent. In two or three instances, I have seen the symptoms so urgent, as to produce great affliction ; in these, the pain was situated in the region of the heart, increased on taking an inspiration, as well as by any considerable motion of the trunk, which produced a tendency to syncope; the breathing PERICARDITIS. 475 anxious and irregular, rather than difficult; cough but slight in pro- portion to the anxiety of the breathing; the countenance sharp, and peculiarly expressive of distress: the pulse was regular at first but small like a wire; it generally becomes irregular, however, during the act of speaking, and when the patient moves. It is of great conse- quence, in all severe diseases, to compare the strength of the pulse at the wrist, with the action of the heart, by applying the ear in the same situation; and this precaution is peculiarly necessary in dis- eases of the heart and pericardium. In the latter, the pulse, as al- ready stated, is generally wiry and small, when the action of the heart itself is perhaps excessively strong, or I should have rather said tu- multuous. Even in insidious cases, an inequality will sometimes be perceived between the strength of the heart's action, and that of the pulse at the wrist. A case lately occurred to me of an insidious nature, which I shall briefly relate:—A middle-aged gentleman, having an extraordinary curvature of the spine, but who had never- theless, enjoyed robust health, remarkable for agility and muscular strength, called at my house to seek advice. He told me that, for a week previously, he had been affected with an asthmatic complaint, which had now increased to such a degree, that he could scarcely take any exercise; that he passed sleepless nights; was afflicted with cough, attended by some expectoration; but he described his greatest suffering to proceed from violent spasmodic contractions affecting the muscles of the extremities. He had not lost much flesh, but laboured under considerable oppression and debility. On examining the chest, he was found to be somewhat chicken-breasted; he was un- able to fill his lungs completely; the action of the heart was felt over a large space, tumultuous and irregular, intermitting occasionally six times in the minute, generally three or four; the pulse at the wrist having the same irregular and intermittent character, but it was small and weak in proportion to^the strength of the heart's action. He stated that his appetite was bad, that it was almost impossible to keep his extremities warm, and that he chiefly attributed his com- plaints to flatulency. I desired him to go home, and upon no account to venture abroad again. Next day I found him rather better, hav- ing had several copious stools, with which he passed a great quantity of flatus;—this was on Wednesday. On Thursday and Friday he still continued to improve; but I had no doubt he laboured under an affection of the heart, and, much to his disappointment gave strict orders that he was on no account to go out. On Saturday, I found him very ill, complaining of great oppression in his breast, and diffi- culty of breathing ; but his chief suffering proceeded from cramps in his extremities, and occasional spasmodic rigidity of the whole body, which was sometimes bent backwards, supported by the occiput and heels; and his landlady said, that the spasms were so severe during the night, that he could scarcely be kept in bed. He died suddenly in the course of the following night. On dissection, the brain was found to be quite healthy. No trace of disease was found in the spinal cord except that a very old adhesion was discovered, and two or three large ossific scales on the surface of the arachnoid mem- brane. The pericardium was large, and contained a considerable 476 PERICARDITIS. quantity of turbid serum, with a deposition of lymph, adhering in various places to the surface of the heart, but which was more abun- dant at the roots of the great vessels ; the heart itself was large, al- though it did not seem disproportioned in its different parts; the valves were sound. That I mistook the case, is very evident, and it is related expressly to show the circumstances which led me astray in the investigation. Had the individual not had a deformed spine, and severe cramps, I might, in all probability, have detected the true nature of the disease. I considered the dyspnoea to proceed from a nervous affection of the lungs, complicated with enlargement of the heart. Previously to the occurrence of this case, I would have de- clared it to be impossible for any one, labouring under pericarditis, to be able to walk more than half a mile up a hill, which this gentle- man did when he came to me on the Tuesday before his death; and when returning home, before he reached his lodgings, he had to mount three flights of stairs.—Since the publication of the first edi- tion, 1 have seen several severe and insidious cases, all of which were connected with acute rheumatic attacks. In one fatal case, there was no pain in the thoracic region, but the patient complained of op- pression, and was affected with slight dyspnoea; the action of the heart was tumultuous, and the pulse quick. The tongue was rough, deeply fissured and red. Laennec and other practical physicians agree, that, in the present state of our science, we are not acquainted with any symptoms which point out, with certainty, the presence of pericarditis. Per- haps this is more to be attribued to imperfect observation of the cases which have occurred, (very good examples of which are quoted above,) than to the obscure nature of the disease itself. M. Louis thinks that our ignorance of diagnostic signs is to be attributed to our imperfect observations—and in this opinion Dr. Scott concurs. According to these gentlemen, the observations of authors have generally been incomplete—many of the means of diagnosis have been neglected, and several circumstances of the greatest importance in forming an opinion of the nature of the disease, have been over- looked. From his own observations on this disease, and from an analysis of the cases on record, M. Louis is inclined to draw the following conclusions:—that pericarditis is characterized by pain in the region of the heart, sometimes extending to the back and epi- gastrium, attacking the patient suddenly, and accompanied with a greater or less degree of oppression, and in certain cases with palpi- tation—irregularity and intermission of the pulse, and more particu- larly by a dull sound in the praecordial region, the other parts of the left side of the thorax remaining perfectly sonorous. Syncope sometimes also accompanies these symptoms, and occasionally infil- tration of the extremities—this probably takes place when the progress of the disease has not been very rapid; but when it does appear, as it is one of the symptoms of disease of the heart, it ought particularly to fix our attention, and lead us to suspect an affection of that organ, or confirm our diagnosis, if we have already formed one. From the cases on record, Louis thinks that the disease may be detected in half of the cases where it exists ; and when free from PERICARDITIS. 477 complication, he considers it to be as easily recognizable as the best marked pleurisy. Causes.—These are, generally speaking, the same as produce other inflammatory affections within the chest. It may be attributed to moral causes also, such as grief and anxiety; and there can be no doubt that it is often occasioned by a metastasis during the course of rheumatism and gout. [Physicalsigns.—One of the most obvious of these is that derived from the attrition of the two surfaces of the pericardium, (which is roughened by the secretion of lymph,) and which has been com- pared to the grating or rasping of woad; or sometimes to the rustling of silk or the crackling of parchment; and Dr. Pennock adds that these friction sounds, when the effusion is inconsiderable, are first heard near the base of the heart; that they are almost always double, and frequently are triple or more; whence the term " to and fro sounds," in use among English writers. The friction, in strongly marked cases, is also perfectly sensible to the touch. Adhesion may be inferred from the cessation of these attrition mur- murs, and a strong jogging action of the heart, even though the fever has subsided.* Contrary to what might be anticipated, effusions of water in the pericardium (hydropericardium) are but obscurely detected by stetho- scopic signs. This condition does not take place until the disease is somewhat advanced, and is first detected by a circumscribed defi- ciency of sound, which extends more or less beyond the limits of the cardiac region, and sometimes occupying a large part of the left side of the chest. But if the effusion be complicated with diseases of the lungs or pleura, the diagnosis becomes yet more difficult and de- ceptive.] Appearances on dissection.—There is very seldom any redness to be seen in the acute affection; but we always find flakes of lymph floating in a larger or smaller quantity of serum, and attached to the membrane itself. Sometimes the pericardium is amazingly distended, containing a quart, and even more of this fluid. When any redness is observed, it is generally in small spots upon the surface of the pericardium. In some chronic cases., the pericardium is much thick- ened, and the heart enveloped with exudation. As Laennec very justly observes, it rarely presents the appearances of an equable membranous layer, like the false membrane of pleurisy; on the contrary, its surface is most frequently marked by a great number of rough and irregular prominences. If the patient survive the first effects of the effusion, the lymphy part becomes quickly absorbed, and afterwards we find the albuminous matter slightly glueing the pericar- dium to the heart. I have seen some cases where there was appa- rently no serous effusion, but a considerable quantity of lymph thrown out everywhere over the heart. Occasionally, we find the pericar- dium closely attached to the heart, forming a dense fibro-cartilaginous mass, incapable of being separated, even by dissection. Within these few years, I have seen two cases of this sort; one individual died * Hope. Loco citat. 478 PERICARDITIS. during an attack of erysipelas, from the united effects of inflammation of the membranes of the brain and mucous membrane of the lungs: the disease in the pericardium must have been of very long standing, but he enjoyed, nevertheless, excellent health, and great activity of body and mind, up to the period of his last illness. The subject of the other case was a young athletic man, who died from inflam- mation of the substance of the brain after a very short illness. About a year before, he had a severe indisposition, which was supposed to be hepatitis, and treated accordingly. After being in considerable danger, he gradually recovered health and strength. On dissection, the pericardium was found thickened and indurated, adhering firmly to every part of the heart, it being impossible to separate it in many places, even by careful dissection, without taking away the proper membrane of the heart. These two cases, and several others which I could quote, completely disprove the assertion of Corvisart, that no person can live, and preserve a good state of health, who is affected with a complete and close adhesion of the pericardiumjo the heart. On other occasions, the false membrane appears to be converted into cellular substance; and, although united to the heart, the adhesions are loose and long, and the pericardium can be easily separated. On the surface of the heart, we sometimes observe opaque, white spots, generally.of an oval figure, about an inch in length, sometimes much smaller, and at others, very much larger. A great difference of opinion prevailed respecting the true nature of these spots. From my own observations and examinations after death, I have no doubt that they are the result of a partial inflammatory action on the sur- face of the proper covering of the heart. I used formerly to find it impossible to separate these in such a manner as to prove whether they were on the outside or beneath the serous membrane. At last, after submitting the parts to maceration for a few days, I have been able to remove them completely from the heart, leaving the serous membrane untouched, and apparently in a healthy state.—Baillie and Laennec are of the same opinion ; Corvisart, on the other hand, considers these productions to be situated beneath the serous mem- brane, and entirely unconnected with inflammatory action. Laennec states, that a tuberculous formation may sometimes take place, and thereby convert the acute into the chronic disease, as it frequently happens in the case of pleurisy and peritonitis, of which he has seen two instances; a third is noticed by Corvisart; and I have seen one case of it myself, in a man who died of a surgical dis- ease, quite unconnected with that of the heart. The muscular substance of the heart, in many of these cases, looks whitish, as if it had been macerated. Corvisart, and many others, suppose this loss of colour, particularly, when attended by softening, to be a sign of inflammation in the substance of the heart itself; but I feel disposed to join Laennec in doubting the correctness of this opinion. He states, that we can never be sure of the existence of inflammation in a muscular organ, unless we find a deposition of pus, or lymph among its fibres. [Adhesions of the two surfaces of the pericardium are a frequent result of their inflammation; and we would, a priori, infer that this PERICARDITIS. 479 condition in so vital an organ, would tend to cripple and rapidly to extinguish the motions of the heart. Extensive observations made by the pathologists of Europe, prove this not to be the case; and such, also, is the result of my own experience. I attended a woman in the lower walks of life who died of protracted phthisis. On ex- amining the heart, it presented continuous adhesions over nearly the whole anterior surface, not less than three inches in diameter; yet there was no remaining disease, nor had the patient during her ill- ness complained of pain or uneasiness in that region. The pericar- ditis had probably occurred a long time previous, and its results had in no appreciable way impaired the subsequent actions of the heart itself. Granulations not unfrequently follow pericarditis. They may occupy or cover either surface of the pericardium, and sometimes attain a magnitude and abundance which would seem wholly in- compatible with the heart's motions. A very remarkable case of this kind occurred a few years since in the practice of Dr. Spack- man, of this city, in the person of a negro of forty years of age. Having been invited to examine the diseased parts, I made draw- ings of them which, together with Dr. Spackman's account of the appearances on dissection, were subsequently published.* The en- tire internal surface of the pericardium, as well the reflected portion as that covering the heart, was covered by a preternatural deposit, in some places constituted of small, irregular, granular masses, ex- tremely vascular, and varying in size from a pin's head to a small bean.. These caruncles were, in some places, so grouped as to form pendulous excrescences, especially towards the base and apex of the heart, and on the reflected pericardium; and some of these were as large as an almond. The pulmonary artery was contracted at its exit from the right ventricle from similar excrescences, and the peri- cardium was enormously distended with water; but the heart itself, excepting a partial dilatation, showed no evidence of disease.] Treatment.—If the disease be detected early, there can be no doubt of the propriety of general bleeding, carried to the utmost extent the patient can bear, and repeated or not, according to cir- cumstances. Leeches are to be had recourse to, when necessary; and it must be recollected, in treating an inflammation of a vital organ, that decision and promptness are of the utmost consequence to the patient. Antimony is to be used, together with contra-irrita- tion. Purgatives must be occasionally employed, together with the strict antiphlogistic regimen. If called late to a case, and when general blood-letting would be, perhaps, attended with immediate danger, we must have recourse to local abstraction of blood, by means of leeches, and throw mercury into the system as quickly as possible. I am disposed to attribute the recovery of the last of the two cases already quoted, (at page 27,) in which the pericardium was found attached to the heart, to the action of the mercury, which was administered for the supposed hepatitis. [♦ Philad. Journal of the Med. & Phys. Sciences, vol. 3, N. S.] 480 CARDITIS. CARDITIS. Inflammation of the proper or muscular substance of the heart \s a very rare disease: I have seen only one case of it, which was treated for the affection commonly known by the term angina pec- toris. The symptoms were unusually acute, and continued for four or five weeks, the patient never passing a night without fever, and never two days without having several severe paroxysms of suffering. In general, however, the symptoms are represented as being simi- lar to those which arise from inflammation of the pericardium, and it appears probable that the two diseases have been often confound- ed. [No stethoscopic sounds have yet been discovered which enable us to detect the inflammation of the heart, not even when ulcers and abscesses have formed.] Appearances on dissection.—Redness, and even injection of the capillaries, are equivocal signs of inflammation of the heart; so is some degree of softening of that organ, which, although sometimes observed after symptoms which indicated disease of the heart, yet is oftener seen when such signs did not exist; and I am convinced that the state which is usually noted down in reports of dissections, as softening of the heart, is frequently nothing more than the natural progress towards decay. Laennec states, that he has met with only one instance of an abscess in the walls of the heart. The subject was a child twelve years old; the abscess was situated in the parie- tes of the left ventricle, and might have contained a filbert. [Par- tial carditis, however, has been often met with by the later patholo- gists, connected with ulceration and abscess, sometimes perforating the inter-ventricular or the inter-auricular septum; and it is this state of disease that usually precedes rupture of the heart. Even this frightful lesion is not always immediately fatal, for a solid coa- gulum, or fibrinous concretion, has been known to arrest the hae- morrhage for several hours.] In another case of a man of sixty years old, he found albuminous exudation, of the consistence of boiled white of egg, and of the colour of pus, deposited among the muscular fibres of the left ventricle. " The patient had presented symptoms of an acute inflammation of some of the thoracic viscera, without precisely indicating its site. Orthopnoea, and a feeling of inexpressible anguish, had been the chief symptoms." (Page 621.) In the case to which I have already alluded, a deposition of a mat- ter, whether pus or lymph could not be determined, was found near the apex of the heart, in the substance of the left ventricle. 1 would particularly refer the reader to Dr. Gairdner's interesting case of car- ditis, recorded in the 2d vol. of the " Medico-Chirurgical Transac- tions of Edinburgh." The subject of it died of another disease, eight months after the original attack, and the following is an abstract of the appearances in the heart: " Near to the apex of the heart, we found a layer of dense, organized lymph, closely investing a part of the parietes of both ventricles. On attempting to separate a por- tion of this layer, it was found to be firmly united to the substance of the organ, dipping between its muscular fibres, in the form of CARDITIS. 481 dense cellular tissue." (Page 241.) The symptoms in this case were, preternaturally violent and rapid action of the heart, and a sensation of throbbing in the temples, with headache. Ulcerations of the heart, according to Laennec, have been more frequently observed than abscess, but it would seem they are more common on the internal surfaces of the heart, than on the externah Dr. Baillie observes, that although authors have mentioned cases of abscesses and ulcers of the heart, he is persuaded they are extremely rare.* He also states that mortification still more rarely takes place. Lieutaud, however, notices it, and Dr. James Kennedy, lately of Glasgow, has published a most interesting paper upon this subject, in illustration of a case of acute carditis, terminating in gangrene of the heart, in the "Medical Repository" for April, 1824, which is well worthy of perusal. It contains sufficient proof, not only of the author's skill in pathological inquiries, but of his critical acumen. On dissection, it is stated, that "twenty ounces of turbid serum were taken from the chest; it had an impure orange colour, and a fetid smell. The pericardium inclosed four ounces of a fluid in all re- spects similar. On the internal surface of this capsule, was much vascular net-work, dark, as if composed of injected veins. All parts of the heart, external and internal, exhibited distinct marks of hav- ing been the seat of gangrenous inflammation. They were preter- naturally flaccid, and dark as the darkest coagulated venous blood ; they could be easily perforated by the finger. When thus torn, they exhaled a putrid odour, but no blood exuded from their ruptured vessels. The left ventricle, in particular, was quite livid, and desti- tute of its muscular tenacity; it was a little firmer than cerebral structure. When lacerated, it threw out a most offensive smell, similar to the odour of putrescent animal substance. All the cavi- ties of the heart were empty; but the large veins, especially the abdominal, were loaded with grumous blood." (Page 279.) Treatment.—A similar mode of treatment as that recommended in pericarditis is to be followed. The result of Dr. Gairdner's case is a strong proof in favour of large bleeding, which prevented the diseased action from spreading, and preserved life, even after exten- sive disorganization had taken place. He took thirty ounces of blood from a vein in the arm, on the 16th March; on the 17th, it was re- peated in the same quantity; and again on the 18th, the doctor states, he " ventured" on another equally " copious" abstraction of blood. During that night, from the shifting of the bandage, the patient lost several ounces more, and subsequently had leeches ap- plied. * Morbid Anatomy, p. 20. 41 482 [ENDOCARDITIS.] [ENDOCARDITIS.] [This disease is an inflammation of the internal lining membrane of the heart; and we are indebted for our first knowledge of it to M. Bpnillaud. It is characterized, in its early stages, by a variable and preternatural red colour, which is sometimes mottled with bluish or brown spots. Sometimes the whole surface is of a uniform scarlet tint, but the capillaries are not obviously injected. Again, the whole or part of the surface exhibits a violet tint; and these and the other appear- ances we have mentioned even extend into the muscular structure of the heart. That these signs do accompany the incipient stage of endocarditis there can be no question ; but it is also certain that they may exist without the presence of inflammation ; whence Laennec long ago declared them of no pathological value unless they were accompanied by some collateral evidence of an inflamed state, such as thickening of the membrane, or injection of its vessels; and the mere redness of the membrane, however intense, may be and often is nothing more than a stain of blood, which may be readily imi- tated by artificial processes, and is of itself not a positive test of in- flammation.* The next stage of the disease presents unequivocal characters; such as the thickening and puffiness of the membrane, and effusion of lymph ; the latter becomes rapidly semi-organized, and assumes the form of vegetations or granulations. The false membranes form to a greater or less extent, either lining the cavity of the heart or even forming partial septa within it. Ulceration is another but very un- frequent attendant on endocarditis; and Bouillaud thinks the disease sometimes terminates in mortification itself. The prolonged duration of endocarditis produces the whole chain of morbid structures so familiar in adhesion, cartilaginous degenera- tion and ossification of the valves, especially in the left side of the heart, with consequent contraction and displacement of those struc- tures. The effused lymph is the original nucleus, which first ap- pears as a simple false membrane, and this finally passes through the several stages we have indicated, until it assumes the hardness of bone. The base and edges of the valves are most subject to these changes, of which more will be said in a succeeding section of this work.t The symptoms of acute endocarditis are inflammatory fever; little or no pain, but rather a peculiar distress in the region of the heart, which sometimes becomes extreme and intolerable. The heart's action is violent and tumultuous, as is evident in the fre- quent, strong, bounding pulse, which sometimes imparts a jerking sensation to the finger. As the disease advances, these symptoms increase; the pulse becomes very quick and irregular, the breathing difficult, the countenance anxious, and the whole frame restless and tossing, with a livid complexion and constant tendency to syncope. [* Laennec] [t Chap. vi. Diseases of the Valves.] [ENDOCARDITIS.] 483 In fact, all the characteristics of an extremely impeded and embar- rassed circulation of blood through the heart are seen in strong relief. Physical signs.—Independently of the dulness on percussion over a large surface, (and which is distinguished from that which occurs in hydro-pericardium by the obviously more superficial action of the heart,) we find the bellows sound strongly developed, which is some- times accompanied by a peculiar tinkling or ringing. This is in the acute stage; but as the disease advances, as it rapidly does, to a more chronic stage, auscultation still detects some modification of the bel- lows murmur, or the rasping, sawing or musical sound. But as these signs are also present in other diseases of the heart, and are even present, as we have shown, in a mere ansemial condition of the circulatory system, it requires often-repeated examinations considered in reference to the external symptoms already described, to enable us to establish an unequivocal diagnosis. When the valves, however, become changed in tissue and position, as hereafter to be described, very little uncertainty remains ; and yet, under these circumstances, the disease has become a secondary, and, in a great measure, an in- tractable affection. Treatment.—Nothing can be more obvious than the necessity for prompt and active depletion in acute endocarditis; not only to pre- vent fatal consequences for the present, but to ward off organic changes for the future. It is unnecessary to repeat the best means of attaining these objects, excepting to impress the importance of repeated leeching or cupping over the praecordial region, conjoined with a succession of blisters on the interscapular space. Perfect rest, the avoidance of all excitement and a very light regimen, need hardly be insisted on when they are so obviously indispensable. Dr. Hope states that in chronic endocarditis he has experienced the most satisfactory results from prolonging the mild use of mercury, so as to maintain a barely sensible effect upon the gums, for three, four, five or six weeks; simultaneously employing a succession of small blisters in different parts of the praecordial region, restricting the patient to a farinaceous and light broth diet, and confining him to his bed for the purpose of ensuring the utmost possible corporeal tranquillity.*] [* Diseases of the Heart, p. 220-] CHAPTER IV. HYPERTROPHY OF THE HEART. By hypertrophy of the heart is understood, a thickening or in- crease in the muscular substance of one or more of its cavities. This may, perhaps, be considered rather as an increase of nutrition than a real organic disease; that is to say, in its simplest state, it may con- tinue for an indefinite period ; it is seldom fatal of itself, and proves so, either from the causes which have given rise to it, or from the diseases which it may induce in other organs. Hypertrophy frequently exists without complication ; at other times, we meet with it combined with dilatation and contraction of the cavities of the heart, as well as ossification of the valves. In this class of diseases, as well as in most others, we are constantly to bear in mind, that when one organ labours under disease, others in a short time give evidence of participation. I shall describe this disease in its most simple state, and point out the leading symptoms which attend it; but young practitioners should be aware, that they must not invariably expect to meet the disease under the precise form in which it may be delineated. After due deliberation, with regard to the different arrangements which have been adopted in treating of hypertrophy, I give a decided preference to that of Bertin, who describes it under three forms: 1. Simple hy- pertrophy, without change in the capacity of the cavities of the heart; 2. With the increase in the capacity of the cavities of the heart—the active aneurism of Corvisart—the hypertrophy with dilatation of Laennec, which is the most common form of the disease; 3. Hyper- trophy with diminution in the capacity of the cavities of the heart. Hypertrophy is more common in the left ventricle than in the right, and is occasionally met with in the auricles. When the whole heart is affected, it sometimes attains an enormous size, appearing, when the thorax is opened, to fill both sides of the chest. In the natural state, the heart is about the size of the closed fist of the subject, not tightly clenched. The thickness of the walls of the left ventricle is more than double that of the right, and of sufficient firmness not to collapse when cut into. The right ventricle collapses when divided; it is a little more capacious than the left, and the columnse carnae are of a larger size. In the diseased state, we sometimes find the heart three or four times the above-mentioned size; and when the left ventricle is af- HYPERTROPHY OF THE HEART. 485 fected, its walls are frequently more than an inch, or even an inch and a half in thickness; the greatest increase is at the base of the heart, decreasing towards the apex, although this rule is occasionally reversed. The columnar carneae also require a proportionate enlarge- ment, and even the septum between the ventricles participates in the disease. The capacity of the ventricle is sometimes so much diminished, that Laennec informs us, in a heart double its natural size, he has seen it so small as scarcely to contain an almond in the shell. In such cases, the apex of the heart is blunted, and formed entirely by the left ventricle, which appears to constitute the whole of the heart, the right looking more like a process of it. In hypertrophy of the right ventricle, the thickening is never so great as in the left, and it is more uniform. The causes of the disease have been already alluded to. The in- crease of the nutrition of the heart has been compared to that of the muscles of the arm of the blacksmith: and all causes capable of in- creasing the action of the heart have been assigned as the sources of hypertrophy ; such are all affections of the lungs, impeding or retard- ing the circulation between the right and left cavities of the heart; and there can be no doubt, that individuals of a sanguine and ple- thoric temperament are most subject to this disease. Signs of hypertrophy of the left ventricle.—The general symp- toms have been already mentioned. In this disease the patient is less subject to violent and sudden attacks of palpitation than in dila- tation, but he is more sensible of the constant action of the heart. On applying the hand to the chest, it.is met by a strong and extend- ed pulsation, sometimes as if the whole heart were raised against the hand, at other times only its apex. The pulse is generally full, strong, and vibrating, appearing as if the artery were constantly dis- tended. The raising of the ribs is quite visible, and in hypertrophy with increase of capacity, the action of the heart can be heard at some distance from the patient. The sound on percussion is dull, and on applying the stethoscope between the cartilages of the fifth and sixth ribs, a very strong im- pulse is felt, sufficient to raise the head of the observer, and accom- panied with a duller sound than natural —it is more prolonged in proportion as the thickening is more considerable. The contraction of the ventricle is very short, and productive of little sound, unless the disease be complicated with considerable dilatation. We must, therefore, distinguish between simple hypertrophy and hypertrophy with increase in the capacity of the cavity. In the for- mer, the sound is confined to a very limited space; it is scarcely per- ceptible under the left clavicle, and forms a remarkable contrast to the force of the shock. In the latter, the intensity of the sound is increased—we have the strong impulse as in hypertrophy, and the loud sound as in dilatation. The sound is sometimes so great, as to be heard over every part of the chest. The pulsations of the carotid and other arteries are frequently visible. Signs of hypertrophy of the right ventricle.—The signs are pre- cisely the same as already described: that is to say, the heart, as ex- 41* 486 HYPERTROPHY OF THE HEART. plored by the cylinder, gives similar results, with this difference: that the shock of the heart's action is greater at the bottom of the sternum than between the cartilages of the fifth and seventh ribs, which is the reverse of what takes place when the disease is in the left side of the organ. This sign, drawn from the place where the heart is heard beating with most force, according to Laennec, is in- fallible. Lancisi described a swelling and pulsation of the jugular, as a sign of aneurism of the right ventricle. This symptom was rejected by Corvisart, who says he has seen it when hypertrophy existed on the left side. Laennec differs with Lancisi, and informs us, that he never met with it in hypertrophy of the left ventricle, un- less there existed at the same time a similar affection of the right; while he has uniformly seen it whenever the right side was affected in a severe degree. We may, therefore, regard this as a pretty cer- tain sign. Hypertrophy of the auricles, considered as a disease, is not of fre- quent occurrence, and therefore is not of so much importance—it appears to be always consecutive to some other affection—either to a disease of the valves, or some obstacle to the circulation. If Laen- nec's notions respecting the sounds produced by the heart's action be incorrect, it follows that many of his stethoscopic indications must also be* erroneous. It is believed by some,'that violent impulse of the heart depends upon hypertrophy of the auricles; 1 have no doubt that occasionally this is the case, but I am inclined to attri- bute this phenomenon to the increased bulk of the left ventricle. Hypertrophy is sometimes primitive, but is, perhaps, more fre- quently consecutive to some other disease. It commonly proves fatal by the effects produced on other organs, more especially the brain and lungs. No fact is better ascertained than the influence which hypertrophy exerts in producing apoplexy, as well as softening of the brain. The attention of practitioners has been particularly called to this, by Le Gallois, Richerand, Bricheteau, Lallemand and Berlin; and it is somewhat surprising to find a learned editor of the Edinburgh Medi- cal Journal, informing us, in 1828, that " no pathologist has par- ticularly examined those effects to which the diseases of circula- tion give rise in the cerebral organ," appearing to claim this as a discovery of his own, as well as the making of incisions in whittloes ! There never were individuals who better understood the mystery " of hanging great weights to small wires" than the editors of this debilitated and puffing periodical. Treatment.—Whether the analogy between hypertrophy of the heart and the muscles of the blacksmith's arm, be true in a patho- logical sense or not, I could quote a number of cases in which it is supported by the result of medical treatment; viz.: venesection, the strict antiphlogistic regimen and perfect rest. Of all diseases of the heart, hypertrophy is that in which the starving treatment of Valsalva will, in general, be found most advantageous, even when complicated with some degree of dilatation. The lancet is necessary in those cases only in which we are ob- liged to diminish plethora more quickly than can be done by diet and HYPERTROPHY OF THE HEART. 487 purgative medicines, and reduce the violent action of the heart, when danger is threatened to the brain or lungs. It is necessary to keep the patient quiet, with respect to bodily and mental exertion, and to prevent him from speaking. Great benefit is frequently obtained from the occasional use of a weak solution of antimony, so as to pro- duce a slight degree of nausea. He should sleep in a well-aired apartment, remote from every noise, and under as few bed-clothes as possible. With respect to his diet, it will be sufficient to say that it ought to consist of biscuit or toasted bread, in such quantity as will barely keep soul and body together. The quantity of fluid should also be regulated, and must at once be considerably reduced. Should he complain of hunger, or be inclined to take liberties with himself, he may be readily enough controlled by two or three additional doses of antimony, which for that purpose should be given in different forms—sometimes in solution, to which substances may be added to change the colour—sometimes in powder, and sometimes in the form of pill. If there be any pain in the region of the heart, the occasional application of leeches is advisable. The length of time necessary to persevere in the use of this restricted regimen and treatment, must entirely depend on the severity of the symptoms, the nature of the disease, and the prospect we may have of being able, ultimately, to cure the affection. I have seen this plan beneficial within a few hours, particularly in two cases. The subject of one was a physician whose complaints had been gradually stealing on for many months; his hair dropped out; he became emaciated; he felt considerable debility, with impaired appetite ; his nights were restless ; but I was not sent for till dyspnoea and oppression in the chest were so great as to threaten speedy death. I found the impulse of the heart very vio- lent, probably the organ was in a state of hypertrophy, and he was threatened with haemoptysis. After bleeding him to sufficient ex- tent, he was put under the antimonial treatment, and starved; not- withstanding which, he began to increase in flesh and strength as soon as the antimony was omitted, and he had perseverance enough to live for a considerable time on two biscuits a day, taking only as much fluid as was sufficient to enable his stomach to drgest them. In the course of some time, he was allowed to take a little fruit, which disagreed with his stomach, produced indigestion and flatulent dis- tension, and occasioned a temporary return of the former symptoms, proving, in a remarkable manner, the necessity of keeping the state of the stomach and bowels constantly in view, when treating diseases of the heart; and I so heartily coincide with the excellent remarks of Dr. Forbes on this subject, that I cannot forbear quoting his words. " One great principle," says he, note, p. 687, " is of paramount im- portance : it is the removal of all disorders hi other organs, which can act as a source of irritation to the heart; I would here add, that from its powerful influence (gastric irritation).in stimulating the organs of circulation to increased action, its previous cure becomes essential to the success of our measures for remedying the disease of the heart." This gentleman gradually recovered, and in nine months was able to accept a medical appointment in India—at the period of his de- parture he appeared in perfect health, had recovered his flesh and 488 HYPERTROPHY OF THE HEART. appetite; he lived like other people, and there was no unusual im- pulse in the region of the heart. I received two letters from him after his arrival in Calcutta, but the event happened which was much to be apprehended. The excitement produced by the heat of cli- mate and mode of living soon made an impression upon his frame. He was at length obliged to leave India, and died on the homeward passage. The other case to which I have alluded, occurred in the person of a gentleman who had been indisposed for six months; and although the case was complicated with dilatation, and perhaps disease of the valves, he felt the benefit of the treatment in a few hours, and en- joyed sound sleep that very night, for the first time since his illness. He increased in strength and flesh; the impulse of the heart daily declined; the agony which he felt in the chest, and outwards to the arms, ceased; cough, dyspnoea and expectoration with which he had been affected from the commencement of his illness, disappeared after the third day from the beginning of the treatment. This gentleman was able, in the course of a few months, to undertake a long journey to the southwest of England. This he performed without inconve- nience. He was distinctly told, however, that he could not be com- pletely cured, but might expect to be greatly relieved, and his life preserved for many years, provided he attended to his diet, and used proper precautions. Soon after his arrival in England, he fell under the care of one of those medical men who practise by routine, who have no pathological knowledge, but are never at a loss to give a name and local habitation to every disease that comes before them, who have a nostrum to cure every symptom, and who furnish their patients with eighteen draughts, three dinner pills, and a red mixture for three days' consumption ! ! Upon a first visit, he denounced the opinion of the " Scotch doctor," and declared that the patient's only complaint was "bile." He removed all my restrictions, told the patient to move about: to walk up the hills, which would open his chest and to eat beef-steaks and drink porter. All this was mighty pleasant news to the poor patient, who was very fond of the plea- sures of the table. But he was in the first place put under a course of mercury, during which he was confined to the house on account of the severity of the weather. Under this treatment, considerable amendment took place, and the most positive assurances were given of a speedy and a permanent cure. The most flattering accounts were received by the patient's friends in Scotland, who are people in the highest class of society; but.my invariable answer was, that the amendment could not be permanent. Some months passed over, and still favourable reports were made. At length, having occasion to be in London on business, my desire to see the patient was so great, that I undertook two long days'journey solely for that purpose. On my arrival at his house, (at half-past ten o'clock at night,) I found he was out at supper. When he came home, he said he was pretty well, but felt the "old sensation always in his chest." On applying my ear to the thorax, I perceived a strong throbbing impulse over every part, with a loud rushing or blowing sound. It was a painful duty to be obliged to open the eyes of his affectionate wife to the HYPERTROPHY OF THE HEART. 489 dangerous state of her husband's health, and the uncertainty of his surviving even a week. Fortunately for her future peace of mind, she believed me ; and, to shorten a long story, he died in less than three months. The correctness of my opinion was afterwards ascer- tained, and admitted by all parties. By degrees we are to allow the patient to return to an animal diet, which is better, when used in moderate quantity, than having his stomach filled with farinaceous food; and in order to prevent either a wilful or an accidental error, the exact quantity of food allowed in twenty-four hours should be given by weight, and liquids by measure. The antimonial ointment is to be rubbed over the region of the heart, and irritation on the surface should be supported for a few weeks, every now and then, while the cure is going on. I think it best not to have recourse to it, however, till such time as the restric- tions of diet are about to be relaxed. CHAPTER V. DILATATION OF THE HEART. Dilatation of the heart consists in an enlargement of the capa- city of one or more of its cavities. Dilatation, complicated with hypertrophy, has already been described. In the morbid alteration now to be mentioned, the walls are much thinner than natural, com- monly conjoined with a degree of softening of the muscular sub- stance, and some change in the colour, which is either more purple or paler than natural. This disease is the "passive aneurism" of Corvisart. According to Bertin, who has written a valuable work on diseases of the heart, there are three forms of dilatation; Is/. Dilatation with the thickening of the walls of the heart, which has already been treated of, under the title " Hypertrophy;"—2d. Dila- tation with thinness of the walls ;—and 3d. Dilatation without any change in the walls. Bertin has truly observed, that the orifices of the heart frequently partake of the dilatation of the cavities, inso- much that the valves become insufficient to close them. Dilatation is sometimes confined to one ventricle, though it more commonly affects both. The heart is more dilated in breadth than in length, and therefore assumes more of a rounded form than natural. The causes of this disease are ascribed by Bertin to some obstacle in the course of the blood, such as disease of the valves: this must be admitted; but probably the most frequent cause is, as stated by Laennec, a congenital disproportion in the parts of the heart. In some cases, the foramen ovale is found open to a considerable extent. Symptoms.—Patients affected with dilatation are more liable to sudden attacks of palpitation and dyspnoea, on any violent emotion, than those with hypertrophy; the pulse is commonly soft, weak and undulating. Weak action of the heart, whether owing to dilatation or not, frequently produces alarming symptoms, such as vertigo, loss of memory, syncope; together with nausea, vomiting, and consti- pation. J. M., aged 29, a medical student, very tall, stooping in his gait, of a fair complexion and light hair, had been affected for about a year with symptoms which he attributed to disorder of the stomach. He complained of a feeling of distension and weight in the epigastrium. Occasionally, he was troubled with a short, dry cough, and palpita- tion of the heart, excited generally by any sudden or unusual exer- tion. The pulse was naturally slow and full. These symptoms gradually became more constant and trouble- DILATATION OF THE HEART. 491 some. In July and August, 1823, he had occasion to exert himself considerably in his professional pursuits, and the feeling of uneasi- ness in the epigastrium and palpitation at the heart, proportionally increased, but appeared to him to be constantly relieved, when his bowels, which were generally costive, became relaxed by the use of medicine. In September, his complaints were much aggravated; towards evening, the short tickling cough became exceedingly troublesome, and, when he placed himself in the recumbent posture, he was fre- quently seized with feelings of suffocation, which forced him to sit up. The difficulty of breathing, accompanied by a sensation of con- striction in the breast, was at times considerable; and the paroxysms which seized him during the nights, he compared to asthmatic fits. He was frequently obliged to rise during the night; and when he did sleep, was often suddenly awakened by a sense of suffocation. Towards morning, he became easier, and enjoyed some rest. Dur- ing the day, he was comparatively well. He was thin and pale, but complained little, except of want of rest. He went about his medical studies with ardour and assiduity; but on making any unusual exertions, he was immediately seized with the short cough, and, on mounting a flight of steps, or an ascent of any kind, he was often obliged to stop suddenly. On walking quickly, his strength failed, and he complained that his limbs refused to perform their office. On examining the pulsation of the heart at this period, it appeared to be placed immediately under the hand; instead of the usual quick and hard stroke, a prolonged pulsatory throb was dis- tinguishable, extending over a larger than usual surface. To the stethoscope both the left auricle and ventricle gave a clear, sharp sound, distinctly observable, also, under the clavicle of the right side. In October and November he became gradually worse. The pa- roxysms at night were more frequent and more troublesome; and he was generally obliged to sleep in the sitting posture. He sometimes, however, passed days and nights pretty comfortably, and he believed that this was principally the case when his bowels were freely opened. In December, the oppression and sense of fulness in the epigastri- um increased to so great a degree as to render the slightest pressure on the part insufferable. The veins of the neck were observed, at this time, to be full, and a strong pulsatory motion was given to them above the clavicle. He still continued his studies with ardour, and refused to confine himself; but on mounting stairs, or walking quicker than usual, he became completely exhausted, and was often obliged to rest himself. On the 12th December, he felt much worse, and weaker. On the 14th, a material change for the worse had taken place; his face was pale and anxious, the lips bluish, and the ankles oedematous;—still he conversed cheerfully, and without the least alarm. The pulse was small, and about 120. On applying the hand to the region of the heart, the usual quick, hard beat, was not to be felt; but there was a kind of violent pulsatory struggle per- ceptible over a considerable space. A physician saw him° and the medicines he recommended were employed with great apparent bene- 492 DILATATION OF THE HEART. fit. Mr. M. thought himself better;, the oedema of the legs disap- peared, and the cough became less troublesome;—the palpitation at the heart had subsided ; and he complained only of a sense of weight in the epigastrium. During the day, he was tolerably well, but about ten at night, he became hot and exceedingly restless, continu- ally shifting his posture in the vain hope of repose. This continued for some hours, when he generally sunk into a slumber, and con- tinued till morning bathed in a copious perspiration. On Friday 26th, he was much worse. At 4 p. m. he was sitting up and convers- ing cheerfully ; but his legs were more swollen; his pulse irregular; the pulsation of the heart could not be felt in the usual place, and an undulatory pulsatory feel was communicated to the hand, when placed on the epigastrium, About 8 o'clock, his breathing became oppressed, he sunk into slumber, and died without a struggle. The body was examined about sixty hours after death. A great quantity of bloody serum seemed to have escaped, and still continued to flow from the mouth and nostrils. The body was much swollen, and the cellular membrane was distended with air; a quantity of serum flowed out on making the several incisions. About a pound and a half of bloody serum was found in each cavity of the thorax. The pericardium contained about, three ounces of fluid. The heart was more than three times its usual size. It was of a deep brown colour, and destitute of fat. On examination, the right auricle was greatly increased in capacity, and extremely thin in its walls. The foramen ovale was sufficiently open to admit the point of the little finger into the left auricle. The right ventricle was nearly natural, as was also the left auricle. The left ventricle was of an enormous magnitude, and more resembled a large bag than a ventricle of the heart. It was more than three times its natural size, its walls of ex- treme thinness, and the fleshy coluAins widely separated from each other. The lungs were more than usually congested with blood; but they, as well as the viscera of .the abdomen, were perfectly healthy. The above case is interesting in many respects, and among others, in having the foramen ovale open, which was, in all probability, produced by the enormous dilatation of the right auricle ; it is wor- thy of remark, that the communication between the right and left auricle existed without producing the diseases termed cyanosis or blue skin. Signs of dilatation.—The only certain sign is the clear sound of the heart with deficient impulse. Laennec says, the degree of dis- tinctness of the sound and its extent over the chest are the measure of dilatation; thus, when the sound of the contraction of the ven- tricles is as clear as that of the contraction of the auricles, and if it be at the same time perceptible on the right side of the back, the dilatation must be extreme. Signs of dilatation of the left ventricle.—A clear and sonorous sound between the fifth and seventh ribs of the left side. Signs of dilatation of the right ventricle. —The sound is heard somewhat better towards the bottom of the sternum than in the region of the heart; to which may be added, in the language of Cor- visart, a "greater degree of oppression, more marked serous diathe- TUBERCULOUS AND OSSIFIC FORMATION. 493 sis, more frequent haemoptysis, and a more livid state of the counte- nance," than in affections of the left ventricle. According to Laennec, the most constant and characteristic of the equivocal signs of this affection, is, an habitually swollen state of the jugular veins without pulsation. The following statements are extracted from the work of Senac (Trait6 du Coeur, torn. 2.)—" 11 est certain que les dilatations des diverses cavitfs (du coeur) peuvent etre distinguies. En general les battements du coeur ne sont pas violents quand le ventricle droit, ou le sac de ce ventricle, sont extremement dilate"es; a peine les dila- tations produisent elles des palpitations; dans beaucoup de cas, les malades sentent seulement un grand poid dans la region du coeur," page 327. And again, " Les dilatations du ventricle droit et de son oreilletle, produisent toujours des battements dans les veines du col----" " U absence de ces battements, lorsqu'une dila- tation du coeur est constatie, itablil cette dilatation dans le ven- tricle gauche," &c. Page 328. My attention has been frequently attracted to dilatation of the auri- cles, since the publication of the first edition. In several instances, the auricles, instead of forming a small part of the whole organ, were of equal size With the ventricles; in others, the proportions between auricles and ventricles were reversed—the former being by far the largest part of the heart. I have occasionally found the walls of the auricles much thickened, not only with respect to the muscular struc- ture, but the lining membrane also. In a healthy heart, the lining member of the auricles is considerably thicker and stronger than that of the ventricles; but in the condition of which I am now treating, the contrast is very remarkable. In concluding this part of the subject, it may be observed, that we have frequently combinations of different diseased states; thus we occasionally meet with dilatation of one ventricle, and hypertrophy of the other; but the comparative exploration of the two sides of the heart will enable us to detect this, after some practice with the ste- thoscope. In other cases, we have dilatation of one ventricle and the opposite auricle. We also meet with cases in which the parietes of the dilated cavity are thickened in certain points of their extent— thinned in others—and in the remaining parts exhibiting their natu- ral structure. TUBERCULOUS AND OSSIFIC FORMATION IN THE SUBSTANCE OF THE HEART. Various kinds of accidental productions have been found in the substance of the heart. I shall merely mention the enormous collec- tions of fat which have been discovered about the pericardium and heart, because I have seen this condition frequently in subjects who have died of other diseases, and in whom no affection of the heart had been suspected ; at the same time, there are cases on record, in 42 494 ATROPHY OF THE .HEART. which the muscular structure was so much weakened, and the fibres so much separated by the interposition of fat, that it has appeared to be the cause of impeded action, and occasionally of rupture of the organ. Ossific depositions in the walls of the heart are avowedly rare. Laennec met with two instances of this formation between the layers of the pericardium; the history of one of the cases, along with the dissection, (at p. 670 of the translation,) is well worthy of perusal. Baillie notices instances of this nature; one case fell under his own observation, in which the ossification had spread over a considerable portion of the pericardium, (p. 13.) He also says, (at p. 49,)" When a part of the heart is converted into an earthy matter or bone, no morbid symptoms whatever have in some cases been observed; and in others, there has been palpitation of the heart, with difficulty of breathing." But the author does not say that he had ever seen such cases. I have seen one instance only of tubercular formation in the sub- stance of the heart; Laennec states that he has seen it three or four times. In the year 1S26, some of my pupils were called upon to examine the body of a young woman, who dropt down dead without any previous indisposition. No diseased appearance was found any- where but in the heart. On opening the pericardium, it was ob- served to contain a little serum. The surface of the heart was vascu- lar, and there was some watery effusion beneath the serous membrane at several points. There were also two considerable projections, the largest at the apex of the heart, the other about the centre of the left ventricle; on making incisions at those parts, tuberculous masses were found occupying the whole thickness of the organ, of a soft cheesy consistence, at the apex, to the extent of an inch and a half in diameter, and at the left ventricle to that of an inch. Upon inquiry, it was found that this individual had led a very irregular life, but had always enjoyed a good state of health. In my museum there is a preparation obtained from a cholera sub- ject, in which a considerable portion of the right auricle and ventricle, together with the coronary arteries, is ossified. The previous his- tory of the patient is not known. ATROPHY OF THE HEART. Diminution of size is mentioned by most authors who have writ- ten upon diseases of the heart. Laennec states, that " the heart like the muscles of voluntary motion, is clearly susceptible of diminution of size." The hearts of individuals who die of phthisis are ob- served to be uncommonly small: Laennec says, that he has thought he " could recognize a sort of withering of the organ indicative of its loss of volume." On examining the body of a young woman, who died from the effects of a tumour, weighing above fifty pounds, which grew from the fundus of the uterus, and extended upwards, RUPTURE OF THE HEART. 495 encroaching so much upon the thorax, that the diaphragm on the right side was pushed up as high as the first rib, the heart was found little above half its usual size, and was very much flattened by the pressure of the tumour. Its action had been so much impeded, that the pulse could be scarcely felt in any artery of the body for a con- siderable time before death. I have another heart in my possession, taken from an adult male, which is not larger than that of a child of six years old. Both coronary arteries were found much ossified. In this case there could be no doubt that the small size of the heart depended upon the diminution of the nutritive process; the pulse at the wrist was exceedingly small for five or six months previously to death, and during the last two months, it was so weak that it could scarcely be counted. Laennec says, that he has never observed any symptom peculiar to atrophy of the heart. " I may remark, how- ever," he adds, " that several hypochondriacs, who are liable to faintings from very slight causes, gave, under the stethoscope, signs of a very small heart; and we know, moreover, that women, who are much more liable to these attacks than men, have, in general, smaller hearts." (Page 614.) RUPTURE OF THE HEART. We are assured by those who have had the best means of know- ing, that this accident is very rare. Laennec thinks that these rup- tures are generally produced by previous ulceration of the ventricular parietes, and Bertin is of the same opinion. Laennec states, that it is surprising rupture of the heart does not more frequently happen in those cases of great accumulation of fat, reducing the walls of the ventricles to extreme thinness. According to Meckel, rupture of the heart most frequently takes place at the point of junction be- tween the aorta and left ventricle ; but this does not seem to accord with the observations of others. Bayle assures us, that in nineteen cases of rupture of the heart, fourteen took place in the left ventricle, principally on its anterior side near the apex; three in the right ven- tricle. In most of the subjects, the heart was remarkably soft, and the substance around the perforation was of a brown colour. Bail- lie's observations upon this subject are very vague, and not worthy of quotation. I have seen two cases of sudden death, in which the pericardium was found to contain a large quantity of coagulated blood. In one of these, the perforation through which the blood had issued, could not be discovered for some time, and when on the point of giving up the examination, a small rent, just capable of ad- mitting the head of a pin, was found at the root of the aorta, which vessel was somewhat dilated, and its texture injured by incipient ossification.—The subject of the other case was a woman about fifty years of age, who had previously enjoyed a good state of health. The night before her death she had walked from the south- west extremity of the Old Town of Edinburgh to New Haven, and 496 RUPTURE OF THE HEART. back again, a distance of about six miles, and had gone to bed with- out making any complaint. After a good night's rest, she got up in the morning, and fell down dead soon afterwards, whilst cleaning her shoes. On dissection, the pericardium was found greatly dis- tended with coagulated blood; the aorta, much injured by ossifica- tion, was seen greatly dilated near its origin, where a small rupture existed, not above two lines in length. Bertin mentions two instances of rupture of the auricles, which is more rare than that of the ventricles: in one of these, the rupture was produced by a fall; in the other, it occurred without any per- ceptible cause, and the heart was enormously loaded with fat. We are assured by Laennec, that rupture of the auricles, ventri- cles, and large vessels within the pericardium, is not always followed by sudden death. In several cases, the blood accumulated in the pericardium formed a solid coagulum, and checked for a time the haemorrhage. CHAPTER VI. DISEASES OF THE VALVES. The valves of the heart are liable to depositions of fleshy, cartila- ginous, and osseous matter, which increase their thickness, alter their shape, and obstruct the orifices in which they are placed. They are sometimes so much altered in structure, as to be unfit to perform their chief function, viz.: to prevent the regurgitation of the blood. The valves at the origin of the pulmonary artery, have a remarkable im- munity from these diseases, while they are frequently met with in those at the aorta. The mitral valves are, perhaps, more frequently diseased than the tricuspid.* Appearances on dissection.—Sometimes the points only of the semilunar valves are affected ; at others, their bases; when they are affected throughout, they are deformed, and often coiled upon them- selves; and when in this condition, they have frequently a red fleshy- looking appearance, smooth, and polished. Very often a small car- tilaginous concretion is observed in the points of the semilunar valves, which may be considered as enlarged corpora sesamoidea, but which can scarcely impede the circulation, until they become of consider- able size. Sometimes these valves seem, as it were, to be encrusted with osseous matter; and I have seen instances in which it was im- possible to trace the inner membrane over the osseous projections. We sometimes find small fleshy vegetations resembling warts. The cartilaginous induration of the auriculo-ventricular valves is sometimes confined to the fibrous bands found in its base. In this case, it has the appearance of a very smooth, though unequal ring, diminishing the size of the orifice; it is sometimes of a semi-cartilagi- nous consistence; at others, it is formed of perfect cartilage. The same kind of appearances is occasionally met with in other parts of these valves, but those situated at the bases and points are usually the thickest. The osseous productions are found in the same situations, and are very unequal as to thickness. Like those already described in the semilunar valves of the aorta, they are often found projecting from the valve, denuded and very rough. We are assured by Laennec, that they are not perfect bone, being whiter, more opaque, more fragile, evidently containing a greater proportion of phosphate of lime. They are sometimes situated on the free marginsof this valve, [♦ The pathology of the morbid changes have been explained in the section on Endocarditis.] 42* 498 DISEASES OF THE VALVES. diminishing greatly the size of the orifice; indeed, sometimes to so great an extent, as scarcely to admit the blade of a pen-knife, of which there are examples in my museum. Sometimes, though rarely, the tendinous chords of the mitral valve are affected in a similar manner. In one case, Dr. Forbes found three of the pillars of the mitral valve completely ossified through their whole extent, with the exception of a minute portion at each extremity.* The auriculo-ventricular valves are likewise found studded with fleshy excrescences like warts; they are, in general, soft, and with difficulty preserved. When ossification is confined to the free margins of the sigmoid valves, or when the base is affected, if still slightly thickened, the valve may perform its functions, provided the middle portion be still sound ; but when the disease is extensive, the valves, according to Laennec, grow together, and get incurvated either towards their concave or convex side, in which state they are immovable, being either fixed on the side of the aorta, or in the orifice of the ventricle. Symptoms.—These are palpitations and dyspnoea, often to such a degree as to be called asthma; both these symptoms are increased by quick exercise, or any unusual exertion or emotion. When the disorganization advances to a certain pitch, the palpitation and dys- pnoea increase in frequency and violence; the pulse is weak, small and thready, and occasionally intermits, which corresponds with intermissions in the contractions of the heart; the feet are observed to become cedematous towards evening. At last the symptoms denoting impeded circulation, augment, the face and extremities become discoloured, the osdema extends to the legs, dropsical effu- sions take place into the different cavities, and the dyspnoea increases to such a degree, that the patient is obliged to remain in a sitting posture, or bent upon the edge of the bed, in a kneeling position. According to Laennec, the following stethoscopic signs are ob- served : " The symptoms of ossification of the mitral valve are little different from those attending the same affection of the sigmoid. According to M. Corvisart, the principal sign of the former lesion is 'a peculiar rustling sensation, (bruissement,) perceived on the ap- plication of the hand to the region of the heart.' This peculiar sen- sation is nothing else than the purring thrill already described. It is assuredly very frequently observed in the case of ossification of the mitral or sigmoid valves, when this exists in a high degree; but, as I formerly stated, it may exist when these valves are perfectly sound, and it is almost always absent when the induration is not so extensive as materially to obstruct the orifices. The bellows sound is a much more constant sign; it accompanies the contraction of the left auricle, when the mitral valve is affected, and that of the ventri- cle, when the induration is in the sigmoid. But even this is wanting when the alteration is not extensive; and as it is, moreover, very common when the heart is perfectly sound, we must lay no stress upon it as a sign, unless it be combined with other circumstances calculated to confirm the diagnosis. Accordingly, when the sound * Original cases, p. 133. DISEASES OF THE VALVES. 499 of the bellows, rasp or file, persists in the left auricle, either continu- ously or interruptedly, for several months; when it is found only then, and exists even in the greatest quietude; when it is scarcely lessened by venesection, or when lessened, if it still leave behind it a degree of roughness in the sound of the auricle—or, yet more, when the purring thrill coexists with this, we may be assured that the au- riculo-ventricular opening is contracted. If the same phenomenon occur under similar circumstances in the left ventricle, we may be equally certain that the aortal orifice is contracted." Three or four times, during the last four years, I have discovered this lesion by means of these signs. Three similar examples, equally verified by dissection, are recorded in M. Bertin's work,* and a fourth is given in the collection of cases published by Dr. Forbes; (Case vii.) "But," continues Laennec, " if these phenomena exist only for a time, al- though as much as two or three months; if they accompany the increase of any other nervous or organic disease of the heart, we must not depend upon them as indications of the lesions now in question, since all the facts formerly recounted, prove that these sounds are not produced (as might be imagined at first) by the pass* age of the blood over a rough or rugged surface, but to the spasmo- dic energy requisite in the muscular contraction, to overcome the obstacles opposed to it. It follows, therefore, that any other cause besides diminution of the orifices, which occasions contraction of the heart, is equally capable of giving occasion to the bellows sound and purring thrill; and it is fair to admit, that in the first edition of this work, I laid too much stress upon these two phenomena, as signs of valvular disease. A slight degree of cartilaginous or bony indura- tion of the valves may exist for a long time without any visible alter- ation of the heart; or even by proper measures of precaution, and by seasonable bleedings, we may frequently preserve, for a long time, the life of individuals, who present every sign of considerable con- traction of the orifices."—(Forbes's Translation, page 634.) Laennec appears to have laid too much stress upon the effects of nervous affections of the heart; and in the latter period of his life he became timid and doubtful with respect to his own powers of obser- vation, which enables us to account for the tenour of the above quo- tation. I believe, however, that these sounds, and more particularly the blowing or rushing sound, may be occasioned by a large quan- tity of blood rushing with violence through the orifices, even when the valves are sound. Within these few years, several cases of sudden death have taken place, even in young persons, and the only morbid appearance dis- covered upon dissection was disease of the valvular apparatus. Treatment.—A similar treatment to that formerly recommended in other diseases of the heart is necessary; viz.: to reduce and obviate plethora, to enjoin rest, and to avoid every cause which can increase the quantity of blood, and hurry the circulation ; and lastly, to mode- rate violent symptoms by applying leeches, producing contra-irri- tation, and administering an occasional opiate. * Observations, 49, 58, 51. CHAPTER VII. DISEASES OF THE BLOOD-VESSELS. The first disease of this class which I shall notice, is inflammation of the internal membrane of the heart* and large vessels near it. Since the last edition was printed, I have had much opportunity of examining this part of the morbid anatomy. Previous to this, I thought inflammation of the internal membrane of the arteries " a very rare disease," but am now convinced it is by no means un- common. I have seen false membrane in every stage, from the commencement of a deposition of lymph, to its complete organiza- tion. There are many specimens of this in my museum. It appears to me that the artheromatous deposit, so often found in the arteries, particularly in the aorta, is frequently produced in this false mem- brane, and not so uniformly in the middle coat as has been hitherto supposed. Bertin has written to prove that inflammation of this membrane is a common affection. The lining membrane of the heart, and of the large blood-vessels, is sometimes found of a brown or violet colour, and also a bright scarlet. It is a subject of contro- versy at this moment, whether this colouring is the effect of disease, or of imbibition of blood after death. From my own observations, I am led to conclude, that it is sometimes from the one cause, and sometimes from the other; and I think our conclusions must depend upon three circumstances : 1st. Whether any blood is found near the discoloured portion ? 2d. Does blood found in the aorta, always impart a colour to its lining membrane ? 3d. Upon the texture of the part so affected. I have frequently found the aorta of a red, brown, or violet colour, when neither it nor the left ventricle contained any blood; and, on the contrary, I have seen the aorta almost filled with blood, partly fluid, partly coagulated, when the inner membrane presented its usual straw colour. When the aorta was discoloured, I have oc- casionally found the inner membrane soft and pulpy, and readily removed with the fingers; and I scarcely remember to have seen in- cipient ossification of the aorta, without observing a vivid redness of its internal membrane. This subject ought to be held as being open to future investigation. The next point which has attracted the at- tention of pathologists, is the exudation of coagulable lymph. It is stated, that this has actually been found; Burns, for instance, dis- tinctly describes it: Laennec says, that he has observed false mem- branes of small extent, strongly attached to the walls of the auricles. The next subject worthy of attention is ulceration. Laennec seems [* Vide Endocarditis.] DISEASES OF THE BLOOD-VESSELS. 501 very much inclined, to doubt the existence of ulcerations in this deli- cate membrane; he supposes the parts, left by the separation of the bony incrustations of the aorta, to have been mistaken for ulceration; he states, however, that small pustules have been sometimes met with beneath the inner membrane of the aorta, and whichfhave discharged their contents into its cavity; and he asserts, that it is probable that what are called ulcers of the aorta, are formed in this manner, being the consequence of inflammation of the middle coat of the arteries, or of the fine cellular substance which unites this to the inner coat. In quoting these statements, I have to remark, that Laennec appears to be determined not to admit that inflammation of these parts can exist, and that he has manifested too much of the spirit of a special pleader. The last point which some individuals suppose indicative of inflam- mation of the inner membrane of the heart and blood-vessels, is the formation of concretions, well known by the name of polypi. One set of pathologists maintains, that they are the result of previous in- flammatory action, which another denies. It is a most interesting question in pathology, and therefore deserves minute investigation. Since the publication of the first edition, two dissections have taken place in Edinburgh, which set this question at rest for ever—several polypi, organized and partially ossified, having been found in the right auricle in one case, and several polypi containing pus in the other. I am well aware that polypi, which have been termed "organized" have been frequently observed, and.that injections have been thrown into the vessels; but doubts have been entertained on the subject, and the appearance of vascularity has been variously accounted for. The following is a short sketch of the first case above alluded to, and the appearances on dissection:—A young woman, of amiable disposition, and regular, industrious habits, died after several years' illness. I was requested to visit her some years before her death; she was then labouring under cough, quick and anxious breathing, palpitation, emaciation and hectic fever. One or both lower extremities were affected in a similar manner to that observed in phlegmasia dolens. Her appearance was so unpromising, that I thought she could not long survive; but she rallied, and for a time became better, but soon relapsed again; in fact she became better and worse at times, occa- sionally much distressed with dyspnoea, cough, pain and distension of the lower extremities, and febrile symptoms. It was thought that her lungs were affected, as the sound of respiration, during a severe paroxysm, was not audible in some parts of the chest. This opinion was subsequently abandoned, when it was supposed that the func- tions of the lungs were embarrassed in consequence of some impedi- ment in the circulation. The action of the heart appeared natural, but the sounds and impulse were weak. There was no irregularity of pulse. Nothing afforded her any relief but venesection ; and during her illness, I am informed she was bled above one hundred times. The uneasiness produced by the tense and swollen condition of the lower extremities, was greatly eased by repeated punctures, when a quantity of serous fluid was discharged. On dissection.—The lungs were somewhat oedematous, but ap- peared otherwise sound. The heart did not appear to be above the 502 OSSIFICATION OF THE ARTERIES. natural size ; the right auricle was found almost filled by a largo hard mass, which adhered by a broad margin to the superior part of the auricle, while its inferior portion projected into the corresponding ventricle; it was tightly held in this position by the tricuspid valve. The superior and inferior portions of this mass were converted into osseous matter, and felt hard to the touch. The centre part was in appearance like a hardened coagulum of blood; and when the pre- paration was recent, there were thin ossific scales seen running in a longitudinal direction everywhere over the surface. In the same auricle, there were three other, but smaller masses. One was like a coagulum of blood, and adhered to the superior part of the auricle, between the orifices of the pulmonary artery and superior cava; ano- ther was small and carneous, attached to about the centre of the auricle, but which was-broken off, and lost during maceration; its base, however, is still to be seen in the preparation ; the third mass has not been examined. It lies deep in the auricle below the large ossified polypus, and we were fearful of destroying the attachments of the latter to the heart. The inguinal veins and the vena cava were found distended with hard coagulated blood; on minute exa- mination the coats were found in a healthy state, perhaps somewhat thickened, but the contents adhered firmly to the sides of the vessels. In some parts, particularly on the right side, the contents of the veins were organized, completely obliterating the vessels. It does not appear that this condition of the lining membrane of the heart and arteries is indicated by any particular symptoms, although some assert that it is the cause of inflammatory fever. OSSIFICATION OF THE ARTERIES. The morbid condition which goes by this name belongs to the class of imperfect ossifications. These seem to be produced in two ways;—1st, By soft cartilaginous depositions, which are gradually converted into ossifications by the deposition of small calcareous spots, which gradually extend. 2d. By the deposition of a soft pow- dery substance, without any cartilaginous formation ; this substance becomes gradually converted into ossific incrustations. Occasionally ossified spots are found only here and there, although sometimes the whole vessel is affected. Some pathologists imagine, that this for- mation invariably takes place between the inner and middle coats, and is not connected with inflammation—this appears to be Laen- nec's opinion; others maintain, that it is the consequence of inflam- mation. After careful observation, I have reason to believe, that artheromatous and osseous deposits are the product of inflammation, and that occasionally they are formed in the situation mentioned; but that they are sometimes found in a false membrane, thrown out by inflammatory action of the internal coat of the arteries, admits of no doubt. When these depositions take place between the proper coats of an artery, the inner membrane in many parts is often even- tually removed, by exposing the bare ossified surface. This forma- tion is frequently the cause of aneurism. All arteries do not seem ANEURISM. 503 equally disposed to take on this diseased action. The aorta, at its origin from the heart, is most frequently found affected ; then the arch, and the descending aorta, the disease attacking the angle at which the vessels branch off, in preference to other parts. The arte- ries of the brain are very frequently found diseased in cases of apo- plexy. I have seen the most minute vessel that could be traced in the brain, in this condition ; and on one occasion, the circulation on one side of the circle of Willis was completely obstructed from the ossification of the vessel. The pulmonary artery, and the arteries of the superior extremities, would seem to enjoy a singular immu- nity, whilst those of the lower extremities are often affected. Ossi- fication of the blood-vessels must influence the functions of various organs. I possess a beautiful preparation, showing its effects upon the kidney—one emulgent being almost obstructed by ossification, while the corresponding kidney is in a state of atrophy. ANEURISM. There is no disease which shows the absurdity of the division of medicine into physic and surgery more than this. When an aneu- rism is within reach of the knife, then it is called a surgical case; if otherwise, it is handed over to the physician. All writers describe aneurisms of two kinds—the true and the false. I can join Laennec in stating that "true aneurism of the ascending portion and arch of the aorta is very common." I have seen it more frequently in such a situation than the false aneurism ; indeed, Laennec is of opinion, that false aneurism of the ascending aorta, or its arch, rarely, if ever, exists, unless formed by a rupture of the. inner coat of a true aneu- rism, after it has acquired a certain size; at least he states that he had never met with any other species of false aneurism in that situa- tion, but that consequent to the true or simple dilatation of the part. The abdominal aorta is also the seat of aneurism : and the arteries of the brain are not exempt. Aneurisms of the aorta exist in va- rious degrees, from slight dilatation, up to the size of the head of a full grown foetus. The vessel is found in one of three states:—1*/. The walls more or less converted into ossific matter, looking scab- rous and irregular, portions, in scales, being easily separated; in many instances these scales are found loose, and already more or less detached:—2d. That in which the whole of-the coats of the aneu- rism are entire, much thickened and cut under the knife like fibro- cartilage, having very much the same appearance:—3d. That in which a natural cure has been effected by the deposition of thick layers of coagulable lymph, filling up the aneurismal sac, leaving sufficient space for the passage of the blood :—4th. That in which a portion of the aneurismal sac is entirely wanting, in consequence of long-continued pressure on surrounding parts; so that sometimes a portion of the lungs, and even the spine itself, have formed a part of the aneurismal tumour. Aneurisms of the aorta produce various effects on the neighbour- ing parts, according to their size and situation. Laennec assures us, 504 ANEURISM. that simple dilatation, when in a moderate degree, hardly produces any effect; but that the most inconsiderable false aneurisms may give rise to very serious disorder. The first and most common of these effects is compression of the heart and lungs, by impeding the circu- lation and respiration. When the aneurism is in contact with the lungs, it most commonly merely compresses them; sometimes, how- ever, the substance of these organs gives way, and the aneurism, when it bursts, pours its blood directly into the air-cells; three re- markable cases of which I have already related when treating of haemoptysis. Frequently the aneurism compresses the trachea, or one of the bronchial trunks, which it flattens and eventually destroys, and death ensues by a species of haemoptysis from the rupture of the tumour. The same occasionally, but not so frequently happens to the oesophagus. Sometimes the aneurism bursts into the pericar- dium; two cases of this are also quoted, (page 50.) Laennec states that he never met with an example of it. The left cavity of the pleura, however, is stated to be by far the most frequent situation into which the rupture takes place. Laennec quotes a case recorded in the Bulletin de la Faculte de Medicine, in which an aneurism of the aorta burst into the pulmonary artery. He mentions a case where the thoracic duct was compressed and destroyed ; and Corvi- sart notices a fatal instance from compression of the superior vena cava. I have seen a preparation of aneurism of the abdominal aorta, which communicated freely with the vena cava. A preparation is in my museum, in which the splanchnic nerve is involved in the aneu- rismal tumour. This might account for the violent epigastric pain, nausea, and want of appetite, experienced for a series of years by the unfortunate man. Aneurisms often destroy a large portion of the vertebral column, and there can be no doubt that this destruction is the effect of interstitial absorption, not of caries. On the side next the vertebrae the sac is occasionally completely destroyed, and to use the words of Laennec—"the circulating blood is bounded by the naked bone :" several instances of which have occurred in my prac- tice. Aneurisms of the ascending aorta and arch sometimes destroy portions of the sternum by their pressure, so as to be at length co- vered only by the integuments. Aneurisms of the arch of the aorta and of the innominata occasionally project above the sternum. There is no complaint more insidious than the one under con- sideration; and many a sufferer has been supposed to be nervous, or hypochondriacal and fanciful, who was found, upon dissection, to have been affected with ossification of the arteries, or perhaps an internal aneurism. Laennec states, that aneurisms of the aorta can- not be detected till they show themselves externally, and often the first indication of such an affection is the instantaneous death of the individual, from the effusion of blood into surrounding parts. The symptoms which are sometimes observed, are oppression in the chest, dissimilarity of the pulse at the wrists; a loud whizzing or rushing at the top of the sternum, perceptible to the hand; obscure sound on percussion; rattling in the throat; and dragging down of the larynx, when the tumour compresses the trachea. In noticing ANEURISM. 505 these symptoms, he observes: "In the present state of our know- ledge, there assuredly exist no certain means of ascertaining the existence of this disease, until it shows itself externally. Even when the aneurismal tumour has made its way through the parietes of the chest, it is not always distinguishable from tumours of a dif- ferent kind." And in another place, he distinctly asserts that his experience has been insufficient to enable him "to say how far the difficulty of diagnosis is likely to be removed by the use of the stethoscope." From my limited experience on this subject, it be- hoves me to speak with very great diffidence; but the little know- ledge I do possess induces me to join M. Bertin who conceives that Laennec has undervalued the stethoscope in detecting aneurisms of the aorta. Along with the symptoms stated above, it may be men- tioned, that persons labouring under diseases of this description are generally observed to be very restless and impatient. The symptoms must vary considerably according to the size, shape and situation of the aneurismal tumour. It may press upon the spine, and occasion violent pain in the back, with weakness and anomalous nervous affections :—it may press upon a principal bron- chial tube, and create dyspnoea, or produce, by pressure, absorption of a portion of the lungs, and occasion dyspnoea, cough and even haemorrhage. Or it may compress the oesophagus, and produce difficulty in swallowing. All these circumstances are well illustrated by dried preparations in my museum. Stethoscopic sighs.—Strong beatings, synchronous with the pulse; in general, a single pulsation is felt, which Laennec terms "simple," in contradistinction to the pulsation of the heart, which is double. There is a greater impulse and a louder sound, than the mere con- traction of the ventricles produces. The single pulsation is generally accompanied by the bellows sound, " bruit de soufflet;" these vary in situation, according to the site of the tumour. If the aneurism press upon the air-passages, a peculiar hissing sound will also be observed during the act of respiration or speaking. When the tumour is large, the chest at that part will sound dull upon percus- sion, and sometimes even the hand, placed upon the part, will convey a vibrating sensation to the observer. Still, however, we must be cautious in pronouncing a diagnosis, for I have lately seen several cases in which, from other causes, one pulsation only was heard; which appears to me to be produced by the long-continued action of one set of cavities masking the sound of the other. Laennec speaks very confidently with respect to one point, which I shall give in his own words:—"If we find under the sternum, or below the right clavicle, the impulse of the circulatory organ isochronous with the pulse, and perceptibly greater than that of the ventricles exa- mined in the region of the heart, we have reason to suspect dilatation of the ascending aorta, or arch—the more so, as it is extremely rare to feel the impulses of the organ of circulation beyond the region of the heart, even in cases of the most marked hypertrophy. If this phenomenon be found constant, after repeated examinations, we may consider the diagnosis as certain." Bertin, in his work on diseases of the heart, states, that it is not by the pulsations that an 43 506 INFLAMMATION OF VEINS—PHLEBITIS. aneurismal tumour is to be detected, but by the great noise which accompanies them. Treatment.—It is very difficult to give any general directions for the treatment of internal aneurism further than that quietness of body and mind should be enjoined, together with attention to the bowels, and a light and rather dry spare diet. If there be signs of plethora, it should be diminished by a moderate bleeding ; if there be any local pain, we are to consider whether it will be most advis- able to subdue it by the application of leeches, a contra-irritant, or by the exhibition of an opiate. From the situation of an aneu- rism of the aorta, and its connection with neighbouring parts, we see at once how the function of the lungs may be impeded by mechanical pressure, independent entirely of the obstruction in the circulation; —how the brain may be affected by impeding the return of blood from the head;—and also how deglutition may be rendered difficult and even painful. It would appear that we are as yet very much in the dark re- specting the functions which the venous system performs, independ- ently of returning the blood to the heart; and I feel convinced that we have as yet no idea of the large share which inflammation of arteries and veins has, and particularly the latter, in different acute and chronic diseases. Many surgeons have yet to learn that much of the want of success attending surgical operations depends on in- flammation of veins, which they too frequently and unnecessarily tie. Phlebitis or inflammation of the veins may be produced by ex- ternal injuries and surgical operations, even by the slight operation of phlebotomy. When saline injection into the veins was first pro- posed in cholera, one of the objections that naturally suggested itself, was the danger of inducing phlebitis. But it is remarkable that, with the exception of two or three slight cases, our fears were proved to be groundless, although very considerable liberties were taken with the veins. Some forms of rheumatism are nothing more than inflammation of veins; and I believe the great majority of cases which are supposed to be inflammation of absorbents, will, if proper- ly investigated, prove to be inflammation of veins. The great danger appears to depend on the tendency which the inflammation has to extend itself towards the heart. Symptoms.—Pain in the course of the vein increased on pressure; tension; swelling and inflammation of the cellulur tissue in the neighbourhood, which at last involves the whole limb, when the dis- ease frequently goes by the name of erysipelas, or diffuse cellular inflammation. When the vessel is near the surface, a red line fol- lows its course, which feels knotty here and there ; the limb cannot be moved without intolerable pain; abscesses frequently form in various parts, when the affection is often called phlegmonous erysi- pelas. I do not assert that erysipelas is always produced by inflam- mation of the venous system, or that inflammation of a vein will always extend to the surrounding parts, and produce erysipelas: but morbid dissections have convinced me, that these circumstances not unfrequently take place. PHLEGMASIA DOLENS. 507 The combination of symptoms denominated fever, takes place, and increases with the disease, and it is too often termed typhus; the circulation is seriously affected; the head suffers, and early delirium often occurs. Inflammation of veins terminates in what is called resolution; that is to say, it is cured without injury to their structure, or to that of surrounding parts. Suppuration is said to be the most common re- sult of inflammation of veins; but it does not appear to me quite certain that pathologists have always been able to discriminate be- tween pus and lymphy effusion. Sometimes the vein becomes obliterated by the thickening of its coats, either with or without adhesions, which form in the canal itself by means of coagulated blood, which becomes organized, or of lymph, which is thrown out, or, as some allege, of pus, which concretes. When the principal trunk of a limb becomes impervious, infiltration into the cellular membrane takes place, producing a great enlargement of the ex- tremity; and Dr. D. D. Davis, professor of midwifery in the London University, has the great merit of being the first who discovered this to be the cause of the disease denominated phlegmasia dolens ; a discovery which has not only thrown light upon the disease in question, but also upon surgical pathology. Inflammation of veins sometimes, though rarely, terminates in ulceration and gangrene, involving the surrounding soft parts. Os- sification of veins is rarely observed; I have seen only one instance of it, and that was in the crural vein. The arterial system was very much disorganized from the same cause. The preparation is in my museum. Treatment.—General bleeding is sometimes necessary in this dis- ease, but in general the application of leeches, and incisions with the knife, are more frequently demanded, to diminish tension. Fomen- tations and poultices are required to the part, and the exhibition of calomel and opium seems indispensable. This disease, being gene- rally considered " surgical;" is not fully treated of here ; but I can- not lose this opportunity of referring the reader to an excellent practical paper on inflammation of veins, by Dr. Dumbreck, fellow of the Royal College of Surgeons of Edinburgh, published in his inaugural dissertation when he graduated in the year 1822. PHLEGMASIA DOLENS. Symptoms.—Some time after delivery, (within the fourth or fifth week,) pain, or some degree of uneasiness, is complained of in the hypogastric, lumbar, or inguinal region, with slight fulness at the upper part of the thigh, which soon increases, and extends down- wards, affecting the labium on the same side. The progress of the tumefaction varies in different cases. In some, the enlargement takes place rapidly; thus, I have seen the limb attain nearly twice the size of the other in the course of thirty hours from the time the person first began to complain. Generally, however, the disease is more slow in its march, the swelling increasing to its greatest size 508 PHLEGMASIA DOLENS. in the space of from forty-eight to seventy hours. On examining the limb, it will be found to be tense, somewhat elastic, white, shin- ing and hot, extremely painful, particularly upon pressure or motion. The patient is unable to move it herself, and experiences a sensation as if it were considerably larger than it actually is. Most frequently the disease is confined to one side—both limbs are rarely affected at once; but it sometimes happens that as it declines in one leg it attacks the other. Occasionally the pain is first felt in the calf of the leg, or the inner condyle of the knee, darting upwards and downwards; but in either case, the tumefaction goes on rapidly. The pulse is frequent; the skin hot; and the thirst urgent, with great restlessness. The lochial discharge cannot be taken into account, as the disease seldom comes on till it has disappeared. The phenomena above described are frequently preceded by de- cided marks of uterine irritation, and often by rigors; indeed, the worst form of this complaint is that which succeeds to peritonitis, and to symptoms indicating considerable irritation or inflammation of the membranes of the brain; and I have seen three instances in which women were attacked with phlegmasia dolens succeeding to affections of the brain; which had been preceded by severe peri- tonitis. The peculiarities of this disease are, that the limb is hot, white, and although swollen, the parts preserve nearly their relative proportions; in anasarca, the limb is generally cold; the swelling is greatest at the most depending part; and it pits on pressure, which does not happen in the first stages, at least of phlegmasia dolens. The duration of this curious affection is very various, depending much upon the constitution of the patient, the severity of the attack, and the mode of treatment in the early stage. In bad cases, which have been allowed to go on too long without applying the proper means, it is tedious and intractable, occupying weeks, and even months, leaving the patient, even then, feeble and in a dangerous situation. Under such circumstances, the limb will rarely recover its former small size, and will be for a long period stiff and powerless. It will be found that Mr. White's description of the symptoms varies from that of Mr. Brandon Trye, and both somewhat from that of Dr. Hull; and Dr. Dickson states, that the march of the dis- ease in the same woman varied in different attacks, which is exactly what I have myself noticed. In the 2d vol. of the " London Medi- co-Chirurgical Journal," it will be found that Dr. Belcombe mentions the case of a lady, the mother of four children, who experienced three violent attacks of this disease, after giving birth to the first, third and fourth child—her labours having always been easy and natural, and her general health good, except a decided tendency to constipation. The first attack commenced with pain in the right groin; the second commenced with pain in the calf of the left leg; the third was the most severe of all, and commenced about four days after delivery, again with pain, in the right groin, and after violently af- fecting that limb, attacked with equal, if not greater severity, the left; no lameness or enlargement followed, but there was a tendency PHLEGMASIA DOLENS. 509 to swell in the evening, and a feeling of stiffness upon the least ex- ertion. Phlegmasia dolens occurs also during pregnancy. In the same volume of the work above quoted, Dr. Dickson mentions having seen one case during pregnancy, and relates another, which occurred to Mr. Henderson, a surgeon in Bristol. He further states, that he is indebted to the same gentleman for an interesting example of this affection in the unmarried and unimpregnated female. Puzos relates three cases which occurred during pregnancy. In Thomas's " Practice of Physic," mention is made of an instance of this affec- tion happening in an aged woman. I have myself seen it under all these circumstances; and it now appears, as I shall subsequently show, that it is not confined to the female sex. Pathological observations.—Some obscure hints are to be found in the works of Hippocrates, which would lead us to suppose that he had seen the disease. Rodericus a Castro, a Spanish author, makes some pointed remarks in the third book of his work,* respecting swellings of the legs after parturition. The celebrated Wiseman no- tices a case, in the fifth chapter of the first book of his surgical works. Mauriceau, however, is the first author, as far as I know, who has given a tolerable account of its symptoms. The twentieth chapter of the first part of his works, is entitled, "Of the swelling of the limbs and thighs of women recently delivered." Puzos and Leve- ret also mention it, and suppose it to be produced by a translation of milk, which they imagine to be infiltrated into the limb. Mr. White, of Manchester, was of the opinion, that the disease is owing to the bursting of the lymphatics, from the pressure of the child's head, and the reteniion of the lymph, in the lymphatic vessels and glands of the limb. Mr. Brandon Trye supposed the disease to be seated in the lymphatic glands themselves, which are obstructed by the pres- sure of the uterus and its contents. Dr. Hull, who wrote a very learned treatise upon this disease, conceives that it "consists in an inflammatory affection, producing suddenly a considerable effusion of serum and coagulating lymph from the exhalents into the cellular membrane of the limb." (P. 204.) He considers that the pyrexia proves, beyond all doubt, the existence of a general inflammatory diathesis; the excruciating pain, tenderness, heat and swelling of the leg, equally evince the presence of topical inflammation; the seat of the disease he believes to be in the muscles, cellular membrane, and inferior surface of the cutis; and in some cases, perhaps, the inflam- mation may be communicated from these parts to the large* blood- vessels, nerves, lymphatics and glands. An attempt has been made to identify this disease with diffuse inflammation of the cellular mem- brane ; but in the disease I am now describing, there are no marks of inflammation of the cellular substance, whether subcutaneous or intermuscular, or of the muscular fibre itself, and the external aspect of the affected part is very different. Dr. D. D. Davis, professor of midwifery in the London University, to whose ingenuity operative midwifery stands so much indebted, being dissatisfied with all the * " De Universa Muliebrium Morborum." 43* 510 PHLEGMASIA DOLENS. pathological opinions that had been laid before the profession, set about the investigation with a mind unfettered by any particular doc- trine ; and so determined was he to be guided by the appearances displayed on dissection, that he resolved to employ a distinguished anatomist, who was to draw up his own report. The first fatal case which occurred in Dr. Davis's practice was that of a poor woman in St. Giles's, in the year 1819, and Mr. Laurence was requested to conduct the dissection. No distended lymphatics were observed, nor diseased lymphatic glands; but the crural vein was found diseased and thickened in its coats, and its cavity obliterated by an organized coagulum, and a matter which appeared like pus. Dr. Davis made public the result of this dissection in his class-room, and it became the subject of discussion at the medical society of St. Bartholomew's hospital; and perhaps it is fortunate for Dr. Davis's fame that that discussion took place, as very daring attempts have been made to deprive him of the merit which is so justly due to him. Subsequently to this period, Dr. Davis and others have had several opportunities of examining fatal cases, and in every instance, as far as 1 am aware, either the crural or the iliac veins were found affected in a similar manner.* After lecturing upon this subject in December, 1824, the late Dr. Dease, surgeon to the forces, who did me the honour of at- tending my class, told me that he had produced such a disease in the person of a sergeant of an Irish militia regiment, by tying the saphena vein to cure a variax. All the phenomena of phlegmasia dolens took place; the inflammation of the vein seemed to extend into, the abdomen. The disease was subdued by copious depletion, but the man had a narrow escape. It would appear that the same circum- stance has happened in the hands of Sir Astley Cooper, by tying the same vein. A case occurred, in the lower extremity, after amputa- tion, in a male patient operated on in the Westminster hospital; phlegmasia dolens took place in the other limb, and after death the disease was traced from the vein of the stump, which became in- flamed soon after the operation. The disease ascended along the vessels, so as to affect the iliac portion of it; after reaching the bifur- cation of the vena cava, the inflammation extended down the iliac vein on the opposite side, which was found thickened, and contained the same kind of plug observed in Dr. Davis's cases.t In the present state of our knowledge, lam far from alleging that inflammation of the veins is the only cause of this affection ; but I conceive that no reasonable mind can reject Dr. Davis's pathology. Treatment.—It would appear that Puzos was among the first who recommended blood-letting in this disease; and Leveret fol- lowed his footsteps ; but topical bleeding was not used until recom- mended by Mr. Trye. If the pulse be strong, and the patient robust, it may be found advisable to take blood from the arm in considerable quantity; but should phlegmasia dolens succeed any other acute disorder, which has left the patient much weakened, either by dis- * Vide Vol. xii: part 2, Med. Chir. Trans, of London. t The reader is referred to the dissection recorded at pp. 52, 53, of this volume. The appearance of the veins is described in a young woman, who' survived an at- tack of the disease for some years. PHLEGMASIA DOLENS. 511 eased action, or the remedies employed to reduce it, the lancet is inadmissible. We must then rely upon topical bleeding by leeches, purging, fomentations and blisters; in all cases, large doses of calo- mel and opium are necessary. As soon as fulness, with pain in- creased on pressure, is observed in the inguinal region, we shall have reason to dread an attack of this disease, and therefore must be on our guard; and should there be the least appearance of its becom- ing worse or extending, ten, twenty, or thirty leeches should be ap- plied over the part affected, and repeated in increased numbers, again and again, if necessary. The great point to be attended to is to arrest the disease before the swelling takes palce in the extremity. In this way, I think I have been able, during the last ten years, to check it several times in its first stage. If not called till the whole limb has become swollen, we must have recourse to leeches in such numbers as the strength of the patient will admit. Antimony is to be used as a contra-stimulant: in all cases it is a powerful means of enabling us to save blood. I cannot agree with Dr. Davis respect- ing the administration of digitalis, when we have a more powerful and certain remedy in antimony. In the latter stages of the disease, blisters are to be applied, so as to occupy the lower part of the belly, as well as the upper part of the thigh of the patient. I have seen good effects, in one case, from the application of ice to the limb in the early stage of the disease, but it might prove a dangerous remedy after the swelling has taken place. During recovery, frictions and bandages will be found very beneficial. With respect to the general treatment of inflammation of veins, it may be shortly stated, that it must be conducted upon the same prin- ciples as recommended in other severe inflammatory complaints. But I would strongly urge the free and early administration of calomel and opium, which is represented to have been so beneficial in inflam- mation of veins in the ordinary state of the system. CHAPTER VIII. PLETHORA, AND EXSANGUINITY. PLETHORA. I wish to restrict the term plethora to express an undue quantity of blood in the system. Although it can scarcely be ranked as a disease, yet it deserves to be treated of in a course of the Principles and Practice of Physic, as a powerful predisposing cause of many serious affections.* Where there is such a redundancy of blood in the system as to threaten mischief, some of the following symptoms will be observed: —an overpowering sense of heat and fulness; flushed face; oppres- sion in the chest, and more or less difficulty in breathing; weight at the praecordia; a sense of uneasiness or fulness in the head; a full strong pulse; occasional vertigo ; a difficulty in keeping awake, par- ticularly after a hearty meal; disturbed nights, from heat of surface and disagreeable dreams; and appearance of debility, which is not real but which induces many people to take more food and more wine, even when the pulse is full and bounding. The bowels will be found to be out of order, and the tongue, in general, loaded. To a person so affected, the least accident, as a fright, or exposure to cold, or drinking a cold fluid, or eating anything indigestible, de- ranges the balance of the circulation, and simple apoplexy may be produced, or accumulation of blood in some other internal organ, terminating in inflammation; or the combinations of symptoms deno- minated fever, may take place. Causes.—In youth, generally speaking, the constitution is pletho- ric, the demand for blood being great to meet the wants of the system, to supply the means of growth, and the development of the various organs and functions of the body. At the age of puberty, the system is very active; and it is sometimes matter of wonder, how quickly the various parts of the body take on the appearance of manhood. This period, therefore, is well known, even to the vulgar, as a criti- cal period of life. The plethora necessary to effect all these changes, subsequently becomes less and less requisite; and its continuance is the cause of many serious maladies which are known to take place at this age, [* See the section on Diseases of the Blood, page 459.] EXSANGUINITY. 513 in the shape of fever, inflammation and consumption. Indolence and sedentary habits are also causes of plethora. Some people make blood quickly; feed them on the lowest diet; but give them liquids, and they will still be plethoric: but there are others, who daily feed upon the richest articles of food, and yet can never be said to be in that state. Treatment.—It is fortunate for mankind that diarrhoea so fre- quently takes place, and assists the constitution when struggling for her very existence; that profuse perspirations are so easily excited; and that the kidneys act occasionally so as to produce an increased flow of urine—all of which circumstances tend, in a remarkable man- ner, to deplete the system. It will be observed, that eruptions of various kinds appear on the face, back, breast and shoulders, at the age of puberty, acting the part of good contra-irritants, to the relief of internal organs; these eruptions, which are generally of the slow suppurating kind, produce considerable local irritation. Sometimes I have seen urticaria appear very generally over the surface of the body, when the system was to all appearance in great jeopardy. Epistaxis, or bleeding from the nose, is known to take place fre- quently in plethoric subjects, and is often productive of the greatest benefit. The buoyancy of spirits, so peculiar to young men, urges them to athletic and manly exercises, and does good, not only by strength- ening the frame, but also by preventing plethora. In females, the menstrual discharge appears to operate in preventing a redundancy of blood. The consideration of these circumstances leads us at once to the proper plan of treatment, not only for the purpose of preventing ple- thora, but of reducing it when it does exist, and threatens danger. Blood-letting occasionally saves life; but it is very far from being necessary in the majority of cases, unless some important organ is threatened with inflammation. At first, the bowels should be very freely acted upon, and subsequently kept regular, so that the patient shall have one or two free evacuations daily. Regular exercise; early rising; moderate indulgence at table; avoiding slops; and sleep- ing in a well-aired room, are all points of the greatest consequence. EXSANGUINITY.—ANEMIA. This disease is characterized by a deadly paleness over the sur- face of the body, particularly of the face and lips. The pulse is quick and feeble, easily excited, and there are frequently palpitations; the appetite is impaired and fastidious; the bowels are disordered; there are languor, general debility and emaciation. There is considerable approach to this affection in chlorosis; and it is sometimes produced by the actual loss of blood. This is an affection which has been noticed by the older writers, but we are not yet acquainted with the pathological condition of the body on which this bloodless state depends, when it is not occasioned by haemorrhage. I have seen the affection occur at all ages, and in indi- 514 EX8ANGUINITY. viduals of apparently very different habits and occupations. The most unsophisticated example of exsanguinity on record, with which I am acquainted, is that related by Dr. Combe of Leith.* This disease affected a considerable number of workmen, who were employed in a coal mine at the village of Anzin, in the imme- diate vicinity of Valenciennes, in which neighbourhood I resided for upwards of two years, and had frequent opportunities of satis- fying myself of the correctness of the statements given in the 9th vol. of the "Journal de Medecine," by Professor Halle, of Paris. Although the disease attacked the men severely, who were employed in a par- ticular mine, yet I observed that a considerable number of others were pale and emaciated, and very few of the colliers looked strong and ruddy. The pit in which the disease occurred, was one hundred and twenty fathoms below ground, excavated in the same manner as the others, only from being longer, it admitted fresh air less readily; its temperature was 64°, and it exhaled an odour of sulphu- retted hydrogen gas, and respiration in it is described to have been difficult. The workmen affirmed, that the water which filters across the mine, on touching their hands, or the naked parts of their bodies, produced blisters and boils. Nevertheless, they had the imprudence to use it occasionally for the purpose of allaying thirst. A descrip- tion of the symptoms was sent to the school of Medicine in Paris, by which it appears, that the disease commenced with violent colics, pains in the intestines and stomach, dyspnoea, palpitations, diminution of strength, distension of the abdomen, and stools of a black and green colour. The patients continued in this state for ten or twelve days, or more, when the abdominal pains ceased, but the pulse re- mained feeble and contracted ; the skin lost its colour, and became of a yellow tinge; locomotion was performed with difficulty, and accom- panied by great fatigue; frequent palpitations caused an extremely painful state of anxiety; the face became swollen, and copious per- spiration took place. This state is represented to have continued even for more than a year, attended by wasting and emaciation. At length, the symptoms recurred with violent headaches ; frequent attacks of syncope; intolerance of light and sound; tympanitic dis- tension, pain in the belly, and purulent stools; and death soon closed the scene. When these details were transmitted to the Society of the School of Medicine in Paris, out of fifty attacked with it, three died, and none were perfectly cured. Upon an earnest request on the part of the Society, four pitmen were sent to Paris, on purpose that the phenomena of the disease might be more carefully watched—the treatment more efficiently directed—and in case any of the patients died, that the appearances on dissection might be minutely recorded. Two of these men recovered perfectly, one imperfectly, and one died. The following appearances were found on dissection. " The abdo- men contained no serous exudation. The intestines, and especially the colon, were very much distended; and the fat, both subcutaneous, and in the omentum and mesentery, was very yellow. The liver * Medico-Chirurg. Trans, of Edinburgh, vol. i. EXSANGUINITY. 515 was small, and did not project beyond the ribs; it was soft and plia- ble in every part; it was of a pale yellow colour, both externally, and in its substance, which was soft and unctuous to the touch. The gall-bladder was half full of bile, of a colour like the yolk of an egg; and when analyzed, was found to contain much coagulable albu- men. The spleen was small and softer than ordinary ; and the liquid which flowed from it, as it generally is, was red, like the dregs of red wine. The stomach, when opened, was found half full of a liquid co- loured like the dregs of wine. The duodenum and the jejunum were lined with a mucus of a similar colour: and when that mucus was removed, the membrane, both in the stomach and intestines in all their extent, appeared white and sound. The matter contained in the rectum was thick and figured, and of a greenish brown colour. All the other abdominal viscera were sound. In the cavity of the thorax, the right lung adhered almost every- where to the pleura, and especially on its anterior part, but the left lung was almost entirely free. In neither was there any remarkable quantity of serosity; both were light, crepitated under the fingers, and there was no congestion. They were externally white, and mottled with dark blue spots; and on incision, a frothy yellowish serosity issued from all points of these substances, but not from any preter- natural collection. The heart was of an ordinary size, and its flesh as pale as that of muscles which have been washed and macerated. Its parietes were soft, and the columnae carnae small. Its structure was not at all affected. Not a drop of red blood escaped from any of its cavities; but in the left ventricle, a coagulum, as pale as the flesh of the heart itself, was observed which contained no perceptible por- tion of colouring matter; the pericardium contained no serosity. The brain was white, the cineritious substance pale, and little distinguished from the medullary substance. Two or three scruples of serosity only were found in the posterior part of the left ventricle, and the choroid plexus was very pale. In the three cavities, all the vessels, both arteries and veins, were destitute of coloured blood, and contained only a small quantity of a serous liquid. No blood was found in the aorta, as far as its crural subdivisions, nor in the axillaries, as far as the brachial subdivision, nor in the accompanying veins, nor in the system of the hepatic ves- sels, nor in any of the sinuses of the brain. Upon making a deep incision into the flesh of the thigh, there flowed out a small quantity of liquid and black blood, but from no other part did any flow. The flesh of the muscles which cover the thorax was exceedingly red; but that of the extremities not much so. With respect to the appearances observed in Dr. Combe's patient, it may be briefly stated that they were similar. Treatment.—Mercury has been tried, but the result does not afford much hope of its being pre-eminently useful; and, in some cases, it was decidedly injurious, by producing febrile excitement. The most favourite remedies are stimulant and tonic medicines, with occasional opiates, when required to relieve the griping pains in the bowels, together with the employment of gentle laxatives. Professor Halle 516 EXSANGUINITY. speaks highly of chalybeates. I have seen several children, who suffered much from the draining of blood after being leeched ; but all of them recovered under light nourishing food, ass's milk, and a small quantity of brandy three or four times a-day, together with warm clothing ; the patients being kept as much as possible in the open air. I am induced to believe, from reflecting on many circumstances con- nected with cases that fell under my notice in the West Indies, many years ago, which were forcibly brought to my recollection when pe- rusing Mr. Twining's valuable observations on diseases of the spleen, in his work already quoted, that disorders of the spleen may be found to produce all the appearances of exsanguinity. I cannot speak with much confidence on the subject, but I have found much benefit from the use of Mr. Twining's spleen mixture in several cases. * [* See section on Diseases of the Blood, p. 459.] CHAPTER IX. CYANOSIS, OR BLUE SKIN. This affection is also known by the term "Morbus Cceruleus." Symptoms.—Discoloration of the skin, which is sometimes blue • at others, livid or violet; the whole surface is in this stale, even the mucous membrane lining the mouth. There are cough, palpitation, sometimes syncope. In some cases dyspnoea is a constant attendant' which is increased by exercise, a loaded stomach, constipation and mental emotions, together with the application of cold and damp. Pathological opinions.—This disease is usually attributed to a communication between the right and left sides of the heart, or to some other malformation of that organ, by which means a consider- able portion of venous blood is circulated in the arteries without having previously passed through the lungs. The passage of blood from the right side of the heart to the left may take place in conse- quence of the foramen ovale or ductus arteriosus, continuing per- vious after birth, or by a communication between the right and left ventricle. Dr. Gintrac, Professor of Anatomy and Physiology in the School of Medicine, at Bordeaux, published a work on this subject in 1824,* and he has collected the results of fifty-three dissections, of which the following is an abstract. In 22 cases the aorta was found to rise from both ventricles. — 33 — the foramen ovale was open. — 14 — the ductus arteriosus was open. — 4 — a single heart, of one auricle and ventricle. — 5 — the ventricular septum was imperfect. — 22 — the pulmonary artery was contracted. — 5 — the pulmonary artery was obliterated! — 1 — the aorta was obliterated. — 4 — the aorta was seen rising from the right ventricle, the pulmonary artery from the left. The above table is very interesting in many respects: it proves that the disease upon which the colour of the skin depends, is gene- rally congenital, when it either very soon proves fatal, or perhaps not till the child suffers from teething, or begins to walk alone. But, as * Observations et Recherches sur la Cyanose, ou Maladie Bleue 44 518 CYANOSIS, OR BLUE SKIN. Bertin remarks, many of these lesions have existed without the appearance of this affection of the skin. It is well known that a disease presenting similar external characters has been produced by the action of the nitrate of silver. I have seen two cases in which the disease followed the exhibition of this remedy; in both it was prescribed by the late Dr. Baillie for the cure of epilepsy, and in neither of the subjects were there any symptoms of organic affection of the heart. It is probable that in such cases the nitrate of silver produces a change either in the condition of the blood, or in that tissue which gives the colour to the surface of the negro. Bertin supposes that the disease depends upon a retardation of the blood in the whole venous system, and not upon the admixture of black and red blood, as has been alleged by others. [An elaborate inquiry by Dr. Moreton Still6 has led him to a similar conclusion; or, to use his own language, no one lesion is entitled to be considered as the ana- tomical character of cyanosis; but it may depend simply upon any cause which, acting at the centre of the circulation, produces general venous congestion.*] Treatment.—Should the disease depend upon any of the malfor- mations of the heart, already noticed, a cure cannot be expected ; but something may be done to mitigate violent symptoms, and pro- long life, by avoiding exercise, as well as every other circumstance which can tend to hurry the circulation, and quicken respiration. In the two cases already quoted, in which the discoloration of the skin was produced by the action of the nitrate of silver, every pos- sible remedy was had recourse to, first by Dr. Baillie, and afterwards by myself, without success, [* American Journ. of Medical Sciences, July, 1844.] PART Y. DISEASES OF THE NERVOUS SYSTEM. CHAPTER I. GENERAL REMARKS ON THE DISEASES OF THE BRAIN, &c. Hitherto a description of the disorganizing effects of diseased action on the matter of which the body is composed, has more particularly occupied our attention ; now, however, a more difficult task has to be attempted, as the inquiries here commenced involve the conside- ration of the functions of the brain, including the investigation of that class of affections commonly, but perhaps erroneously, termed the "diseases of the mind." There are great difficulties to be encoun- tered at every step; one of these relates to the nature of that which is called " nervous energy," and the manner in which it is propa- gated and conveyed to the different parts and organs of the body. Many important discoveries must be made by anatomists and physi- ologists before pathologists can be expected to explain fully and satis- factorily the true nature and seat of the numerous and complicated diseases of the brain and nervous system. Another obstacle, which too often thwarts us in our investigations, proceeds from the speedy manner in which the functions of the brain become so much affected as to render the sick unable to give a correct account of their feelings and symptoms. The first step to improvement is to acknowledge our ignorance; but in doing so, it must not be supposed that these branches of medical science have been allowed to stand neglected. On the contrary, there are many able and industrious cultivators in the field, both at home and abroad, and much substantial advance- ment has been already effected by their investigations. " Universa Arabum schole mansiones multas, in cerebro statuit et singulis facultatibus singulas sedes assignat." So says Lauren- tius, and, from the experiments of Rolando, Flourens, Serres, Magen- die, Sir Charles Bell and others, it would appear to be incontestable, that different parts of the brain and spinal marrow perform essen- tially different functions. It is, indeed, true, that there is a want of complete agreement in the results of the experiments of some of these distinguished physiologists, and that these discrepancies must be decided by subsequent experiment before the precise value of the statements already laid before the public can be accurately deter- mined. In the mean time, however, it must be held that the grand and leading fact is already proved, that the brain performs some actions essentially different from those emanating from the cere- 522 GENERAL REMARKS ON bellum; and both of these parts from the medulla oblongata and spinal marrow: and that the ganglionic system is, in some measure, independent of the brain, and is engaged in performing peculiar functions. The brain has been divided by those distinguished anatomists and physiologists, Gall and Spurzheim, into a number of organs, which they conceive to be separate ganglions; and although I must confess that I have had neither time nor opportunity to examine their sys- tem with that care and attention which the importance of the sub- ject demands, and which might enable me to give a decided opinion respecting the truth of all its parts, yet experience and observation oblige me to state, that much of their doctrines appears to be true, and that science owes a great deal to the labours of the gentlemen who have been engaged in phrenological inquiry. It would seem that the superiority of man to animals, and of one man to another, does not depend on the absolute size of the head, or even on the relative size of the brain; for it has been proved that the brain of a sparrow bears as large a proportion to its body as that of a man, and that of the canary bird a still larger proportion. Man owes his superiority over the rest of the animal creation to a larger development of the anterior lobes and hemispheres of the brain, and to the number and depth of the convolutions.* One man would seem to excel another in intellectual and moral worth, not from the absolute size of the head, but from a difference in the proportion of certain parts in the cerebral mass. Upon the repeated observation of these facts the phrenological doctrines have been founded. It appears to be established by experiment that there are nerves devoted solely to sensation, and others to muscular motion, while there are nerves combining both these properties. In a work published by Flourens, in the year 1824,t the results are given of a great many experiments performed on the lower ani- mals, which prove that different parts of the nervous system perform different functions. When the two lobes of the cerebrum were simultaneously removed from fowls, deafness and blindness were produced; the animals fell into profound torpor; they appeared to have lost all sensation; could neither eat nor drink, except when food was put into the throat; but when irritated and roused, they could walk, jump or fly. When the experimenter removed one lobe of the cerebrum only, the animals became deaf and blind on the opposite side of the body; the sensibility was only partially de- stroyed, and the lethargy was not so profound. When he removed the cerebellum from a number of animals, they did not lose their sensibility, neither did they become deaf, blind nor comatose. The animals still possessed the power of muscular mo- tion, but they were unable to control it. They could not balance their bodies ; their movements were tottering, like those of a person in a state of inebriation. * Magendie first observed a connection between the number and size of the con- volutions, and the vigour of the intellectual faculties. t Recherches Experimental sur les Proprietes et les Fonctions du Systeme Ner- veux, dans les Animaux Vertebres. DISEASES OF THE BRAIN, &c. 523 In a third set of experiments, he removed the corpora quadri- gemina in some of the animals, and total blindness of both eyes, with immobility of the iris, were the consequence. When the right was removed, blindness of the left eye took place. When the left was removed, blindness of the right eye was produced. When the corpora quadrigemina were wounded, contraction of the iris and weakness of vision occurred on the opposite side. Partial removal weakened the action of the iris, and produced partial blindness on the opposite side. Deep wounds of the corpora quadrigemina pro- duced partial blindness; but as the parts healed, vision was restored. The organ of vision seems to be the only part affected by injury or removal of the corpora quadrigemina in the lower animals. Flourens next performed a series of experiments to ascertain the functions of the medulla oblongata. He found that injuries and wounds of this organ produced convulsive movements in the parts supplied by nerves issuing from it: and he draws the following con- clusions.—1st. That the lobes of the brain, which neither regulate nor excite voluntary motion, are the seat of intellect, volition and sensation. 2c?. That, if the lobes of the brain or cerebellum are irri- tated or wounded, contractions of the muscles never follow; but he has proved by experiment, that the spinal marrow is the immediate agent of all the muscular movements and contractions; but it is not the seat of volition, nor does it possess the power of regulating the muscular action. 3d. That the cerebellum possesses the power of regulating the muscular action. 4th. That in the lower animals the power of vision depends upon the corpora quadrigemina. 5th. That the medulla oblongata is the centre of the involuntary move- ments. 6th. Another important result is ascertained, that deep wounds may be made into the substance of different organs of the brain, and considerable portions removed, without destroying the functions of the parts. And further, that complete recovery of their functions may take place as the brain heals, after they have been for a time partially or totally lost. From these and other statements in his work, it will be observed, that Flourens believes there are three distinct phenomena in every voluntary motion; first, volition, which depends on the hemispheres; secondly, co-ordination, or regulation of movement, which depends on the cerebellum; and thirdly, irritation, or that power which ex- cites muscular contraction, which depends on the medulla oblongata, the medulla spinalis and nerves. He has been led to believe that volition, sensation and perception constitute but one faculty, which is a function of the hemispheres of the brain. It may be briefly mentioned, that Rolando, from experiments performed previously to those of Flourens, came to similar conclusions, but with this excep- tion, that while the latter makes the cerebellum the regulator of voluntary movement, the former considers it the source whence the motion proceeds. Flourens next performed experiments on many animals, to ascer- tain the precise effects of opium, belladonna and alcohol. He con- cludes that opium acts more particularly upon the functions per- formed by the lobes of the cerebrum; belladonna on those performed 524 GENERAL REMARKS ON by the corpora quadrigemina; and alcohol on the cerebellum. It must be confessed, however, that these experiments are not worthy of so much attention as the former. It would appear, by a report made to the Academy of Sciences, upon the memoir of Flourens, by Portal, Count Berthollet, Pinel, Dumeril and Baron Cuvier—that these experiments were performed with the greatest care and circumspection; that Flourens repeated the principal ones before these philosophers ; and that they appeared correct. It would be difficult to find five men better qualified to decide upon a scientific subject. In the work published by Professor Serres* in 1826, it is asserted, at page 662, of vol. ii., that when an instrument is plunged into the lobes of the brain, or into the cerebrum, to a certain depth, severe pain and great sensibility are manifested; although he alleges, that the medulla oblongata is the principal seat of sensibility. At page 664, this author assures us, that disease of the tuber annulare and medulla oblongata produces paralysis, equally in the superior as in the inferior extremities; whereas disease of the lobes of the cere- bellum affects principally the sacral extremities; and disease of the lobes of the cerebrum, the superior. He thinks that disease of the corpora striata is shown, by effects being produced on the inferior extremities ; that of the thalami nervorum opticorum on the supe- rior. He also alleges, at page 687, that disease affecting the radia- tions of the thalami nervorum opticorum impedes respiration more than that of the radiations of the corpora striata; and that disease of both affects the voice, speech and pronunciation. The same author also asserts, at page 689, that the lobes of the brain exercise a very powerful influence over the voluntary muscles; and that injuries of these lobes are followed by paralysis on opposite sides of the body. Flourens contends, that when the medulla oblongata is injured, convulsions are produced on the same side of the body, which Serres thinks deceptive, and asserts that the same law holds good with respect to the medulla oblongata as with other parts of the brain, viz.: that injuries on one side produce paralysis on the opposite side of the body. Serres believes, that the cerebellum is the seat of sexual desire; and has brought forward facts which appear to show a remarkable coincidence between great and long-continued excitement of the sexual organs in both sexes, and marks of irritation and disease in the lobes of the cerebellum. The experiments of Magendie appear, in some respects, to con- firm, but in the majority of points to refute, those of the individuals already mentioned. He states, that it is not in the brain proper, nor in the cerebellum, that the principal seat of sensibility or of the special senses is placed. The hemispheres of the brain and cere- bellum may be removed in a mammiferous animal, and it will con- tinue to experience sensations, odours, sounds and sapid impressions. Vision, however, is abolished. Injury of the thalamus opticus is * Anatomie Comparee du Cerveau, dans les Gluatre Classes des Animaux V£rte- bres appliquee a la Pathologie et &. la Pathologie du Systeme Nerveux. DISEASES OF THE BRAIN, &c. 525 also followed by loss of vision in the opposite eye: for the exercise of sight, "the integrity of the hemispheres, of the thalami, and per- haps of the anterior corpora quadrigemina, and finally, of the fifth pair, is necessary."* The parts of the nervous system, he continues, which appear to be more particularly destined to motion, are " the corpora striata; the optic thalami in the inferior parts; the crura cerebri; the pons variolii; the peduncles of the cerebellum; the lateral parts of the medulla oblongata, and the anterior fasciculi of the medulla spinalis."^ Magendie's experiments on the cerebellum and its appendages have been followed by results of the most inte- resting nature, more particularly as to the agitated and prominent appearance of the eyeballs, and the movements of the animals ; but I must refer my readers, for further information, to Dr. Milligan's excellent and condensed translation of the work. It appears, from the investigations and experiments of Sir Charles Bell and Magendie, that the old notion respecting the existence of two distinct powers possessed by the nerves, is correct: but the former gentleman goes still farther. According to him, each side or half of the spinal marrow consists of three columns, each column performing peculiar functions. All the nerves which arise from its posterior column, are devoted to sensation ; those which arise from its anterior column, to muscular contraction; while the middle column gives origin to the respiratory nerves. The only part of the nervous system which it remains for me to notice, is that of the nerve called the great sympathetic, which, to- gether with its numerous ganglia, are in communication with the brain through the medium of the 5th and 6th pairs of nerves, and the spinal marrow through its whole course on each side of the spine. It is provided with numerous ganglia, which are for the most part deeply seated along the sides of the spine. The nerves of this system are smaller, with more of a reddish colour than the cerebro-spinal nerves, and are distributed in a peculiar manner, not only to organs not under the control of the will, viz.: lungs, heart, stomach, intestines, bladder, uterus, &c, but are also arranged in plexuses around the arteries and vena porta?. They would seem to possess no exquisite degree of sensibility; indeed, Magendie denies that they possess it in the least degree. There are different opinions respecting the structure and functions of this, as well as other parts of the nervous system, and the whole subject stands much in need of revision. It would be well for science if an association of phy- siologists were formed for the purpose of repeating the experiments which have been already made upon this subject.^ I hope there are few who will agree to the singular assertion made by Dr. George * Magendie's Physiology, by E. Milligan, M. D., p. 112. t Ibid., p. 120. t This statement was made in the first edition, and I have lived to see such a plan carried into practice by the British Association. It is to be hoped, however, that although nothing can be done in Edinburgh, without a practical illustration of a system of jobbing, which has long been a disgrace to her Medical School, that the Association will not again be led into such gross errors as happened in 1834, in the appointment to committees of men whose names are not known out of the street in which they reside. 526 GENERAL REMARKS ON Gregory, who, alluding to these experiments, states,"that no reason- able hope exists of deriving from them, even if considerably im- proved, any practical advantage."* For the purpose of preventing frequent repetition hereafter, it is essential to lay before the reader, in this introductory chapter, a short sketch of the principal symptoms which are supposed to indicate disease of the brain. It is also desirable to notice, in this place, the nature and causes of those symptoms, which are usually ranked in other works as diseases—viz.: headache, vertigo, convulsions, rigidity of the extremities, coma, delirium, paralysis, &c. 1. Headache.—Exclusively considered, headache is, perhaps, less frequently a symptom of disease within the head than of disordered action of the stomach and bowels. We sometimes meet with violent pains in the head in cases the terminations of which show that there has been no degree of inflammation going on; while, on the other hand, instances are not rare of great destruction of parts where head- ache has not been a prominent symptom. Headache may be pro- duced by determination of blood to the head, and is occasionally very much complained of after excessive depletion ; some individuals never partake of certain articles of food, without being severely afflicted ; and with many, long fasting has also the same tendency. The common effects of intoxication, more particularly when pro- duced by champagne, are too well known as a cause of headache to require being here insisted on. There can be no doubt, that loss of balance between the arterial and venous systems in the head, pro- duces this symptom. Persons who are frequently afflicted with head- aches, when these are preceded by rigors, attended by giddiness and drowsiness, and especially when produced by every slight exertion; by exposure to cold during the course of ordinary occupations, en- tering a heated apartment, or taking any stimulant, become objects of serious attention, and require -medical treatment. The most effi- cacious plan is to enjoin rest and quietness, to open the bowels, apply cold to the head, and to bathe the feet in very warm water. Some cases will be relieved by a stimulant, a nourishing meal, or an opiate, while others will require general or local depletion. 2. Vertigo.—This is a more important symptom than the former, and is produced by various and opposite causes, viz.: by determina- tion of blood to the head, as in inflammation of the brain ; by the want of a proper supply of blood in the head, as in haemorrhage, or after considerable depletion; by loss of balance in the circulation between the arterial and venous systems; by extravasation within the skull; by ossifications of the arteries of the brain; or by the growth of tumours and other disorganizations which may occur either on the surface or within the substance of the brain itself. Ver- tigo is one of the well-known effects of drunkennessj it is also oc- casionally produced by indigestible substances in the stomach and bowels—by the motion of a ship, a carriage, or a swing—by looking over a precipice, or climbing a ladder—or by running round in a circle; and it is rather a curious fact, that vertigo shall take place * Practice of Physic, p. 331. DISEASES OF THE BRAIN, &c 527 upon rising out of the recumbent posture after confinement to bed only for a day or two. Vertigo is likewise produced by dilatation of the cavities of the heart, and disease of the valvular tissue. 3. Convulsions.—Convulsions sometimes indicate disease of the brain. They frequently attend inflammation, and there can be no doubt that they occasionally depend on organic lesions. It would appear that convulsions are occasionally produced by too much blood in the head, and there can be no doubt that they are frequent- ly occasioned by too little blood, as after excessive depletion, particu- larly when the body is brought into the erect posture. They some- times take place from the loss of balance in the cerebral circulation. Indigestible substances in the stomach and bowels, and worms, together with the excessive use of stimuli, opium, &c, are well- known causes of convulsions. But I shall speak more at length upon this symptom when treating of epilepsy. 4. Rigidity of the extremities. The occurrence of this symp- tom, combined with paralysis, according to some French authors, is never wanting in the state called ramollissement of the brain. My experience is in general confirmatory of their opinion, that it takes place in a great majority of such cases; but I shall speak more fully on this point when treating of ramollissement of the brain. 5. Coma.—Coma, or even a tendency to it, is a very alarming symp- tom, more so than any of those already mentioned. It may be produced by various and even opposite conditions of the brain ; by inflamma- tory action, or the growth of tumours ; but it is, perhaps, more fre- quently occasioned by the state which has been denominated venous congestion of the vessels of the brain, than by any other cause; in fact, this would appear to be the condition of the brain in simple apo- plexy. An opinion, too, generally prevails, that coma always occurs in consequence of compression of the brain by effusion; but this is not the fact, as effusion, if it take place very slowly, may exist in great quantity without having such an effect. Coma is a frequent and a very alarming symptom in the fevers of this country, and it is difficult to discriminate the different states of the brain which give rise to this evidence of disease. He who shall be able to point out a sure method of discriminating between the coma produced by the advancement of diseased action, which will terminate, if not sub- dued, in disorganizations of the brain, and that occasioned by lost balance of the circulation, or by other causes capable of being re- moved, will confer a lasting boon upon society, and hand down his own name to posterity. One class of cases requires depletion, the anti- phlogistic regimen and the application of cold to the head ; while another sometimes requires the most potent stimulants, and will be injured rather than benefited by the application of cold. 6. Fever.—Febrile symptoms are produced by^inflammation of any organ or tissue of the body, including, pf course,the brain and its mem- branes. Yet it must be stated, that inflammation may exist in the brain, producing the most extensive disorganizations, without caus- ing those symptoms which, when combined, are termed fever. For example, the pulse, instead of being frequent, may be reduced in point of number and strength much below the natural standard—to 528 GENERAL REMARKS ON sixty, fifty, or even forty pulsations in the minute. It may be slow at the first onset of the disease, become quick, and continue so for a day or two, then sink below the natural standard, and rise again to one hundred and forty or even higher, during a subsequent period of the disease. During the course of one hour, great variations of the pulse may be discovered in affections of the brain ; sometimes it is very rapid and intermitting, then slow and irregular; oftentimes be- coming so weak as scarcely to be felt, and soon again recovering its strength. The character of the pulse must depend upon the consti- tution of the patient, as well as upon the treatment pursued; and I am acquainted with no disease in which the pulse becomes so quick after considerable depletion. A hot skin does not always accompany inflammatory action. There can be no doubt that very generally it does, but experience proves that the exceptions are numerous. The effects of extensive inflammatory action have been frequently discovered in the brain after death, in cases where the heat of skin during life had been below the natural standard, and where the face was deadly pale rather than flushed. Restlessness and thirst generally attend inflammatory action; some- times they occur in inflammation of the brain; but a tendency to lethargy, and even to coma, is perhaps more common than restless- ness. 7. Delirium is no doubt a very general consequence of inflamma- tion of the brain. But the young practitioner should be aware that it does not occur in all cases, and that delirium may exist without any inflammatory action; nay, that delirium may take place from the want of sufficient circulation through the vessels of the head, particularly when there is a determination of blood to some other organ, as in inflammation of the liver, bowels, and even in small circumscribed inflammations of the skin and cellular tissue. A slight external irritation, such as that produced by a blister, will, in some constitutions, occasion temporary delirium. The French practitioners, who have devoted much attention to the subject of arachnitis, allege, that inflammation of the arachnoid which covers the convexity of the hemispheres of the brain, always produces delirium; but Lallemand, who is one of their best writers, states,* that he does not think that the arachnoid is the seat of delirium, but that inflammation of the arachnoid produces that symptom by affecting the functions of the brain in the same manner as inflammation of the pleura will produce functional derangement of the lungs, as evinced by the occurrence of cough and dyspnoea. 8. Paralysis.—This is a very frequent result of inflammatory dis- eases within the skull, and of tumours and apoplexy. In paralysis the muscular or motive powers of the part affected may be weak- ened, or entirely destroyed, while sensation may continue unim- paired, slightly diminished, or entirely destroyed. In some instances, sensation is partially or completely destroyed, while the motive pow- ers continue nearly in the natural state. There is another condition * In his Second Letter, p. 246. DISEASES OF THE BRAIN, &c. 529 which is worthy of notice—a limb may preserve its powers of motion and sensation, but the person may have lost control over muscular action; and 1 have seen instances of this condition in the upper as well as in the lower extremities. I have observed it also very often in the hind legs of dogs affected with the disease called " the distem- per." Paralysis has been very properly divided into three varieties; hemiplegia, paraplegia, and palsy affecting a particular limb or part. Hemiplegia sometimes follows an acute affection of the brain, and very frequently succeeds to an attack of apoplexy; it does occur, how- ever, without being so preceded, when it is said by many to depend upon disease of the liver. Paraplegia is very frequently produced by disease of the spinal marrow; but the best pathologists believe that it may sometimes be produced by disease of the brain. Paralysis of one limb may, I be- lieve, be produced by disease of its own nerves; I have seen cases of paraplegia, and of great muscular debility of the lower extremities, occasioned by noxious sexual habits; and it is in these cases where local application and nux vomica, or its active principle, strychnia, appear to be of so much use. Two instances have fallen under my notice, of general debility of the whole of the voluntary muscles with paralysis of the superior extremities, which were attended by rigidity of the flexor muscles of the fingers, while the intellectual faculties remain entire. The disease, in both instances, was produced by the action of mercury. The individuals stood in the relation of uncle and nephew. Paralysis is sometimes sudden in its attack; at other times it is slow and insidious. The recovery is sometimes complete ; more fre- quently it is only partial, and occasionally the patient remains in the same state for life. The short sketch now given of these leading symptoms is intended to show how difficult it is to understand the diseases of the brain and nervous system; and it is to be hoped, will stimulate practitioners to be minute in the observation and comparison of phenomena, and unwearied in the prosecution of examinations after death. Not- withstanding all that has been so ably written on diseases of the brain, a great deal of error and ignorance yet prevails on the subject. This is not much to be wondered at, when we consider how slowly mankind throw off the effects of long-cherished opinions. Never- theless, it is surprising to meet with the most decided affections of the brain, which have been allowed to go on to a fatal termination unsuspected, because the symptoms did not tally, either in point of number or severity, with those laid down in Cullen's erroneous de- finitions. It was a favourite speculation of the late Dr. Monro, that the ves- sels of the brain cannot contain more blood at one time than another. Dr. Abercrombie entertains the same opinion ; and as he is the most recent writer on the pathology of the brain, and, moreover, as the point involves important practical results, I shall lay before my readers a short examination of his statements and reasoning.* Dr. ♦ Pathological and Practical Researches on Diseases of the Brain and the Spinal Cord. 2d ed., p. 315. 45 530 GENERAL REMARKS ON Abercrombie thinks he may assume, "that in the ordinary state of the parts, no material change can take place in the absolute quantity of blood circulating in the vessels of the brain. But the blood circu- lating in these vessels must be divided in a certain ratio betwixt the arteries and veins of the brain ; and it is probable that the healthy state of this organ will depend upon the nice adjustment of the cir- culation in these two systems." This gives, in my opinion, too arbi- trary an influence to the circulation. It is the general belief, that all the organs of the body are liable to be affected in their functions, sometimes with, at others without any alteration in the circulation ; and why should this be denied to the brain ? Dr. Abercrombie thinks that the brain is not compressible, "because, (says he,) we may safely assert, that it is not compressible by any such force as can be conveyed to it from the heart through the carotid and vertebral arte- ries." This appears to be rather a hasty assertion; the state of the respiration must have a great influence, not only on the quality or condition of the blood, which I believe to be a source of many cere- bral derangements, but on the quantity of blood in any given organ, and more particularly in the brain. In proof of the force with which the heart may act on the cerebral circulation, the following case may be mentioned. A young lady fell down suddenly and died on the spot. On dissection, and aneurism about the size of a hazelnut, situated at the origin of the sylvian artery, was found, which had been ruptured with such force as to break down the substance of the brain, so that a large quantity of blood found its way into the ven- tricles. Dr. Abercrombie endeavours to trace the various ways by which, in such an organ as the brain, derangements of the circulation may be supposed to take place. In a plethoric state of the body, he ad- mits that "the arteries going to the head will partake of this general condition, and there will be an effort or impulse which tends to pro- pel an undue quantity of blood into the arteries of the brain. Though no addition to the whole quantity of blood in the brain can actually take place, because the vessels of the brain are already full, the con- stant impulse will be such as tends to introduce an additional quan- tity, and consequently, tends to derange the healthy relation betwixt the arterial and venous systems; for any increase of quantity in the one system, if such actually took place, would lead to a correspond- ing diminution of the quantity in the other. Let us say, for example, that the whole blood circulating in the brain is as ten, and that it is divided between the arteries and veins as five to five. In the loaded state of the system now referred to, we can suppose a case, in which, by some sudden impulse from the general circulation, the arteries of the brain are, at a particular moment, distended by a quantity as six. In any other part of the body this will be followed by similar disten- sion of the corresponding veins, and the healthy balance of the circu- lation would be speedily restored; but in the brain the very reverse would happen: for as the whole mass of blood must continue at ten, if the arteries were distended by a quantity as six, the quantity in the veins must be diminished to four; because the increased capacity DISEASES OF THE BRAIN, &c. 531 in the one system of vessels can only be gained by a corresponding diminution of capacity in the other." Dr. Abercrombie here asserts, that the quantity of blood in the head can undergo no variation; it must be always the same; but he admits that a derangement may take place in its distribution between the arteries and veins; the former may sometimes contain too much, which necessarily leads to a diminution in the latter, and vice versd. Let us follow out Dr. Abercrombie's example, assuming the whole blood circulating in the brain to be as ten, and that it is divided be- tween the two systems as five to five. Now, whether we begin by adding or by diminishing, it allows an addition or diminution to the whole quantity of blood in the head, which Dr. Abercrombie believes cannot take place. An increase in the arterial system of the head cannot take place before a diminution occurs in the veins, nor in the veins before a diminution takes place in the arteries; so that if Dr. Abercrombie's position were correct, no loss of balance could by any possibility occur in the vessels of the head. In tracing the various ways by which derangements of circulation may be supposed to take place in the brain, and in following out the same line of argument, Dr. Abercrombie states that "if a depression has been produced of a portion of bone, so as considerably to en- croach upon the cavity of the cranium, or if a coagulum of blood has been deposited, so as to occupy a considerable space upon the sur- face of the brain, the diminution of space thus produced would pro- bably affect chiefly or entirely the venous system of the brain. It would not diminish the quantity of blood which tends to enter the arteries of the head, but it would diminish, in proportion to its extent, the capacity of the veins, and thus derange the relations betwixt the two systems of vessels, in a different manner from that which has been supposed under the former heads, but analogous in its effects upon the circulation in the brain." We are entitled to ask, why the arteries should have such a re- markable exemption ? Why should the veins be more affected by the pressure than the arteries, unless the depression or coagulum be in the course of the longitudinal or lateral sinuses? If the skull be completely filled during life, and if a piece of bone be depressed or a coagulum be deposited, every part of the brain, and all the vessels, arteries as well as veins, ought to feel it, and not .one set of vessels alone. From all the facts referred to by Dr. Abercrombie, in his work, he arrives at last to an important practical conclusion, that we can- not diminish by treatment the quantity of blood in the head, for, however guardedly Dr. Abercrombie has surrounded himself by cautious expressions, and more particularly in the second than in the first edition, that seems to be his decided opinion. But he shall speak for himself: "Upon the grounds already referred to, there is reason to believe that we cannot, by our evacuations, diminish, in any material degree, the quantity of blood in the head." But the effect of evacuations, he supposes, will be to take off the excessive impulse from the circulation. The experiments of my lamented friend, the late Dr. Kellie of 532 GENERAL REMARKS ON Leith,* and the mechanism of the skull, show, not as Dr. Abercrom- bie supposes, that the quantity of blood in the vessels of the head cannot be diminished, but rather, how difficult it is to deplete the brain altogether, or so much as to render it cognizable to our senses on dissection, even in animals purposely bled to death. Certainly we are not entitled to conclude, from any known facts or experiments, that the brain must always and in all circumstances contain the same quantity of blood. When blood is taken from the arm, the brain sooner or later becomes affected, as is shown by the occurrence of giddiness, singing in the ears, impaired vision, &c.; and if the ope- ration be still continued, syncope, perhaps convulsions, will follow. We then favour the flow of blood to the head, and do all we can to impede its return, by placing the body in the horizontal posture, allowing the head, in severe cases, even to hang lower than the rest of the body. Were Dr. Abercrombie's hypothesis correct, the cir- culation in the head, and consequently, the functions of the brain, ought not to be materially affected by position; it ought to be nearly the same whether the body were supported upon the crown of the head, or on the tuberosities of the ischia. In a practical point of view, then, both experience and common sense loudly rebel at the bare idea of such notions as those entertained by this author; for if it were wished to subdue a true inflammatory action in the arterial system of the brain, a vein must not on any account be opened, and more particularly the jugular, because, by emptying the venous system within the skull, or doing any thing which has a tendency to empty it, as a matter of course it must follow that the quantum of blood in the arteries will be increased in the same ratio, because the vessels of the brain must always contain the same quantity;—if there be too little in the veins, a proportional accumulation must take place in the arteries. Upon the same hypothesis, the converse must also hold good, viz.: that when there is great accumulation of blood in the veins of the head, acute action ought to be an impossibility; and the most effectual method of extinguishing inflammation in the brain would be to place ligatures on the jugulars, or by some other means to im- pede the return of blood from the head. Cupping, leeching, and the application of ice to the head ought also, upon this principle, to be injurious rather than beneficial, and the head and shoulders should be placed in a depending rather than an elevated position. In conducting this important critical examination of Dr. Aber- crombie's doctrines, I have not availed myself of the arguments which could be fairly drawn from the experiments of Drs. Carson and Barry, by which it would appear that the heart exerts a sucking, as well as a propelling power, and according to which Dr. Abercrombie would have still greater difficulties to contend with. Neither have I taken advantage of certain anatomical facts respecting the cavities in the brain—the free communication between the ventricles of the brain and the bony canal which contains the spinal marrow nor of the serous fluid which is known to exist in and about the brain and * In Dr. Kellie's death, the world has lost an accomplished physician : and I have to regret the loss of an able friend, to whose advice and assistance I had often to apply when in difficulty: DISEASES OF THE BRAIN, &c. 533 spinal marrow, and which is found on dissection to vary so much in quantity. I have seen many dissections made with a view to ascer- tain whether there existed a communication between the ventricles of the brain and the spinal marrow. The subjects being placed on the face, the slightest pressure made on the surface of one of the hemi- spheres, caused a wave of fluid to ascend beneath the arachnoid of spinal marrow as high as the 4th rib. Pressure applied on both sides of the Brain caused the fluid to mount over the convexity of the back, and find its way to the inferior part of the spinal canal. [Recent pathological investigations have fully confirmed the fact already adverted to, that various diseases of the brain are mainly owing to or dependent on morbid conditions of the heart. Among these is ramollissement; which is often consequent, not as has been generally supposed, to excess of blood in the brain, but to a defi- ciency of that fluid from disease of the aortic or mitral valves; whence the importance of inquiring into the state of this apparatus in all chronic cerebral affections.] 45* CHAPTER II. INFLAMMATION OF THE BRAIN AND ITS MEMBRANES. 1. Inflammation of the membranes of the brain as the disease occurs in adults*—It must be carefully kept in recollection, that in all inflammations there may be not only several degrees of the dis- eased action, as the acute, subacute, and chronic, but there may also be a congestive variety, giving various shades of symptoms. The .extent and duration of the disease, the age, sex and constitu- tion of the patient, must also necessarily give to the symptoms a wide range of character. . Hence, a person who has enjoyed robust health up to the period of an attack of inflammation of the mem- branes of the brain, will generally be affected in a different manner from another who, for months before, had been daily losing blood in consequence of haemorrhage from the nose, the. uterus or the bowels. Inflammation of the membranes of the brain may also be compli- cated with diseases of the lungs, heart, kidneys, or some other organ, producing endless modifications: therefore it is impossible to convey a correct notion of a disease, by means of a definition con- taining an enumeration of a few of the symptoms. Cullen has classed all the acute, subacute, and chronic diseases of the brain and its membranes under one head, which-he has termed phrenitis; and the following is his definition : "Pyrexia vehemens; dolor capitis; rubor faciei et oculorum; lucis et sone intolerantia; pervigilium: delirium fefox, vel typhor mania." This definition will neither suit inflammation of the membranes of the brain nor of its substance. It represents a case of very rare occurrence, indeed, and one which is therefore an exception to the rule. Those who have studied nature, will join me in stating) that we rarely, if ever, see the combination of symptoms as above de- scribed; and that a patient may show them all, without the existence of inflammatory action. On the other hand, we often meet with * Under this head, I shall treat of inflammation of the arachnoid and pia mater;. because ihere are ho diagnostic symptoms by which we can distinguish inflamma- tion -ot' the one membrane from that of the other; but as this distinction is interest- ing in the present state of our knowledge with reference to morbid anatomy only, I shall defer for the present the further consideration of the subject. I believe that all pathologists, especially the French, have attributed too many of the phenomena of inflammation of the membranes to the arachnoid, and have overlooked the influence of diseased aption in the pia mater. INFLAMMATION OF THE BRAIN. 535 inflammations within the skull without symptoms of fever, the face being decidedly pale, instead of red: and the pain of head is not always a prominent feature of the disease. Vogel had probably similar views in his mind when he declared that " all the acknowledged symptoms of inflammation of the brain are equivocal, not only as to a distinction of one morbid part from another, but as indications of inflammation in any part." Phenomena of inflammation of the membranes of the brain. —1. This disease sometimes attacks a patient in the following man- ner: There is a well-marked rigor followed by pyrexia, intense headache, redness of face and eyes, intolerance of light and sound, violent delirium, pulse at first considerably above 100. In a day or two coma steals on the patient, followed by partial or general con- vulsions, terminating in death. This, as has been already hinted, is the rarest case to be seen in practice; and it is unaccountable to me how Cullen should have been led, in drawing out a description of the disease, to choose it as his model. 2. Cases are sometimes met with, in which the first prominent symptom is convulsions ; but upon making minute inquiry we shall generally find that the patient had been for some days out of his usual state of health; that he appeared drowsy, and rather inactive. There may be only one severe convulsion followed by paralysis, coma and death; or there may be repeated convulsions for days, with intervals of sense, till the fatal termination, which is generally preceded by paralysis and coma. 3. At other times the disease comes on with severe headache; violent terror producing loud and long screaming, attended with considerable disturbance in the intellectual functions, so that the patient can scarcely give any account of his sensations; and coma soon makes its appearance. 4. Occasionally a.patient complains, for perhaps a week, of slight feverish symptoms, and tinnitus aurium, but does not suffer much from headache; nor is he observed to have more intolerance of light or sound than most patients labouring under fever, in which the brain is not peculiarly affected. He may complain most of giddiness, and a feeling of weight on the crown of his head; his bowels are ob- served to resist the action of laxative medicine much more than usual; his pulse may be about 100, without any characters indicat- ing a serious affection: the heat of skin may be somewhat increased at night. At length restlessness gives way to what is thought to be drowsiness; the patient does not answer readily when spoken to, which is attributed to deafness; and as this is neither an uncommon nor a bad symptom in fever, it is not much regarded, particularly as, when roused, the patient appears quite sensible, and will take any thing which is offered him. But, at last, the coma becomes pro- found, the pupils dilated; he will sometimes grind his teeth; squint- ing will be observed, with partial or total blindness; paralysis of one side of the body sometimes follows; and the patient will gradually sink after repeated convulsions, which in most cases are in the first instance general, but by degrees become more partial, till at last they only affect the muscles of the face, and some of those connected with 536 INFLAMMATION OF THE BRAIN. respiration. Occasionally, however, the convulsions are partial from the first, affecting the muscles of one superior extremity; perhaps only some of the muscles, in which case the hand will probably be found to be twisted during the paroxysm. A fifth form occurs without much fever, but with some degree of headache, intolerance of light and sound and considerable giddiness. The patient may complain very much of nausea and pain in the sto- mach, which being the most prominent symptoms, together with constipation, the disease may be attributed to disorder of the digestive organs. Vomiting sometimes takes place, and becomes intractable ; every thing taken into the stomach being quickly rejected. The cerebral disease goes on advancing, but in such a manner as to avoid notice, till at last the patient becomes drowsy and comatose, or convulsions appear, and death sooner or later follows. 6. Another form under which the disease advances, is: a patient, after being affected with some acute disease for two or three weeks, during which he may have been bled and otherwise properly treated, the original disease appearing to be quite subdued, may complain, while in a state of collapse, of passing restless nights, being disturbed and agitated by frightful dreams. His strength suddenly becomes increased so as to require restraint to keep him in bed; his pulse is weak, perhaps quick, so weak and quick as scarcely to be counted; the extremities are cold, and cannot, by the most assiduous attention, be kept warm; one or both cheeks present a flush, the size of a shil- ling, the rest of the face being deadly pale. The raving is constant. There may be subsultus tendinum; picking or twisting the bed- clothes, or one or both hands may constantly be in motion, wiping the angles of the mouth and eyes, or engaged as if drawing hairs, either from the fingers of the opposite hand, or from some parts of the face. The tongue, as in the progress of most of these cases, becomes parched and brown ; paralysis takes place, with convulsions or coma; and as death approaches, respiration becomes difficult, and the pulse gradually weaker. 7. A person may complain of passing restless and uneasy nights; he cannot lie long in one posture. When about to fall asleep, he is annoyed by some unpleasant thought or frightful dream; the feet, perhaps cold when he went to bed, become very hot; and he has some uneasiness in his head. Towards morning, a slight relieving perspiration takes place; he sleeps a little; and awakes with some degree of headache, which is attributed to bile, or to the bad position of his pillow. His urine may be very scanty and high-coloured ; the mouth clammy and the tongue fout; but after being washed and dressed, and taking his breakfast, he feels better, and proceeds to attend to his business. During the course of the day, he is weak, and experiences a difficulty in applying his mind to the affairs which usually occupy him. Every thing he does costs him a struggle ; his feet are cold; he feels chilly, and every exposure produces a ten- dency to rigor. He is observed to be impatient and irritable, even about trifles; and he longs for the hour when his business is to ter- minate; but he retires from it with increasing headache. When he goes home, his family attribute his complaints to cold, or to over- INFLAMMATION OF THE BRAIN. 537 exertion, or to weakness, and he is pressed to take nourishment, and even wine or spirits and water. These symptoms may be relieved or may continue, the patient getting better and worse for many days, till at last symptoms of a more urgent nature take place, which une- quivocally announce the progress of some serious disease; and when a physician is sent for, he finds symptoms denoting a very dangerous affection of the brain, or a complicated case which suits his notion of typhus fever. The case may be now beyond the reach of reme- dies, and coma soon becomes profound. In the general remarks, it has been observed how very variable is the pulse in diseases of the brain, even in the course of the same day. The same remarks are peculiarly applicable to inflammation of the membranes of the brain. The pulse may be quick—140,150, or 160, and weak, for in general, when the pulse is so very rapid, it is also very weak ; or it may be above 100, and rather strong; it may be at the natural standard, or a little above it, and either strong or weak ; or it may be much below 70, very strong, or only of the proper strength; and under all these conditions, the pulse may be irregular, intermitting, and varying very much in strength. Upon the whole, a very slow or a very quick pulse indicates danger; per- haps the former is a more dangerous symptom than the latter, as a pulse often becomes very quick in irritable constitutions under the application of the usual remedies employed for the cure of inflam- mation. The observations already made in the general remarks respecting the heat of the skin, and the other symptoms usually denominated febrile, equally apply to this part of the subject, and therefore need not be repeated. From a careful examination of the eyes and general expression of the countenance, the experienced physician gathers much assistance in forming an opinion whether the brain is or is not affected. The pupils, in the first stage, are generally found more or less contracted; as the disease advances, they often become dilated. One pupil may be dilated, while the other is contracted. An immovable pupil, whether dilated or contracted, is an important symptom. In almost all cases of inflammation of the brain, the conjunctiva is very vascu- lar; in the worst cases, I have observed an angular patch, having more or less of a bloodshot appearance, situated near the inner can- thus, the apex pointing towards the cornea, the latter part appear- ing usually dry and slight muddy. When there is wild delirium, the eyes have a very brilliant, animated expression ; when there is coma, or a tendency to it, they look stupid, and are sometimes void of all expression. There may be squinting of one or both eyes, or they may roll in a frightful manner; may appear as if fixed in their sockets; or one or both may be turned up, giving the expression de- nominated pathetic. The eyelids are generally kept closed in the commencement of affections of the cerebrum, perhaps to avoid the light; as the disease goes on, however, one or both are observed to be half opened; and there may be partial or total blindness of one or both eyes. This, it may be remarked, is always a more unfa- vourable symptom than deafness. With respect to the expression of 538 INFLAMMATION OF THE BRAIN. countenance, it is sometimes animated, bold and even audacious; at others, the expression is subdued; in some instances, there is a total want of animation, with an expression of stupidity, as if the mind were not acting at all; and sometimes there is an appearance ex- actly resembling that of a man considerably advanced in a state of inebriation. Occasionally the teeth are observed to be clenched, approaching to the state of locked jaw. Sometimes there is an expression as if the patient were labouring under violent pain; at others, it gives the idea of passive suffering. The speech is variously affected. Patients sometimes show great volubility; at other times they are taciturn. In cases where there are marks of considerable oppression of the brain, the words hang, as it were, in the mouth; the patient forgets the names of his nearest relatives even before he is observed to confound one individual with another, and he frequently falls asleep before he has half finished a sentence. The tongue may be paralyzed partially or completely : in general, when the patient shows it, it appears in a tremor; or it may be in constant and violent motion, pushing out the cheeks, or protruded out of the mouth. It may be either moist and loaded, or dry and covered with sordes. Respiration is not necessarily affected in inflammation of the brain or membranes; sometimes, however, it is very much so ; but dis- section has yet to reveal upon what lesions this depends. Occa- sionally, particularly in young persons, the respiration has a crowing sound resembling that in the back draft of hooping-cough, of which I shall speak more fully under the head of hydrocephalus. Before a convulsive paroxysm the respiration sometimes becomes very much hurried, and after it subsides it is so slow as to appear altogether suspended. Causes of inflammation of the membranes of the brain.—Ex- perience teaches us that some individuals, from peculiarity of consti- tution, or from hereditary conformation, are more liable to inflam- mation of particular organs than others. Whatever cause disturbs the balance of the circulation between the venous and arterial sys- tems may cause inflammation of the brain and its membranes. In the fevers which prevail in this country, and which are called ty- phoid, there are symptoms decidedly indicating disease of the brain from venous congestion ; and it is a nice matter to discriminate be- tween a case purely of this nature and one of inflammation; and still more difficult if the two are united. In the one case, stimulants may be used with advantage, and in the other, they may do irrepa- rable injury. Cold; fright; external injury ; suppression of any of the exertions; the sudden disappearance of an old discharge or erup- tion, or the healing of an old ulcer; exposure to a vertical sun with the head uncovered, are all causes of inflammation of the brain. But constipation of the bowels in a plethoric habit, in addition to some of the causes just enumerated, most frequently, 1 believe, occasions this disease. Infants are more liable to inflammation of the mem- branes of the brain than adults, particularly during the period of dentition. This appears to be owing to determination of blood to- wards the head, caused by the irritation of the gums. Although INFLAMMATION OF THE BRAIN. 539 men are more frequently attacked than women, yet it is a mistake to suppose that thinking men are more liable than others to diseases of the brain. It requires something more than the continued exer- cise of thought and ardent study; there must be conjoined long-con- tinued anxiety of mind, high living, abuse of stimulants, want of exercise, cold feet, or inattention to the bowels. All these circum- stances predispose to this affection. Appearances on dissection.—A person may die in the first stage of inflammation of the brain, when the balance of the circulation in the vessels of the head is disturbed; and the patient is said to owe his death to simple apoplexy. On dissection, the only diseased ap- pearances discovered, will be considerable engorgement of the cere- bral vessels, with more or less effusion of limpid serum. In inflam- matory affections of the brain, we must not always expect to meet with effusion, because the patient may die before this result has taken place, and death may be owing to what is called the shock of the disease, or that produced by the remedies. We sometimes meet with considerable venous engorgement, not only of the great sinuses, but of the trunks of the veins running into them, and very small vessels containing red blood will be seen arbo- rescing with each other in every direction. In many decidedly con- gestive cases, I have seen the carotid and vertebral arteries distended with dark-coloured blood; occasionally ecchymosed spots are dis- covered here and there on the surface of the brain. Pure arachnitis must be a rare disease. The arachnoid, in a state of health, is not a very vascular membrane; at least its vessels do not convey red blood. In my whole experience, I have not met with above six cases of inflammation of the arachnoid membrane. In ninety-five cases out of the hundred, the effusion is situated, not on the serous surface of the arachnoid, but between it and the pia mater. In general, if the least effusion be discovered between the membranes of the brain and in the ventricles, it is noted down with- out farther examination as the result of inflammation; but I believe there is always some fluid between the two membranes in a state of health. The same remark equally applies to the ventricles; besides which, it must be recollected that venous congestion, or any other cause tending to impede the circulation in the veins, will speedily give rise to a great increase of the quantity of fluid in the brain; and this is what Cullen and others have called serous apoplexy. If, however, there have been febrile symptoms during life, and a con- siderable effusion found after death, and particularly if conjoined with vascularity, the appearances may be attributed to inflammatory action. This is rendered more certain if the effusion look turbid, or contain flakes of coagulable lymph; if the convolutions of the brain be glued together by lymph, extending either from convolution to convolution, or dipping down between them; if the arachnoid which lines the dura mater adhere to the proper arachnoid coat; if the arachnoid coat be ulcerated, or capable of being separated from the subjacent membrane in tolerably large flakes. In inflammation of the membranes of the brain, portions of the cerebral mass are occa- sionally found to adhere very firmly to the surface of the pia mater, 540 INFLAMMATION OF THE BRAIN. such portions appearing softer and of a redder colour than the rest of the brain. There is one appearance of the arachnoid, to which my attention was first directed upwards of twenty years ago by my lamented friend the late Dr. Gordon, as indicative of deep-seated in- flammation. This is a dry, unshining appearance of the membranes of the brain ; but I believe it is more frequently observed in inflam- mation of the substances of the brain than in that of the membranes. The membranes of the brain are sometimes found to be much thickened by a deposition of coagulable lymph between them, both surfaces exhibiting considerable vascularity. There are small white bodies found on the arachnoid membrane in the close neighbourhood, and in the course of the longitudinal sinus, which are called glandule Pacchioni. When large clusters are discovered, they are sometimes, perhaps erroneously, attributed to inflammation. Small granular tubercles are occasionally seen on the arachnoid; these generally exist in connection with the same kind of degeneration in the lungs. On slicing the hemispheres of the brain to reach the lateral ventricles, the brain is observed to pre- sent many red points, which, if examined for a few minutes, will be seen to yield a little blood, and eventually to become small drops. The ventricles are sometimes found greatly distended with a serous fluid ; and when much distended, the communications between them will be seen much enlarged ; perhaps a part, or the whole of the septum lucidum, may be soft, broken down and ragged. Effusion is rarely, if ever, seen in one lateral ventricle without being found in the other. I should not be inclined to attribute two or three drachms of serum in the ventricles to inflammatory action; and should be still less inclined to attribute the death of the patient to the efforts of such an effusion, because I believe there is always some fluid in these cavities. The lining membrane of the ventricles oc- casionally shows a considerable number of red vessels, particularly if the disease have been of long continuance; the membrane itself may be softened or thickened; but this appearance shall be more particularly spoken of under the head of hydrocephalus. The cho- roid plexus consists of a congeries of small blood-vessels connected together by a very loose cellular membrane. I have seen large flakes of yellow lymph adhering to this plexus, the corpora striata and thalami. The plexus is sometimes thickened, granular and occasionally vesicular. The vesicles are often mistaken for hydatids; but they appear to me to have no resemblance to these bodies, and to be nothing more than an effusion of serum into different parts of the cellular tissue. I attribute much of the effusion found in the ventricles to diseased action of the choroid plexus, as well as to that of the membrane lining the ventricles. On removing the brain from the skull, considerable vascularity will, in general, be discovered in the membranes at the base of the brain, and when there is any effusion, it will be found generally about the central parts, involving the origin of all the nerves, with the exception, perhaps, of the olfactory. The effusion may consist of a colourless fluid, but in general it is turbid ; lymph of considerable thickness and consistence is very often found extending directly back- INFLAMMATION OF THE BRAIN. 541 wards from the point of decussation of the optic nerves to the termi- nation of the medulla oblongata; and there are several preparations and drawings in my museum, in which the effusion is in such quan- tity, and the membranes so thickened, that the origins of the nerves, the circle of Willis, the basilar, and even the vertebral arteries, are all conglomerated in one confused mass, and some of the parts, par- ticularly the basilar artery, and the vertebrals, are twisted out of their natural situation. In some instances, I have seen the lobes of the brain adhering by an interposition of lymph. I have also ob- served the same appearance in the hemispheres, and, in two or three instances, the adhesions were old and extensive—no doubt the result of a former inflammatory attack. Treatment of inflammatory affections of the brain.—There are two difficulties to be encountered in practice. The first is to ascertain whether inflammatory action be actually going on in the brain; and secondly, if it be going on, whether the disease is not already too far advanced to admit of the application of the most potent remedy for the cure of acute disease—general blood-letting. The most expe- rienced physicians are sometimes at a loss to determine these two points. The remedies necessary are—bleeding, general and local; purga- tives; antimony; cold applications to the head, and warm to the ex- tremities ; blisters and antiphlogistic regimen. There can be no doubt of the propriety, nay, the necessity of open- ing a vein in the arm, and abstracting a sufficient quantity of blood, if the inflammatory action be acute, if there be marks of venous congestion in the head, and if there are none of the usual signs of extensive organic lesions present. Even should these exist, if the pulse preserve some degree of strength, if the respiration be natural, the heat of surface considerable, the tongue not parched, and the teeth not covered with sordes, bleeding may be tried. But in all cases of inflammation, of whatever organ, the lancet should be cau- tiously used, if used at all, when the tongue is dry and parched, when the pulse is exceedingly rapid, and more particularly if it be irregular. It appears to me, that bleeding from the arm, in cerebral affections, has advantages over opening the temporal artery, independently alto- gether of the disagreeable consequences which sometimes happen from the latter operation. By opening a vein in the arm, a very con- siderable determination of blood is necessarily produced towards the extremity operated upon, and the blood flows more rapidly. The right side of the heart itself is, perhaps, more immediately relieved by preventing the usual quantity of blood from returning to it, which will, in all probability, favour the return of blood from the head, par- ticularly if the shoulders be considerably raised, or if the patient be bled in the erect or half-erect posture. No physician, however wise and experienced, can tell what quan- tity of blood ought to be taken in any given case. To bleed in a quantity much under that which is required to subdue a disease com- pletely, is almost worse practice than not to bleed at all; because the patient is robbed of much strength without destroying or decidedly 542 INFLAMMATION OF THE BRAIN. mitigating the diseased action, and thereby the subsequent treatment is embarrassed. When bleeding a patient late in a disease, and in doubt whether the application of this remedy may not do harm, the practitioner should be watchful of the expression of the countenance, the state of the respiration and the pulse. If the countenance become pale and haggard; if the respiration should be either quicker or slower, or more laborious; and if the pulse flag, or become weaker and quicker, then we may be certain that general bleeding should not be pushed further, and our hopes of safety must depend upon other means. Even in the most favourable cases for bleeding, it behoves physicians either to use the lancet themselves, or to see the operation properly performed. I am persuaded that valuable lives are often lost in acute diseases from neglecting these points, and particularly in the class of diseases now under consideration. It is of great consequence to watch the effects as the operation is going on, and to be particularly observant after a large quantity, say 30 or 35 ounces, have been abstracted. The finger should then be constantly upon the radial artery of the opposite arm, to notice the pulse; and when in doubt about proceeding further, it is by far the wiser plan to tie up the arm, reconsider all the features of the case, and, in the course of an hour or two, to renew the bleeding or not, according to circumstances. But in order to show the success of a bold measure, judiciously em- ployed, very late in a bad case, the following short history is quoted. A young gentleman, aged ten years, after an attack of scarlatina, became dropsical. Every part of the cellular tissue was infiltrated; even the scrotum was enormously distended. All the usual remedies were employed, except venesection; and I was induced to avoid taking blood, from an idea that the patient was too weak to bear the remedy, and because the urine coagulated on the application of heat, and contained a very large quantity of albumen, the specific gravity being 1008°. One forenoon, when under the action of mercury, he appeared to labour under nervous symptoms. Smart laxatives were ordered; but, in a few hours afterwards, violent tonic convulsions took place. My friend Dr. Lewins, of Leith, was sent for; he opened a vein, and bled till relief was obtained. I weighed the blood next day, and found that two pounds avoirdupois had been abstracted. The boy had no return of the convulsions, the dropsical effusion diminished daily, and from that time his recovery went on rapidly. I have endeavoured to impress upon my youthful readers the necessity of perfect devotion to the exercise of their profession; and that they will be successful in the means they employ for the cure and alleviation of diseases, exactly in proportion to the attention they pay to their patients. In inflammatory diseases of the viscera, and more especially of the viscus now under consideration, ah hour's delay in the application of an important remedy may cost a patient his life; the visits of practitioners should, therefore, be frequent, and I would not allow a longer interval to take place between the visits than two or three hours. Leeches to the temples in considerable numbers are very service- able ; but the bleeding should not be allowed to go on long if the INFLAMMATION OF THE BRAIN. 543 patient be much reduced. Warm water should not be used; and before the application of the leeches, it will be highly proper to have the head shaved. Sufficiently powerful purgatives must be used. This is almost the only class of diseases in which drastic medicines should be ad- ministered, because the bowels are not only difficult to be moved, but experience has taught us, that considerable advantage is gained, not only by the evacuations, but by keeping up a constant irritation along the whole alimentary canal. I am in the habit of giving, in very severe cases, large and repeated doses of calomel or croton oil, or both conjoined. Three or four scruples of calomel may be ad- ministered in divided doses to patients, in such circumstances, without producing ptyalism. Should a sore mouth take place, it may be regarded as a very slight evil if the patient's life be saved. My rea- son for giving calomel in cases of inflammation of the brain is sim- ply this: many eminent practical men have written so strongly in its favour, that I do not think myself justifiable in withholding it, although I place less confidence in its action than many others. But in no case do I relax in the employment of other, and, as I think, more potent remedies. The doses of laxatives should be repeated at intervals of three or four hours; and many cases, which appear to be hopeless, and too far advanced in their progress to admit of de- pletion, have recovered under their free and constant use. But care must be taken that the purging be not continued too long. In pro- portion as the disease gives way, the doses are to be diminished, and the intervals between their administration lengthened. The application of cold to the head is a most important part of the treatment, and the physician should see that the remedy is pro- perly applied. It has been already mentioned, that the head should be shaved before leeches are put on ; the mere removal of the hair will sometimes produce a considerable change upon the temperature of the head, and perhaps nothing further may be necessary; but if otherwise, iced water may be applied. A very good plan, and one which saves a great deal of trouble, is to put pounded ice or snow, mixed with salt, into a large ox's bladder, till it is about half filled, and use as a pillow. A small bladder filled in the same manner may be laid across the crown of the head; a cloth dipped in ice water may be placed over the forehead. If these means cannot be obtained, the best plan is to bring the head over the edge of the bed, keeping it at the same time elevated, and to pour a small stream of cold water out of a jug or tea-kettle upon the head for five or six minutes at a time, taking care to have a basin properly placed underneath, to avoid wetting the bed or the floor. I have seen patients roused out of deep coma, and violent delirium subdued, by cold properly ap- plied to the head, when bleeding had been unsuccessful. At the same time, we are to be careful not to continue the cold application for too great a length of time, particularly after the patient's strength has been much exhausted, either by the long continuance of the dis- ease, or the application of the more important antiphlogistic means. It is of very great importance to support the heat of the extremities, and more particularly in severe cases, which is to be done by frictions, 544 INFLAMMATION OF THE BRAIN. hot fomentations, heated bricks, small flannel bags filled with hot sand, or bottles filled with boiling water. Antimony, used in small doses as a contra-stimulant, is a power- ful remedy in controlling the circulation after bleeding. It is a reme- dy which is of great assistance during recovery, and may be given from time to time when the patient's appetite is likely to be too much indulged, or when he is disposed to be too loquacious. I beg to enter my strongest protest against the application of blis- ters to the head, or even to the upper part of the neck, in the acute stage of inflammation of the brain. They ought to be applied to the lower extremities. I urge this recommendation from the result of long and attentive observation ; and independently of the disputed theory, as to whether the vessels of the head can contain more blood at one time than at another. Mustard poultices may be applied to the feet. That these remedies "may fail, however, and that advan- tage may be derived from more powerful means, the following case will strongly illustrate: Cornelius Hervey was attacked with fever in the beginning of winter, 1823. In the course of the disease, he required several gene- ral and local bleedings, for the removal of slight local inflammations. On the 21st day of the fever, when perfectly sensible, and being in a state of very great weakness, he told me he had passed a confused, restless night, and that he had had some headache, which he attribu- ted to repeated errors of diet, and having overloaded his stomach. He was relieved by the exhibition of laxative medicines. On the 23d day, when he was reduced to a state of great debility, he be- came quite delirious, and so furious, that it required two men to hold him down in bed. The extremities were cold ; pulse weak at the wrist, of thready smallness, and beating 160 in the minute; his head was hot, and there was a small flushed spot upon each cheek. During the two following days, four leeches were applied to the head, and afterwards ten, without any mitigation of the symptoms, and he was thought to be too weak to bear any further loss of blood. Ice was assiduously applied to the head from the commencement; hot fomen- tations to the legs; sinapisms to the feet; and hot bricks were placed round the extremities. Still his legs and feet were cold; the sina- pisms, although frequently renewed, had not produced the least red- ness ; the pulse had become more feeble; he raved incessantly; there was subsultus tendinum to a great degree; the tongue was hard, dry, fissured, and of a dark colour. As neither coma, convul- sions nor paralysis had taken place, and as the pupils still contracted upon the application of light, it was thought that no organic mischief had as yet taken place; and as the usual means had failed to pro- duce heat in the extremities, hot spirits of turpentine, both separately and conjoined with aqua ammonie, was applied to the legs and feet, but without producing the slightest redness. Blisters had been ap- plied to each leg and thigh the night before, but they produced no effect. As a last resource, a towel was dipped in boiling water, and applied to each foot. This measure succeeded in producing a con- siderable degree of redness; but it is remarkable, that there was only INFLAMMATION OF THE BRAIN. 545 one very small vesication, about the size of a sixpence, produced on the left instep. At the moment of the application of the boiling water, lie became calm and sensible, looked about him as if he had awakened out of a sleep, and knew every person in the room, which he had not done for several days, and he complained of great pain in his feet. The pulse soon became more distinct, less frequent; and the tongue moist. Blisters were again applied to the thighs. Towards the afternoon he became worse, and at night I found him delirious and insensible, with subsultus tendinum, a dry tongue, and a small quick pulse. The extremities, and particularly the feet, were quite cold, although warm fomentations and hot bricks had been alternately applied, and although the scalded feet were dressed frequently with hot spirit of turpentine to keep up the action which had been excited in these parts. The blisters which had been renewed on the thighs had not risen. Boiling water was again applied to both legs from the knees to the ankles. The relief was as instantaneous and decided as had been produced by the same means in the morning, but it was permanent, and from this time his recovery went on without a bad symptom. A superficial slough separated from each leg in the course of ten days, and there was some constitutional irritation pro- duced during the course of that process; but the ulcerations healed kindly. He was for several months very lame, not from the imme- diate effects of the ulcerations, but from the contraction of the flexor muscles of the leg, which inconvenience arose from the bent position in which he kept his limbs during his illness, but he gradually re- covered the free use of them; and the last accounts I heard six years afterwards informed me that he was in the enjoyment of perfect health and strength, and able to earn a livelihood for his family by manual labour. To conclude what I have here to say of the treatment of inflam- matory affections of the brain, it is necessary to mention that the diet should be strictly antiphlogistic for the first few days; it ought chiefly to consist of drinks, such as thin gruel and arrow-root; and during recovery, great care should be taken to avoid bringing up the patient's strength too suddenly. The utmost quietness is absolutely necessary in all severe diseases; but it is more particularly essential in those of the brain; and for a considerable period, patients who have recovered from a severe attack of this kind, should be kept in a very tranquil state both of mind and body. Application to business must be strictly forbidden, sometimes for several months, and great attention must be paid to diet, bowels, clothing, and keeping regular hours. Immediately after the severity of the disease is subdued, and more frequently during recovery, opiates are often productive of great benefit, by allaying irritation both of body and mind, and producing sleep. In many cases of inflammation of the brain, the secretion of urine is either suspended or suppressed; but in every case practitioners should examine very carefully into the state of the bladder, as some- times the secretion of urine is rather increased in quantity than di- 46* 546 INFLAMMATION OF THE BRAIN. minished, and I have seen much distress occasioned by its retention in the bladder. INFLAMMATION OF THE SUBSTANCE OF THE BRAIN. The profession is much indebted to Lallemand, Rostan, Georget and others in France, and to Dr. Abercrombie in this country, for many important facts concerning inflammation of the substance of the brain, and the peculiar softened condition into which the organ is reduced by diseased action. Symptoms of inflammation of the substance of the brain.—In- flammation of the substance of the brain seldom exists uncomplicated; it is often the result of congestion in the vessels of the head, and is always marked by loss of balance of the circulation. Like inflam- mation of the membranes, there may be different shades between the acute and chronic forms; the attack being sometimes sudden, but for the most part insidious. The precursory symptoms are generally similar to those which precede inflammation of the membranes. The functions of the brain are impaired; the patient complains of vertigo or tinnitus aurium; a feeling of weight in the head; head- ache ; indeed, Dr. Abercrombie describes this last symptom as being very severe, and as giving to the disease a peculiar character, but I cannot say that this consists with my experience. There are optical delusions, strabismus, contraction or dilatation of the pupil; difficulty is sometimes experienced in articulating words; the patient's temper is observed to be much altered and easily irritated; the pulse may be quite natural. Through the day, the patient does not appear to be very ill, but in the night the symptoms become much aggravated. Perhaps no alarm is yet taken, till weakness is observed to affect one side of the body, or convulsions take place; and when a medical man arrives, he finds the patient affected with paralysis, and more or less coma. Inflammation of the substance of the brain sometimes attacks a patient more insidiously. He may complain of lumbago and rheu- matic pains in the limbs, or may be affected with vomiting or purg- ing; the true disease is, perhaps, not detected till coma is decidedly marked. Inflammation of the substance of the brain occurs in the progress of the simplest as well as the most severe form of fever in this coun- try; it may also take place when the body is much weakened by the long continuance of hsemorrhage. In fact, this disease occurs under circumstances as different as those already so fully described in inflammation of the membranes of the brain. When the disease is somewhat advanced, there is considerable stupor, and more or less insensibility, without violent delirium. The power of speech is lost early, perhaps before intelligence is destroyed. The pupil still contracts, showing sensibility of the retina. The countenance varies a little in appearance; sometimes there is an expression of severity with a frowning brow; at others, it looks stupid and vacant. The patient is observed to be deaf, and vision INFLAMMATION OF THE BRAIN. 547 imperfect. At length paralysis takes place on one side of the body, but the superior extremities are more frequently affected than the inferior, and the flexor muscles of the paralyzed limb are in a state of morbid contraction. It would appear also that the limb preserves a degree of sensibility, for the moment the arm is touched to count the pulse, or any attempt is made to extend the forearm, the contraction becomes more violent; but towards the fatal termination of the dis- ease, it becomes flaccid and insensible. Lallemand thinks it important and highly characteristic, that the pain and the disease of the brain be on one side of the head, and this peculiar affection of the limb on the opposite side of the body. Convulsions frequently take place, and during these attacks, the muscles of the paralyzed limb are affected. The rigidity of the flexor muscles is not always permanent, but takes place occasionally, some- times alternating with general convulsions. A urinous smell is also said to be characteristic; but this is proba- bly a mistake, owing to a neglected state of the bladder, or to a con- stant dribbling of urine which soils the bed. Constipation is a very general symptom, although occasionally an opposite state of the bowels exists. Respiration is not necessarily affected till towards the last. The pulse is seldom much altered till towards the termina- tion: the French writers say it is never affected till that period, unless some other organ is diseased, but this appears to me to be a too arbi- trary statement; indeed, the pulse is frequently slower than natural. French authors also allege, that when there is violent delirium and a quick pulse, inflammation of some other organ or tissue has taken place; although Rostan states that delirium sometimes shows itself in the first period of ramollissement. The common position of the patient is upon the back. The characteristic symptoms are, an absence of violent delirium; speedy insensibility; paralysis, accompanied by morbid involuntary contraction of the flexor muscles; a urinous smell. Cases occasion- ally occur in which there is a different train of symptoms, and in which paralysis and rigidity do not coexist. Indeed, Lallemand observes, that in some cases there is no paralysis of the voluntary muscles, in which circumstances, he alleges that the inflammation has always its seat in parts of the tjrain which have no direct com- munication with the spinal marrow, viz.: the corpus callosum, the septum lucidum and the fornix. It is alleged, that when the para- lysis is general, the inflammation occupies the tuber annulare, or is so extensive as to occupy a whole hemisphere: so much so, that the other side of the brain becomes greatly compressed by the tumefac- tion of the diseased parts. An interesting and very fatal affection of the brain and its mem- branes, connected with disease of the petrous portion of the temporal bone, and a discharge from the ear, has attracted the attention of many distinguished medical authors. The disease is frequently very slow in its progress: often no suspicion of disease in the brain is entertained prior to dissection, when considerable portions of its substance have been found either in a state of softening, or converted 548 INFLAMMATION OF THE BRAIN. into pus; the membranes being partially destroyed, or very much inflamed and thickened. Acute inflammation of the substance of the brain often terminates fatally in seven or eight days, frequently in a shorter period, but is sometimes prolonged till the third week. There is no doubt that it is a very fatal disease ; but not so deadly, under proper treatment, and in persons not too aged, as is generally represented. I have seen several recoveries take place in circumstances which were at first sight most unpromising; and in five instances in particular, where all the characteristics and all the bad symptoms described by Lallemand and Rostan, were present. In two of these cases, Dr. Kellie was conjoined with me in consultation. In a third, I had the able assistance of Dr. Abercrombie. A fourth I was requested to see by Dr. Moffit, surgeon of the 70th regiment; and a fifth I at- tended with my friend Dr. Lewins. I shall here subjoin the particulars of the fourth mentioned case: J. S., aged 34. His complaints began with nausea and purging, which continued for several days, during which time he frequently complained of slight headache. On the 5th of August, 1827, after appearing to be convalescent, he complained, towards evening, of considerable headache and general debility; pulse 80; face rather flushed ; tongue white ; pupils dilated. The head was shaved, and 36 leeches applied; and he took a laxative medicine. In a few hours he appeared to be gradually sinking into a state of insensibility; the face flushed, and the expression of the countenance anxious; pulse S5 ; tongue white. Next morning he was found in a State of coma, lying on his back, with general paralysis ; but the flexor muscles of both arms were rigidly contracted, the fingers seemed to be in con- stant spasmodic action, and his jaws were clenched ; pulse 85, rather weak and intermitting. A vein was opened in the arm, and 36 ounces of blood were abstracted; a blister was applied between the shoulders; cold lotion to the head. 1th. Passed a disturbed night; no improvement in the symptoms; insensibility continues, and the state of the extremities is the same; urine and faeces passed involuntarily; countenance has a severe ex- pression ; eyes fixed ; pupils dilated, and he appears to be perfectly blind ; pulse S5, and of natural strength. Ice and 30 leeches were applied to his head. Vespere; he has derived some benefit from the leeches, which bled profusely; the countenance has lost the expres- sion described in the morning; he opens his eyes occasionally, and takes drink when offered to him; pulse 90, and soft. The applica- tion of ice to be continued to the head. SM. Had a better night, and appears rather improved ; the coun- tenance has a milder expression ; but the pupils are dilated, the eyes fixed, and to all appearance blind; the paralysis of the superior ex- tremities, with rigidity of the flexor muscles of the arms, still con- tinue, together with the involuntary action of the fingers; the lower extremities are still paralyzed, but not rigid ; passes urine and faeces involuntarily; pulse 95. Venesection xii oz., and a fresh blister ap- plied between the shoulders, the former one not having risen. The evening report states, that the symptoms have progressively improved INFLAMMATION OF THE BRAIN. 549 since the bleeding in the morning, and he is so far sensible as to ask for drink, which he appears to relish; pupils more natural; tongue white; the blister is now beginning to rise. The ice to be continued to the head. 9th. Appears better, and has in part recovered his speech, recol- lection and vision; blister rose well. In the evening he was found gradually improving; had one stool since the morning, of which he gave previous notice. The cold applications omitted. 10M. Had some good refreshing sleep during the night; counte- nance natural; pulse soft, and although quick it is regular; asked for food, and got up without assistance to the close stool. From this time his improvement went on rapidly. In five or six days he was able to sit up in bed for two or three hours at a time; all the func- tions were natural; and in a short time he was able to walk about. His ultimate recovery was complete and permanent. In the case which I saw with Dr. Abercrombie, the appearances were fully more unpromising, and the diseased state of the brain of longer continuance. For ten days or a fortnight, this patient had had symptoms which resembled the regular paroxysm of an inter- mittent; and it was supposed he was affected with that disease. During each attack, the functions of the brain were observed by his friends to be considerably embarrassed, and coma followed the last. In this case there was also remarkable rigidity of the flexor muscles of one of the arms, with paralysis of the extremity. The practice employed was very active, and although employed late, it was suc- cessful, but the patient's recovery was more tedious. Causes of inflammation of the substance of the brain.—The causes of inflammation of the substance of the brain are the same as those in inflammation of the membranes, and need not be here repeated. But it may be mentioned, that the disease is frequently produced in the substance of the brain around tumours and tubercles which may have existed for years, without occasioning much annoy- ance to the patient, till some accidental circumstance rendered them a source of irritation to the surrounding parts. This class of cases generally terminates fatally. I have a number of drawings and pre- parations which show these appearances; and it is strange that Ros- tan should never have met with a case of this kind; but at page 70 of his work, he says he has no doubt that such a complication may exist. Inflammation of the substance of the brain, terminating in ramollissement, also frequently takes place round apoplectic deposi- tions, whether small or large. I have seen it .round an effusion of about four ounces of blood; in these cases the symptoms are, in gene- ral, rapid in their progress to a fatal termination. Appearances on dissection.—When the structure destroyed is extensive, and particularly when situated in the central parts of the brain, the arachnoid coat sometimes looks dry, having lost its usual shining appearance. On making slices of the brain, more particu- larly in the neighbourhood of the diseased part, its substance will show many red points, out of which blood will ooze : the white sub- stance of the brain presents a somewhat reddish colour; sometimes 550 INFLAMMATION OF THE BRAIN. it is as red as if a penful of red ink were splattered over it; occa- sionally there is a deep mulberry spot of larger or smaller size. The* central parts of the brain are most frequently the seat of ramollissement, viz.: the walls of the lateral ventricles, the septum lucidum, and the fornix. These parts are sometimes wholly con- verted into a white liquid matter like cream, showing the septum lucidum ragged and broken down, with some effusion into the ventri- cles. This appearance is sometimes very extensive; at others it is confined to the walls of one ventricle, or it affects the septum lucidum and the fornix. When the disease is not far advanced, the degree of softening is so slight, that it is impossible to determine whether the part has been diseased or not; but in this case we are sometimes assisted by discovering very considerable redness in the surrounding cerebral mass; at other times the softened part is of a red colour, as if blood had been mingled with the substance of the brain itself. Some suppose that inflammation of the substance of the brain is more frequently met with in the white substance than in the cortical. Andral thinks not. I have seen it in both, but am disposed to think it is more frequent in the white substance. Perhaps the white liquefaction, which is most frequently seen in the corpus callosum, the septum lucidum and fornix, may be pro- duced by a somewhat different cause from the red softening, which is most frequently seen, according to my observation, in the corpora striata, thalami optici and tuber annulare. Pathologists are much divided in opinion as to whether ramollis- sement of the brain is or is not the effect of inflammation. Rostan admits it is sometimes the effect of inflammation; but asserts that more generally it is a peculiar degeneration of the brain, unconnected with inflammation, which has its own signs and proper characters. He appears to have three reasons for considering that it is not gene- rally a product of inflammation:—1st. In the cases which terminate in this softening, the patients have not been affected with the head- ache; 2d. Febrile symptoms have not existed; 3d. The colour of the substance of the brain often appears not to be in the least changed. Rostan's subjects were all old ; he never saw the disease in a very young person, and only once in an individual under 30 years of age; but in that case there was no dissection. Dr. Abercrombie, with a view of reconciling the opposite opinions which prevail on this interesting subject, throws it out as a probable conjecture, that there may be two causes, each of which may pro- duce ramollissement; the first is inflammation, and takes place in young people ; the second is in consequence of a failure of the circu- lation depending upon diseases of the arterial system, and this occurs in old subjects. He supposes that this degeneration of the brain has a close resemblance to mortification in other tissues; but this appears to be a forced analogy. The effect, upon all tissues, of inflammation in its first stage, is to soften them—at least this is the case with the lungs, the liver and the spleen; and why not with the brain ? Sometimes inflammation of the substance of the brain terminates in the formation of one or more abscesses; and we frequently observe the same effort of nature to circumscribe and confine pus in the brain, INFLAMMATION OF THE BRAIN. 551 which takes place in other tissues, viz.: the formation of a false mem- brane round the diseased part. A medical friend lately presented me with a brain, where there were innumerable small abscesses resembling so many phlegmons, dispersed in every direction through the cerebrum and cerebellum. Some were situated on the surface of the brain and cerebellum con- tiguously to the membranes; others in the very centre of its substance. Some were in the white, others in the gray portion. The pus found in abscesses of the brain resembles the same mat- ter found in other tissues of the body; sometimes it is quite inodo- rous; at others very fetid. 1 am not aware that any symptoms have been remarked as indicating the formation of pus in the brain, which discriminate it from other organic lesions. Treatment of inflammation of the substance of the brain.—The treatment already so fully detailed under inflammation of the mem- branes, is equally applicable to inflammation of the substance of the brain-, but with a view of impressing upon young practitioners the danger of delay, the following case and dissection are annexed. Their perusal will serve also to show the insidious manner in which inflammation of the brain sometimes steals on, concealed by some prominent affection in a distant part of the body. No case can better exhibit the advantage of active treatment, even when applied late— unfortunately too late, in the present instance, to save the life of the patient. J. H., aged 30, tall, active, athletic, and of sober habits; for seve- ral months complained now and then of severe lumbago, for which blisters had been applied with relief. On the 13th July 1827, he ap- plied for medical advice, in consequence of a return of the lumbago, which had been very severe for several days; he became gradually relieved by confinement to bed, the application of a blister, laxa- tives, and occasional doses of Dover's powder; on the 3d August, to all appearance, he was very much better, but his bowels were rather confined. During the whole of that day, however, he became, according to the account of the people about him, more and more stupid, without any apparent cause. When spoken to he replied, but always as if abstracted. Pulse natural; countenance heavy, and rather vacant. 4th. Makes no complaint; reposes in one posture, on his back; appears fatuous; and when spoken to, returns a vague, inconsistent answer; articulates indistinctly; both hands are in constant motion; pulse natural and soft; had two stools. Head to be shaved, and cold applied; sixteen leeches to the forehead ; a blister between the shoulders. In the evening no alteration; the leeches bled well. Pounded ice has been constantly applied to the head ; pulse 80 and regular ; tongue white and dry; skin moist. Passes urine and faeces involuntarily. 5th. Had a bad night; is insensible; superior and inferior extremi- ties paralyzed ; but the flexor muscles of the arms are rigid, the fore- arms bent, that of the right arm more than the left; jaws clenched; but the lower one can be depressed a little by using considerable force; countenance pallid and bedewed with perspiration ; eyes 552 INFLAMMATION OF THE BRAIN. fixed, pupils dilated and immovable ; pulse 86, regular, and of natu- ral strength; has lost the power of deglutition. In the evening, no change of symptoms, except that the countenance has assumed a severe expression. There is a strong urinous odour, owing to the involuntary passage of urine in the bed. He appears, although in- sensible, and having lost the power of voluntary motion in all his extremities, to feel the impression of cold disagreeable when the bed- clothes are drawn down. Venesection ad 28. The bleeding was persevered in till the pulse rose from 86 to 100, and became some- what weaker. During the latter part of the operation he appeared to awake as if out of a deep sleep, and looked about him; and soon after was able to reply to any question by a sign, although he could not speak. 6th. Some time after the bleeding last night, he made signs that he wished to lie upon the right side, and upon being turned, expressed satisfaction; has since taken his drink occasionally, and put out his his tongue when desired; his countenance is certainly more cheerful, and the eyes are sensible to light, but in other respects does not seem much improved; passes stools and urine involuntarily; pulse 130; skin moist; tongue white and rather dry. Thirty-six leeches to the head, and a large blister to each leg. 1th. Passed a more composed and comfortable night; countenance more animated; is able to articulate, but with difficulty, and when spoken to, returns an appropriate answer; pulse 150; pupils dilated; tongue white and furred; skin moist; stools and urine still passed in- voluntarily. The application of iced water ordered to be persevered in. During the course of the day, the symptoms continued to im- prove, and in the evening his looks were more lively; the counte- nance had a more natural expression ; had two stools during the day and made water, of which he gave warning, and desired to be raised upon the night chair. There is still a little rigidity of the flexor muscles of the forearms, as well as spasmodic motion of the fingers; and both hands embrace the genital organs; pulse 140; skin moist. Had gruel and arrow-root frequently. 8fh. Appears better to-day; has recovered in a considerable degree the use of his extremities; reposes frequently on his side ; gives dis- tinct answers, and is better able to articulate than yesterday; coun- tenance mild; pupils less dilated; tongue moist and less loaded; pulse 150; skin natural; complains now, for the first time, of debility; and ordered to have food at short intervals. At the evening visit he appeared tp be doing well, but still complained of being weak; the pulse 130, and of moderate strength; bowels moved twice during the day; countenance natural and more lively; tongue moist. 9th. He was found in a weak, depressed and sinking state this morning; respiration and deglutition difficult; pulse 160. Wine was ordered ad libitum; but he continued to sink, and died a little before midnight. Examination of the body 30 hours after death.—Slight emacia- tion ; countenance composed; considerable rigidity of the flexor mus- cles of the right arm. On removing the calvarium and dura mater, the brain appeared full and distended; a little serosity between the Missing pages 553-556 HYDROCEPHALUS. 557 membranes; ramiform injection of the vessels of the pia mater, forming a complete anastomosis over the surface of the hemispheres; the whole presented a deep scarlet colour. In the cortical substance of the brain, several red spots from numerous little bloody points closely aggregated. The brain, in these places, softer than natural, and tore readily on separating the membranes from it. Medullary substance also presents bleeding points when cut into. On the base of the brain the membranes are in a similar state as on the hemispheres; several ecchymosed spots on the lateral parts of the middle lobes. After removing the membranes in a very care- ful manner from all the central parts at the base of the brain, from the part anterior to the point of decussation of the optic nerves to the commencement of the medulla spinalis,^ number of bright red spots were observed in different places. On the left tractus nervi optici a considerable spot of a bright red colour, found to penetrate through its whole depth ; also several smaller spots on the opposite side. On each side of the pons varolii, there were similar red marks, but par- ticularly one on the right side, of a dark mulberry colour, about the size of the thumb nail; this was examined minutely, and was found to extend deeply into the medullary substance, and to be formed by an intimate mixture of blood with the cortical and medullary band of the pons. There was a considerable spot of a similar description on the right side of the medulla oblongata. The membrane lining the ventricles was very vascular, and the choroid plexus loaded with blood. Nothing remarkable in the cerebellum. Spinal marrow not examined. Thorax.—Strong and general adhesions on both sides between the pleura pulmonalis and costalis; particularly firm on the left side. Pericardium strongly attached to the diaphragm, and anteriorly so firmly united to the heart as to form only one body with it; the bond of union formed by a very dense, almost cartilaginous substance, varying in thickness—in some places more than one-third of an inch, in others only a few lines; the pericardium could with great difficulty be separated from it. A part of the posterior surface of the heart was unattached to the pericardium. Mucous membrane of the stomach generally, but more especially of its great curvature, of a dark brown colour, with numerous vari- cose vessels running below it; in some places there were little patches with stelliform injections of the minute branches; other patches were of a uniform blackness. Intestinal canal natural. Bladder contained about half a pint of urine. hydrocephalus. The frequency and fatality of this disease have strongly excited the attention of practitioners, with a view to d;scover its nature and seat. Two opinions at present divide the profession: according to one hydrocephalus is a disease of inflammation; according to ano- ther, it is one of debility. My own opinion is, that it is most fre- quently a disease of inflammation; but that sometimes it may be 558 HYDROCEPHALUS. occasioned by other causes, which shall be mentioned in the proper p'ace. There are several forms under which this disease appears. The division which I propose to adopt is as follows: Acute Hydrocephalus. Chronic Hydrocephalus. Under the acute form, we meet in practice with numerous vari- eties ; and I shall attempt to give a slight sketch of four of the prin- cipal. 1. Attended with severe and striking symptoms, such as fits of screaming; grinding the teeth; hot skin; quick pulse; bold expres- sion of countenance; red face and eyes; convulsions; coma; the children dying on the third or fourth day. In such instances, I have seen the first stage terminated in twenty-four hours. 2. With symptoms very mild and insidious, so much so that no alarm is taken for several days. The little patients complain, but this is attributed to peevishness or to teething, till at length the pa- rents become alarmed by the long continuance of the indisposition, together with the rapid emaciation which has taken place. 3. A third set of cases commences with gastric irritation, attended either by constipation or diarrhoea. The febrile symptoms are ob- served only at night. Medical men are often thrown off their guard, their attention being attracted by the more urgent symptoms con- nected with the state of the bowels. By and by the child becomes quiet when allowed to rest in the horizontal posture; it grinds the teeth occasionally; and although showing signs of some suffering, yet it never cries or becomes very fretful unless when raised. The moment the head is elevated, great impatience is manifested, and it gives vent to loud expressions of pain, which I suppose to be pro- duced by headache or giddiness. 4. Very frequently hydrocephalus occurs during the course of other diseases, such as fevers, measles, small-pox, hooping-cough and pulmonary affections; and not uncommonly runs through the first stage and part of the second before discovery is made of diseased action in the brain. Convulsions and coma take place at different periods in the course of the disease. The former is sometimes the first symptom, and occurs early in the disease, at other times not till towards the fatal termination. In other cases, coma takes place be- fore the convulsions, and is the first alarming symptom that occurs; in fact, the statements already made respecting inflammation of the membranes of the brain, and also of its substance, equally apply to this particular subject. The description given of the expression of countenance, the state of the pupils, the redness or paleness of the face, the state of the respiration, the mental faculties, the pulse, skin and bowels, all apply with equal force to hydrocephalus. Appearances on dissection.—In the most rapid cases, the patients are carried off before organic lesion to any extent is produced. Al- though the membranes of the brain may display considerable arbo- rescent vascularity, still the effusion is in very small quantity—too small to account for death. In cases of longer standing, the effusion into the ventricles will be in greater quantity ; or thickening of the HYDROCEPHALUS. 559 membranes may be found not only where they cover the hemi- spheres, but likewise at the base of the brain, involving all the im- portant parts in the centre, from the point of decussation of the optic nerves to the commencement of the medulla oblongata. The thickening of the membranes is produced by the intermediate depo- sition of tenacious lymph. The membranes have been found exten- sively ulcerated, and considerable portions of the brain itself in a state of ramollissement, in children who have died with all the symptoms of hydrocephalus; and in these cases, there is not always any con- siderable effusion into the ventricles of the brain. I forbear, at present, to allude to other diseased appearances, such as tumours, tubercles, disease of the great sinuses, &c, because these more fre- quently produce chronic hydrocephalus. Pathological remarks.—The chief point of inquiry relates to the cause of the effusion. Is it the product of inflammation ? The best pathologists of the present day consider it as proceeding, for the most part, from inflammatory action of the membranes of the brain ; but at the same time there can be no doubt that a serous effusion is frequently the consequence of any cause obstructing, or even retard- ing the circulation in the head. Thus it is believed to be occasioned by venous engorgement; and dissection affords ample proof that it is often owing to obstructions in the great venous channels in the head.—Others allege that hydrocephalus is produced by debility. This is a pathological question of the utmost practical importance, because the remedies will be depletory in a certain stage of the dis- ease, according to the one view, and stimulating in all the stages according to the other. In order to place the subject in a clear point of view, I shall take the liberty of offering a few critical remarks upon a work by Professor Monro,* because it is the last published work which defends views that I conceive to be erroneous. At page 101, Dr. Monro states that, before subscribing to the hypothesis that the effusion in hydrocephalus is owing to some degree of inflammatory action, " it is necessary to inquire whether this disease usually occurs in persons who are disposed to inflammatory disorders at or near the meridian of life, when the human body is most liable to suffer from inflammatory diseases. With regard to the first of these points, it may be observed, that hydrocephalus is so rare after puberty, when the constitution is most liable to inflammatory disorders, that Cullen and other writers of eminence have described it as being peculiar only to infancy. That the disease is rather to be imputed to debility, follows from the well-known fact, that hydrocephalus is frequently a disease which may be traced to bad nursing, improper food, dentition, the sequel of the most tedious and debilitating disorders, as hooping- cough and scarlatina." Cullen's authority is a most unlucky one to quote in the present day for the true pathology of any disease, and more particularly of any disease of the brain. In the work of this author, there are only two pages and seven lines devoted to a detail of the symptoms, causes, pathology and treatment of all the inflammatory affections * Entitled, The Morbid Anatomy of the Brain, 1827. 560 HYDROCEPHALUS. of the brain and its membranes; and all that he has jsaid respecting hydrocephalus is comprised in three lines, in the shape of an erro- neous definition! It is a fact, that children, particularly those under two or three years of age, are peculiarly liable to inflammation of the brain from several causes:—1. From the wonderful changes which take place in the circulation early in life; 2. The large size of the head at that period in proportion to the rest of the body; 3. The change the brain undergoes in appearance and consistency; 4. The great acti- vity of the circulation, and the high state of irritability of the ner- vous system at that period of life; 5. Difficult dentition, which per- petually excites a determination of blood towards the head. Besides these causes, accounting for the frequency of the diseases, something must be said respecting its fatality in infants. Children cannot tell their feelings, or direct the attention of practitioners to the seat of the disease. Their fretfulness and peevishness are too often attributed to bad temper, or to the state of the bowels, or to the irritation of the gums from the advancement of teeth; and the disease in the brain, as has already been shown, often advances in the most insidious manner, till convulsions or coma take place: and even the latter symptom, although observed in its progress, is too often overlooked until the patients become insensible. Bad nursing and improper food, upon which Dr. Monro has laid so much stress in support of his own views, certainly tend to produce debility; but children badly nursed, insufficiently clothed, who are allowed to remain wet, and receive improper food into the stomach, are peculiarly liable to in- flammation and ulceration of the bowels. They will be far more liable than healthy children to irregular determinations of blood, and, from want of vigour in the constitution, venous engorgement may take place, the vessels of the head may suffer, and effusion may in consequence follow ; perhaps subacute inflammatory action may be lighted up in the brain. The experienced eye of a careful observer will be able, in general, to detect the disease in the brain, although it is not announced by symptoms so violent and imposing as Dr. Monro seems to expect should be produced if actual inflammation had taken place. That venous congestion of the vessels of the head, ter- minating in effusion, and that inflammation of the membranes of the brain, should sometimes take place in hooping-cough and scarlatina, which Dr. Monro designates as debilitating disorders, will not sur- prise any who will study nature, or who will refer to the patholo- gical descriptions given of these diseases in their proper places in the 1st vol. of this work. Dr. Monro next asserts, that if hydrocephalus were an inflam- matory disease, it ought, like inflammation of the lungs, and other inflammatory complaints, to be more prevalent in robust men during the period of life when the human frame is most prone to other in- flammations. Dr. Monro might have known that the periods of life at which inflammatory complaints most frequently occur, are infancy and childhood, and that for one inflammatory fever, or inflammation of the lungs, or of any other organ, in robust men during the prime of life, we meet with at least fifty in early life. HYDROCEPHALUS. 561 Dr. Monro has committed a sad mistake respecting the opinions of two distinguished French pathologists. "If it be supposed, (says Dr. M.,) that hydrocephalus is always connected with inflammation of the brain; and that inflammation gives rise to the softening of that organ, which is the favourite opinion of Lallemand, Rostan and Others; in that case the brain should be found invariably in a soft- ened state, which is not consonant to my observations." But I have already shown that modern pathologists do not assert that the effu- sion is always caused by inflammation; it is sometimes produced by venous congestion, and by any mechanical cause impeding the circu- lation. Neither Lallemand nor Rostan attribute the softened state of the brain to inflammation of the membranes, which Dr. Monro appears to confound with inflammation of the substance of the brain, and who has also attributed to Rostan an opinion quite contrary to that which Rostan actually maintains. At page 104 of Rostan's work already quoted, he explicitly states, that although softening is occasionally produced by inflammation of the brain, yet, that it sometimes takes place unconnected with inflammation, and is a pecu- liar degeneration, which has its own signs and proper characters. At page 103, Dr. Monro further urges, that, "If inflammation of the brain had given rise to this species of hydrocephalus (acute,) the attack of the disease should be sudden and well marked, and its course rapid, like to that of phrenitis; whereas the origin of the dis- ease is generally not well marked; indeed, so much so, as often to escape the notice of the parent, and even that of the experienced physician." And he further states, that " It is admitted, even by those who impute hydrocephalus to an inflammation of the brain, that the symptoms of phrenitis are well marked, whereas those of hydrocephalus are often very obscure." It has already been shown how very insidious inflammatory affections of the brain are, even in adults; they cannot be more so in young subjects; but the reader shall see what Cullen himself says on phrenitis in his "Outlines," at page 103. " Many of the symptoms by which this disease (phre- nitis) is most commonly.judged to be present, have appeared, when from certain considerations it was presumed, and even from dissec- tion it appeared, that there had been no internal inflammation; and, on the other hand, dissections have shown that the brain had been inflamed when few of the peculiar symptoms of frenzy had be- fore appeared." And Dr. Monro concludes, that if acute hydroce- phalus be owing to an inflammatory state of the brain," there ought to be no distinction as to the symptoms, origin, progress and conse- quences of phrenitis and hydrocephalus." To make the statement still stronger, he quotes Cullen's erroneous definition of phrenitis, and then states, with great self-complacency, that " The symptoms of this species of hydrocephalus do not correspond with the above defi- nition." " One of the most striking features of inflammation of the brain, (says Dr. Monro, at page 104,) is the state of the pulse; but that character is also wanting in hydrocephalus; for the state of the pulse is widely different from that of a person affected by apoplexy or in- flammation of the brain. It is not full as in the former, or hard as 47* 562 HYDROCEPHALUS. in the latter. It is no doubt quick, as in other diseases which are the effect of debility. Besides, no author, who has described the symp- toms of phrenitis, has stated that the pulse becomes slower some time after the commencement of the disorder."—It is almost unnecessary to comment upon the erroneous statements made in these passages; but this opportunity may be taken to mention, that Morgagni has clearly shown the great varieties of the pulse in acute diseases: and there are few practitioners of the present day who are not well ac- quainted with the varieties of the pulse in cases of affections of the brain. Dr. Abercrombie, in giving a general view of the symptoms which indicate inflammatory affections within the head in adults, makes the following observation at page 12. " The pulse is about the natural standard or below it, frequently about 60." And again: " The pulse having continued from 70 to 80 through the whole course of the disease." After alluding, at page 14, to the circumstance of the pulse becoming slower some time after the commencement of the disease, he observes, "As the pulse falls, the patient is disposed to sleep; this is, perhaps, considered as favourable; it falls to the natural standard; he then sleeps almost constantly; and in another day this sleep terminates in coma. The pulse then begins to rise again ; it rises to extreme frequency, and, in a few days more, the pa- tient dies." Is it not a curious circumstance, that Cullen, in the seventy lines that he has written on inflammatory affections of the brain, does not notice the state of the pulse? Neither does he mention it in his definition. At page 110, Dr. Monro endeavours to establish an invariable con- nection between hydrocephalus and dropsy, both depending on debility; now, if this were true, children ought to be very liable to dropsical affection in other parts of the body, which is decidedly not the case ; but, nevertheless, looking pathologically at these affections, there is a strong analogy. Dropsy sometimes arises from inflamma- tion ; so does hydrocephalus. Dropsy sometimes arises from morbid alterations in the structure of the heart; so does hydrocephalus. Dropsy is sometimes produced by disease of the lungs, and particu- larly bronchitis; so is hydrocephalus. Dropsy in the belly frequently depends on diseases of the liver impeding the circulation; so does hydrocephalus occasionally depend on obstructions in the venous system of the head. Dropsy sometimes depends on diseases of the kidneys; so does hydrocephalus. Lastly, dropsy is sometimes cured by bleeding; so is hydrocephalus! Treatment of acute hydrocephalus.—If so much discrimination is required in the treatment of inflammation of the brain in adults, still more is necessary in treating the disease in young subjects. With respect to bleeding, in particular, much depends upon the duration of the disease, the age and peculiarities of constitution of the child, and whether the disease has taken place subsequent to other disorders, in the course of which the child has been much weakened. But if called early, no lesion having as yet taken place in the brain, and the child being above two years of age, I have no hesitation in opening a vein, if one is anywhere to be found. This recommendation is urged after considerable experience of its advantages, in controlling diseased HYDROCEPHALUS. 563 action in the brain at an early period of the disease, and from which I have never seen any bad results. It would appear that the danger of bleeding children from a vein is far overrated. In two cases, the bleeding produced syncope, and yet no bad consequences followed. Capuron says, at page 495,* " It is sufficiently proved, that general and local bleeding are the means of fulfilling the first of these two indications, above all in the beginning, where every thing announces a movement of reaction towards the head; apply leeches round the neck, open the jugular vein or the temporary artery, and be not, like Dr. Odier, afraid of breaking down the vital powers; these are too energetic, particularly during the first period, when they tend to concentrate themselves towards the head, to irritate the brain, to pro- duce a turgescence of its vessels, to leave traces of inflammation, and to produce effusion." It is impossible to give any particular direc- tion as to the quantity of blood which ought to be abstracted. The operation is to be performed when there is high excitement only, and in the earliest stage of the disease. In other circumstances, leeches must be applied to the feet, which may be afterwards placed in warm water, to encourage the flow of blood; and when it is wished to pre- vent further loss, pressure can be conveniently and effectually used. A great error is committed by practitioners allowing the effect of the first bleeding to be entirely lost, and not following it up, either by taking an additional small quantity after a short interval of two or three hours, or applying leeches. Another error is frequently com- mitted by allowing leech-bites to drain blood from the system by slow degrees, thereby producing great weakness without affecting any diminution of the diseased action. Antimony is sometimes of signal benefit in these cases. Cold applications to the head, purgatives, and all the other remedies mentioned so fully when treating of in- flammation of the membranes of the brain, must be employed ac- cording to circumstances. The gums should be always carefully ex- amined, and lanced if necessary. Mercury has been highly extolled in the treatment of this disease; but principally by those who regard it as a disease of debility, terminating in dropsy, and not one of in- flammation. There are only two classes of cases in which this remedy ought to be trusted to;—1. Those in which we are called too late to employ the most powerful antiphlogistic means; and 2. Those in which these means have been employed without decided amendment. In subacute cases, as well as in those of an acute nature, after the force of the disease has been subdued by the appropriate reme- dies, I have seen very beneficial results from the production of a pustular eruption on the head, with the tartrate of antimonial oint- ment. This is only following the steps of nature, it having been often observed that threatening symptoms have subsided upon the occurrence of porrigo or some other cutaneous eruption. When the disease has advanced to its last stage, it has been proposed to draw off the water by tapping the brain. But the water is not the dis- ease ; and, therefore, unless the diseased action were cured, and the healthy condition of the brain restored, it is of no use to draw off * Traits des Maladies des Enfans jusqu'a la Puberte, 1820. 564 CHRONIC HYDROCEPHALUS. the water; not to speak of the danger and uncertainty of such an operation, even when performed by the most .skilful hands. What- ever good effects are represented to have been produced in chronic cases of hydrocephalus, no benefit can be expected from such an operation in the acute form of the disease. CHRONIC HYDROCEPHALUS. Sometimes, in young subjects, acute hydrocephalus runs into the chronic form, and constitutes one variety. A second variety, the effect of very slight inflammatory action, may be very insidious, and slow in its progress. A child so affected shows marks of suffering, with loss of flesh; but there are no de- cided symptoms, till perhaps a stranger remarks its head to be much larger than it ought to be. The head may go on enlarging slowly for a number of years, remarkable instances of which are on record; or if the disease attack a very young subject, the bones of the head separate to a considerable extent. A third variety is sometimes observed, in which the head, perhaps very large originally, does not become larger during the course of the disease ; but the bones are found to be remarkably thin, and some- times after they have become so, the sutures are so much weakened and their mechanism so much altered, that slight separation of the bones is observed. Children affected in the manner, described in the first variety, sel- dom live so long as the others; and in the third variety,shorter than those in the second, who may live for twenty or thirty years; and it is an interesting pathological fact, that in all the varieties death is often occasioned by some other disease, very frequently ulceration of the bowels, sometimes phthisis pulmonalis, and occasionally an in- flammatory affection of some of the tissues of the lungs. The symptoms vary much; and, in some cases, it is difficult to conceive how children, under such extensive disease, preserve their intellectual faculties'. Occasionally the sense of sight, hearing and taste are destroyed permanently, or only for a time; in some, one sense only is affected; in others, two or more, the rest remaining en- tire. Emaciation is a common symptom, as is also some degree of giddiness in the erect posture. The bowels are in different conditions; but when diarrhoea is intractable, and in some cases even when very slight, I have found after death-extensive ulceration in the mucous membrane of the bowels. Strabismus is frequently, and opacities of the cornea are occasionally, seen in this affection. In some instances, convulsions are very violent, many of the muscles remaining con- stantly rigid; the convulsions may be general, like those of the epileptic kind, with foaming at the mouth ; or they may be partial, affecting one or more of the extremities, or the muscles connected with respiration, or, perhaps, only those of the face. Appearances on dissection in chronic hydrocephalus. — The membranes of the brain are generally very vascular; the veins some- times very large and turgid. In three instances of chronic hydroce- CHRONIC HYDROCEPHALUS. 565 phalus, I found extensive traces of disease in the longitudinal sinus: in one, it was almost obliterated by the thickening of its coats; in two others, the area of the vessel was very much diminished, partly by thickening of its coats, but principally by deposition of lymph in its cavity partially organized, and requiring some degree of force to separate it. The collection of water in the ventricles sometimes amounts to several pounds; and in cases where the effusion is considerable, the convolutions of the brain become more and more obliterated, from the distension occasioned by the fluid, and in some instances I have seen them completely unfolded. The ventricles will be found largely developed, the lining membrane occasionally vascular, and frequently thickened ; I have seen this membrane as thick as the rind of an orange, and easily separated from the surrounding brain, which was softened. The brain itself is occasionally of a natural consistence; at other times it is softened. In some cases, particularly where the convulsions have been violent, considerable effusions, presenting more or less of the appearance of lymph, have been found, involving the central parts at the base of the brain. In some instances, the effusion has been seen external to the brain itself, which has been described as a variety, under the term "exter- nal hydrocephalus." Not meaning to deny the existence of such a case, I feel convinced, from my own examinations of brains, where the effusion appeared to be external, that in fact it was owing to the fluid having found its way out of the ventricles, and distending to a great degree the arachnoid coat alone; one instance of which occurred to me a few years ago, and another lately. Treatment of chronic hydrocephalus.—In the treatment of cases of this nature, the chief object of the physician is to palliate symp- toms as they arise, by the occasional application of leeches, the fre- quent use of blisters or issues, and the contra-irritation produced by tartar emetic sprinkled upon the surface of a pitch plaster; attention to the bowels, regulating the diet, together with the administration of an occasional small opiate. Mercury has been much praised in this form of the disease; and although I have never seen any benefit arise from its employment, yet there can be no objections, in any case, to a fair trial of its powers. When considering the treatment of acute hydrocephalus, I stated my disapproval of the irrational practice of puncturing the brain to draw off the effused fluid; but 1 will not venture to speak so decid- edly against the practice in chronic cases. If the operation of tap- ping the brain is ever to prove successful in producing a cure, it must be in chronic cases, where an inconsiderable quantity of fluid is effused, or where there is no considerable organic lesion. Neverthe- less, experienced pathologists will, I am persuaded, join me in stating that such cases are exceedingly rare; so rare as not to be met with oftener than once in a thousand instances ! Pressure has been highly extolled : of course it must be employed after the operation of tapping. Similar remarks to those already made respecting the results to be expected from that operation, are applicable to the effects to be expected from pressure. CHAPTER III. DISEASES OF THE SPINAL MARROW. Inflammation of the Spinal Marrow and its Membranes; and under this head I shall at present include Tetanus—Trismus- Trismus Nascentium—and Hydrophobia. INFLAMMATION OF THE SPINAL MARROW AND ITS MEMBRANES. It has been considered expedient to treat of inflammation of these tissues together, because it does not appear to be established that in- flammation in one texture has such distinctive characters as to enable us to distinguish inflammation of the membranes from inflammation of the substance of the spinal marrow. We are indebted for many important observations on this subject to several French writers and Dr. Abercrombie; nevertheless, systematic authors must be slow in drawing practical conclusions from them, until they be more nume- rous, and more fully elucidated. Symptoms of inflammation of the spinal marrow and its membranes.—The chief symptoms of inflammation of these parts are stated to be pain in the back, occasionally shooting upwards and downwards, being very severe in one spot, increased by motion, but not always by pressure, unless it be connected with caries of the bone ; rigors ; some degree of fever; headache; slight incoherency, and even coma occur. In some cases dysuria takes place; in others retention of urine; convulsions sometimes general, at other times partial; rigidity of the muscles of the back and neck. Sometimes the body is bent backwards, in a state called opisthotonos; in some extremely rare cases, the body is bent forwards, in the state termed emprosthotonos. Sometimes there is locked-jaw, and occasionally complete tetanus. Sometimes there is great pain or tingling in the extremities, particularly in the lower; and occasionally paralysis, not only of the lower, but of the upper extremities. When the superior extremities are affected with pain, tingling, convulsions or paralysis, it is stated that morbid appearances have been found in the cervical region. In some instances, the limbs are permanently contracted, rigid and painful; while in other cases they are flaccid and without pain. The muscles of deglutition are occasionally affected, sometimes so much so that there is a dread of swallowing any fluid, and in this way the disease stimulates hydrophobia; and there is reason to be- DISEASES OF THE SPINAL MARROW. 567 lieve this class of diseases has been often mistaken for the latter. The functions of the stomach and bowels are deranged ; at first, the bowels are constipated and moved with difficulty, but towards the last, stools are passed involuntarily, as in the urine. The tongue presents different appearances; from being loaded and moist, it be- comes dry and hard. The pulse is various, and has no particular character. The faculties of the mind, generally speaking, are not much impaired, although there is occasional incoherency. Some allege that it is only when the disease is situated high in the cervical region that the functions of the brain are impaired. When they are permanently, disordered and particularly, if blindness and deafness take place, it may be concluded that the brain is also affected. The respiration, in many cases, becomes slow as the disease advances, so much so, that there may be so few as ten, seven, five or even three inspirations in a minute; occasionally death is suddenly produced by asphyxia. Sometimes the disease terminates fatally in a few days, but the general course of its acute form is from ten to fifteen; it would ap- pear, however, that it may exist in a chronic state for an almost inde- finite period. In the practice of French physicians, we are told this disease has been very generally fatal; but I have seen a number of severe cases treated successfully, which, there was every reason to be- lieve, were inflammation of the spinal cord and its membranes, but by means very much bolder than those which are generally pursued on the opposite side of the Channel. If the disease be produced by caries of the vertebrae, or by blows causing considerable injury to the bones, it will generally prove fatal, at least much more frequently so than when it occurs spontaneously. Probably many affections which now go by the vague name of nervous, and many of the painful sensations in the chest and abdomen, experienced particularly by females, will hereafter be found to depend upon some functional derangement, or slight disorganization of the spinal marrow and its membranes. Causes of inflammation of the spinal marrow and its mem- branes.—This disease may be produced by the application of cold, particularly in damp situations ; fatigue, and every other circum- stance which may upset the balance of the circulation, and produce venous engorgement in different organs ; as also by blows, caries of the vertebras, and tumours growing from different parts within the vertebral canal. Appearances on dissection in inflammation of the spinal mar- row and its membranes.—It may be remarked, that the description given of the morbid appearances of the brain and its membranes, will equally apply to the spinal marrow and its membranes. The effusion will be found beneath the arachnoid. The reader must keep in mind, that there is always a considerable quantity of serous fluid in the spinal canal, which has a free communication with the ven- tricles of the brain ; and that the spinal marrow is rather harder than the substance of the brain. Treatment of inflammation of the spinal marrow and its mem- branes.—This consists in bleeding, generally and locally; the frequent 568 [SPINAL IRRITATION.] administration of purgatives; the application of contra-irritation, and attention to the bladder, to prevent over-distension. In this, as in all diseases affecting vital organs, the life of the patient depends upon the timely application of the proper remedies, which must be made assiduously. Some cases, thought to be of the nature of those now under description, have been successfully treated, by applying twenty or thirty leeches, after copious general bleeding, and by reapplying them, (even in increased number,) to the part chiefly affected, till the disease was subdued ; and by the exhibition of repeated doses of calomel and opium.* [SPINAL IRRITATION.] [In addition to the preceding account of the diseases of the spinal marrow, I shall now offer a few remarks on those modifications of disease which have of late been referred to irritation of the spinal marrow and nervous ganglia. It must be confessed that some of the advocates of these views have given them a much too general application; yet it cannot be denied that they are of great practical value, and should be familiar to every physician. As the basis of the doctrine of spinal irritation, it is assumed that "disease of the larger nervous masses, as the brain and spinal mar- row, is not so much evinced by phenomena in the immediate seat of disease, as in those more remote parts to which the nerves arising from the diseased portion are distributed."* Hence it is, that se- vere neuralgia of the limbs may be attended by comparatively trivial uneasiness in the spinal cord, while the latter is the real source of the irritation, and the part to which the curative means should be directed. It often happens that the patient is wholly unconscious of pain or sensitiveness of the spine, until the latter has been subjected to some degree of pressure, when the connection becomes manifest by the occurrence of a neuralgic paroxysm. In other instances the secondary effect consists in numbness, or in a sensation like fatigue; and again, in very many cases, the spine itself may be very sore to the touch, and yet pressure there has no obvious effect on the remoter symptoms; so that the connection between them is rather to be in- ferred from other circumstances. Let us now briefly inquire into the symptoms of spinal irritation in connection with the distribution of the nerves. 1. Irritation of the medulla oblongata, and the nerves arising from it, (especially the 5th pair,) gives rise to those painful affections of the face called tic-doloureux. 2. Irritation of the upper cervical cord gives rise to neuralgic pains of the scalp, and a stiffness and sense of fatigue in the muscles of the neck. * The last work written exclusively upon this subject, is that of M. Oliver, of Angers, entitled " De la Moelle epiniere et de ses Maladies." [t Teale on Neuralgia, p. 3.—I have freely availed myself of this valuable work on the present occasion.] [SPINAL IRRITATION.] 569 3. Irritation of the lower cervical cord produces its effects on the shoulders and upper extremities. 4. Irritation of the upper dorsal cord causes uneasiness in the chest, and is supposed to give rise to that affection of the intercostal muscles called pleurodynia. 5. Irritation of the lower dorsal cord induces soreness and pain in the inferior part of the chest, and especially a sense of constriction of the epigastrium, and pains of the abdominal muscles. 6. Irritation of the lumbar and sacral cord gives rise to pain, spasm and other uneasiness in the lower extremities, and especially a feeling of instability in walking. These sensations are sometimes intermittent, sometimes constant; and they present a diversity of character which it would be both difficult and tedious to describe. Pain of every grade; spasm, tre- mors, debility, weariness, coldness, numbness and loss of feeling, are among the more common symptoms—symptoms which are not un- frequently attended by great physical suffering, and which, for want of our ability to explain them, have been too often considered imaginative, and therefore unworthy of attention. Mr. Teale has also drawn the attention of the profession to an analogous irritation of the ganglia of the sympathetic nerve. He observes, that this disease of the ganglia is seldom found except in conjunction with that of the corresponding portion of the spinal cord, whereas the latter is often affected without implication of the former. This irritation may occur in any of the sympathetic ganglia, but those most frequently affected are the middle and lower thoracic, and the cervical ganglia. The organs which derive their nerves from these sources, are the seat of a series of symptoms of which the following are the most common : palpitation of the heart, asthmatic breathing, gastric disease of various grades, as spasm, gastrodynia, flatulence, pyrosis, pulsation in the epigastrium, and, in fine, all the indications usually called dyspeptic. Leucorrhosa and irregularities of the catamenia also take place from this cause, together with various perversions of the other secretions. Mr. Tate, an English surgeon, has, within a few years, called the attention of the profession to the manifest connection between hys- teria and spinal irritation; which views, however, will be briefly noticed in the chapter on hysteria. As yet we know very little of the absolute pathological condition of the spinal marrow and nervous ganglia, under the circumstances above described: they appear, however, to be in a "subacute in- flammatory state," which is extended to their envelopes, and, by continuance, to the adjacent integuments: for on no other principle can we account for the extreme sensitiveness which sometimes exists in the course of the spine, and which is aggravated by very slight pressure. Some physicians seem unwilling to acknowledge that this tenderness of the integuments of the spine can arise from irritation of the nervous masses which are deeply shut up in the bones of the vertebral column. Some have even considered this objection as an insuperable difficulty in the view before us: but on this point we may draw a familiar illustration from an inflamed tooth, which, if 48 570 [SPINAL IRRITATION.] not soon relieved, renders the adjacent integuments acutely sensible to the slightest violence, and will even cause extreme neuralgia of the whole corresponding side of the face. Now, in this instance, the nerve which supplies the tooth, and which is the primary seat of the irritation, is as completely enveloped by the maxillary bone as the spinal ganglia are by the vertebrae. However isolated either may appear at first thought, it will be found that there are connections between them and the surrounding parts, which fully account for the propagation of disease from one to the other; and that this dis- ease will consecutively affect the nervous mass, its bony envelope, the periosteum and the integuments, until the skin itself becomes acutely sensible. Of the latter fact a singular example is given in a late quarterly journal (British and For. Med. Rev.,) in which the act of passing the finger lightly over the fine hairs covering the nape of the neck, threw the patient into an agony. Spinal irritation is not necessarily connected with disease of the vertebrae, although the two may coexist. I have lately met with a remarkable case of spinal irritation in which the vertebras do not appear to be involved ; and yet on each side of the upper portion of the sacrum a distinct tumefaction can be felt, upwards of an inch in diameter, very sore to the touch, and accompanied by neuralgic pains of the lower extremities, great weariness in walking, and various dyspeptic symptoms. This disease had continued upwards of six years before I saw it: it is irregularly paroxysmal, and has tended much to enfeeble a previously delicate constitution. Treatment.—It may be briefly mentioned, that almost all the ordinary counter-irritants have been resorted to in these derange- ments, together with local depletion in the course of the spine. Cups or leeches, followed by blisters, constitute our principal resources; but after the acute symptoms have been relieved by these or analo- gous measures, irritation of a more permanent kind should be insti- tuted without delay. For this purpose the tartar-emetic ointment answers best. Many cases yield to the first application of these remedies; but others require a much more prolonged treatment. The usual mode of applying tartar-emetic to the spine is by means of the tartar-emetic ointment, formed by mixing one drachm of the mineral salt with an ounce of simple cerate. Much time, however, is often lost in waiting for the effect of this uncertain preparation. A much more active formula is that recommended by Dr. Hannay, of Glasgow, viz.: R.—Tartrat. Antimonii, 3i. Muriat. Hydrargyri, gr. v. Aquae distillatae, %i. Spiritus Lavend. Compos., %i. Dissolve the salts in water, and then add the spirit. This solution is applied by wetting the fingers with it, and then rubbing them on the skin. To be still more effectual, portions of the antimony itself (much of which remains undissolved,) may be rubbed on: by these means, persisted in for 10 or 15 minutes, an eruption will invariably follow in a few hours. When tartarized antimony is applied, or a Burgundy pitch plaster, TETANUS. 571 as is sometimes done, it may be very difficult to remove it when the irritation comes on, and the patient may hence suffer much unneces- sary distress. It is important to know that during the operation of tartarized antimony, the nervous symptoms are often greatly aggravated, and the relief is not to be expected until the eruption begins to decline. Care should be taken not to allow the irritation to exceed a reason- able limit, for which purpose its progress must be watched from day to day; and if by any chance it becomes too severe, a starch or bread and milk poultice is well calculated to mitigate the pain. Galvanism, as directed in the chapter on epilepsy, and moxa have occasionally produced remarkably good effects. "Where the case is not sufficiently severe to justify the employ- ment of either of the preceding applications," observes Dr. I. Parrish, " or where, from the suddenness of the attack, it is desirable to pro- duce a speedy impression in the vicinity of the spinal marrow, fric- tions down the spine, with spt. terebinth, either alone or diluted with some unctuous matter, or a decoction of capsicum in brandy, with other similar articles, will be found highly beneficial."* But while our attention is thus directed to the spinal track as one of the points of diseased action, we are by no means to neglect the various coexisting functional derangements. These require to be treated on general principles, by the judicious interposition of ape- rient and tonic medicines, with a suitable diet, exercise, and, in some instances, change of air. In concluding these brief observations, it may be remarked, that spinal irritation is not to be viewed as a simple or isolated affection, but rather as a complication involving various dissimilar organs, and having for its basis a true neuralgic condition. It is a condition from which many different diseases are produced, and these, by long con- tinuance, tend to impair and disorganize the structures in which they are located, however remote from the spine itself; so that the consecutive disease may become infinitely worse than the primary irritation : whence it happens that by removing the latter we cannot always guarantee the cure of the former; or, in a familiar phrase, a chain of morbid actions is established, in which the spinal affection becomes a link of but secondary importance; nor have I a doubt that it is itself sometimes a strictly consecutive affection. The subject, in truth, is comparatively new, and requires abundant additional observation and reflection, before its real merits can be ascertained.t] TETANUS. This is a disease characterized by tonic convulsions, and, for the most part, by rigidity of the affected muscles. Sometimes the mus- [* Vide Remarks on Spinal Irrit., &c, Amer. Jour. Med. Sci., Aug. 1832.] [t The best information on this subject will be obtained from the works of MK Teale and Mr. Tate, already mentioned: and from the ingenious and truly practical essay of my friend Dr. Isaac Parrish, above quoted.] 572 , DISEASES OF THE SPINAL MARROW. cles which close the jaws are solely affected, with perhaps those of the neck, when the disease is usually termed locked-jaw or trismus. When the muscles of the back are convulsed and contracted in such a manner as to make the body be supported by the head and the heels, the trunk being arched, the term opisthotonos has been ap- plied. When the body is bent in the opposite direction, the term emprosthotonos has been used. In a practical point of view, these varieties may be considered under the general term tetanus. An important distinction, however, must be made between the symptomatic tetanus, which is so frequently the result of wounds, and that which comes on without any assignable cause, and which has been denominated, in contradistinction to the other, idiopathic. It affords me much pleasure to hand to the surgeon who boasts of the superior success of his art over that of physic, the traumatic tetanus in the hope that he may be more successful in discovering its true pathology and treatment than his wise ancestors; and I shall now proceed to consider that form of the disease which has been called idiopathic, and afterwards make a few observations on tris- mus nascentium. Symptoms of tetanus.—Tetanus has no precursory symptoms which can be depended upon ; sometimes patients complain of rigors, or merely chilliness, with pain and stiffness of the muscles of the neck and shoulders, which extend, by degrees, to those of the jaw. By and by rigidity of the muscles takes place, accompanied by pain- ful spasms; the jaws are immovable, and if not yet completely shut, soon become so tightly clenched that it is impossible to separate them; deglutition is difficult, at length impracticable; the faculty of the speech is impaired, and at last the power is altogether destroyed, although intelligence may remain; the countenance is exceedingly anxious; the oppression at the praecordia is great, together with a sense of tightness and suffocation. The spasms sometimes extend from the face and neck to the back, from whence they spread to the rest of the muscles of the trunk, ab- domen and extremities, the muscles always remaining rigid; but their convulsive action comes on at regular intervals. In the most severe cases, the paroxysms are violent, and the spasms succeed each other very rapidly. The oppression at the praecordia increases as the spasms extend from the muscles of the jaw and neck to those of the trunk, when there come on a severe sense of constriction in the chest and a violent darting pain extending from the lower part of the sternum to the spine, the return of which the patient constantly dreads. The mental faculties, for the most part, remain sound till near the approach of death ; which circumstance gives the disease a distinguishing character from epilepsy. The pulse is generally little affected in tetanus, even in the traumatic form of the disease; occasionally, however, it is quick, particularly towards the fatal termination. The functions of the lungs seem to be seriously im- peded, respiration being very rapid, or slow, not exceeding three, five, seven or nine inspirations during a minute. The skin is seldom hotter than natural, that is to say, there is no feverish heat; the body is frequently bathed in perspiration, which, as the disease advances, TETANUS. 573 is converted into a cold, clammy sweat. The functions of the stomach and bowels are sometimes unaffected. Deglutition is, in many cases, very difficult, which may be partly owing to the tough phlegm lodged about the fauces in considerable quantity, and partly, also, to the spasmodic action of the muscles. Greater difficulty is experienced in swallowing fluids than solids, which the patient is apprehensive will produce complete suffocation ; and, if he is a per- son of irritable temper, he may, perhaps, show a marked dislike to fluids when presented to him, which will give an appearance of water-dread. Should such an individual have received a bite from a dog, even twenty years before, he will be said to be affected with hydrophobia; and I am convinced, after much patient investigation, that many of the cases recorded as pure hydrophobia, were nothing more than trismus, conjoined with difficulty in swallowing fluids. Tetanus is a disease which is very rapid and fatal in warm climates, terminating as early as the third day; in this country, it is seldom fatal till between the fifth and tenth. The danger of the disease is to be calculated by the frequency, violence and duration of the con- vulsions. Causes of tetanus.—In warm countries, it is believed that the black population is more liable to tetanus than the white. Individu- als possessing what is termed a nervous temperament, are, perhaps, more subjeet than others. Long-continued fatigue, together with exposure to cold damp air, conjoined with the excessive use of ar- dent spirits, are the causes usually, and, perhaps, truly assigned. Appearances on dissection in tetanus.—Many distinguished pa- thologists believe that tetanus has its seat in the spinal marrow, and that its nature is inflammatory. There can be no doubt that there is a striking resemblance between the symptoms of tetanus, and those produced by inflammation of the membranes of the spinal marrow. Tetanus, well marked in its symptoms, however, has proceeded to a fatal termination, and, upon the most minute exami- nation, no morbid appearance could be discovered either in the membranes or in the spinal cord itself. And, on the other hand, in- flammation and other organic lesions of this part have been found, upon dissection, in cases where no symptoms of tetanus had mani- fested themselves. Others allege that the ossific scales, found on the surface of the arachnoid membrane of the spinal marrow, are the cause of tetanic convulsions; but I have frequently seen these ossi- fications where symptoms of tetanus never appeared.—The lungs have been often found loaded with blood; but this can scarcely have any connection with the causes of the disease; it is, perhaps, only an effect of the impeded respiration. It is said that the cardiac portion of the stomach and the lower end of the oesophagus have always been found inflamed, and attempts have been made to con- nect the occurrence of the disease with this appearance; but were this a cause of tetanus, it would be a disease of very frequent oc- currence in these latitudes. A similar remark applies equally to worms having been occasionally found in the alimentary canal, but they may possibly give rise, in some constitutions, to symptomatic tetanus. 48* 574 DISEASES OF THE SPINAL MARROW. Treatment of tetanus.—After a careful review of the cases recorded in the annals of physic, no plan of treatment, hitherto em- ployed, seems to have been attended 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 suc- cess. 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 determina- tion of blood will be altered—and any tendency to inflammation, if such exist, so far at least subdued. But venesection 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 the spine, either by applying a considerable 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 rendered more violent, by the constant exhibition of drastic purgatives. Tobacco enemata have long been used,* and have of late years been again strongly recommended in this disease by Dr. O'Beirne of Dublin. Opium, in 5 grain doses, ought to be exhibited every 2d, 3d or 4th hour, ac- cording to circumstances; or what is better still, a hundred drops of Jaudanum, sixty or seventy of Battley's sedative solution, or half- grain doses of acetate of morphia. From the beneficial effects pro- duced by colchicum in gout and rheumatism, in both of which the nervous system is very much implicated, large doses of that medi- cine might be conjoined with the opium. Patients labouring under tetanus appear to bear immense doses of opium: many cases are re- corded, in which twenty and thirty grains have been exhibited daily, and persevered in for two or three weeks without causing any appa- rent bad consequences. Mercury has been much in favour among medical men in the treatment of this disease, and it has been asserted that those patients have recovered in whom salivation had been ex- cited ; but there is a great deception likely to arise from this state- ment. It is difficult to excite this action in violent diseases, which run on rapidly to the destruction of life: the very severe cases run through their course in too short a period of time to allow the mer- cury 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 by other means. The remedy, however, has been too strongly recommended to be passed over. A large blister should be applied to the spine. As to cold and warm bathing, it may be shortly stated, that I have no faith in either, as the least motion will very generally produce a paroxysm. The strength must be carefully watched, and nourishment, with or without a little wine, should be given at short intervals, long before there is any decided appearance * Vide Observations by Mr. Duncan, 11th vol. Ed. Med. and Surg. Journ., p. 198. TRISMUS NASCENTIUM—HYDROPHOBIA. 575 of sinking. When the stage of collapse approaches, stimulants must be had recourse to, and there can be no doubt that their judicious exhibition has occasionally saved lives. Among other remedies which have been recommended, I may mention assafoetida, 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 in- fants. It is a disease seldom seen in this country, and is more pecu- liarly an affection of negro children in warm climates; attacking them between the 7th and 15th day after birth, seldom later than the 17th, and, in general, neither preceded nor accompanied by any febrile movement. The disease steals on in the following 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 gra- dually puts on a yellow appearance; by and by the jaw is observed to become stiff, its muscles rigid ; general convulsions sometimes pre- cede 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 navel-cord; to the irritable state of the umbilicus upon the separa- tion of the cord at the natural period; while others maintain that it is owing to some diseased state, or retention of the meconium. No treatment hitherto tried appears to have had much effect in controlling the disease after it is fairly established; but that which has been found most beneficial, is the application of turpentine to the navel. 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 Indian 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 probably of still rarer oc- currence than is generally imagined, being frequently confounded with tetanus, when, along with that disease, there is 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 I was able to judge of such matters for myself, who was said to be affected with hydropho- bia: it terminated fatally; but I have never met with a medical man who could say he had seen even one case in this country. Hydro- phobia is produced by a morbid poison generated in the dog, wolf, fox, and occasionally, although rarely, in the cat. The poison ap- pears to be mixed with the saliva; and the characteristic of the dis- ease produced is a dread of liquids. That such a disease does exist 576 DISEASES OF THE SPINAL MARROW. and that it is capable of being communicated from one animal to another, has been satisfactorily proved by experiments performed in the year 1S13, 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 the same disease. Expe- rience has proved,that all the animals bitten are not necessarily affect- ed with hydrophobia. Of this fact, Mr. Hunter gives a striking ex- ample. 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 disease ; and it is probable that hydrophobia may be sometimes produced by the con- stant 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 shows 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, lassitude, severe mental depression, irritability, anxiety, restlessness and watchfulness. Occasionally a shooting pain is felt in the neighbourhood of the injured part. As the disease advances, the anxiety of the countenance, the irritability and watchfulness, the oppression at the praecordia and sense of contraction of the chest, increase ; slight tumours, affecting every part of the body, appearand difficult deglutition ; a considerable quantity of viscid phlegm is ob- served in the mouth and fauces ; stiffness of 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 convul- sions will be found to be of the clonic kind. In pure hydrophobia, the body is said to be affected more with tremors than 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 tre- mors, at a time too when the thirst is very urgent. On some occa- sions, the dread only takes place when the patient attempts to drink. As the disease goes on advancing, the least noise or motion made by any of the attendants 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 gene- rally remains entire till towards the termination of the disease. The thirst and sense of constriction increase in urgency; respiration becomes painfully hurried and short; the pulse and heat of skin are 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 pro- per sense of the term, is scarcely ever present till towards 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 HYDROPHOBIA. 577 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 sus- pected symptom. Two hours before death, his patient ate bread and jelly with an appetite. Another case, which Mr. Marshall at- tended, terminated fatally in a shorter period. Appearances on dissection in hydrophobia.—A great many dis- cordant statements will be found, in different works, respecting the seat of the disease. Some pathologists, after the most careful exami- nation, have not been able to discover any morbid appearance what- ever in any part of the body; while others have seen vascularity in the pharynx, oesophagus, the cardiac extremity of the stomach, and even in portions of the intestinal tube, particularly the ileum; and these parts have been represented to have been even in a gangrenous condition. Magendie found no diseased appearances 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 treat- ment 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 membrane of the air- passages, which was coated over with a frothy matter, (according to his view,) of a. peculiar kind, and which he supposes to contain the specific virus; the lungs were gorged, and apparently emphysema- tous ; in some instances air was discovered in the heart and large blood-vessels; the blood was black, uncoagulated, 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 in- vestigated this disease—that the salivary glands, and the surround- ing cellular substance, have always been found healthy. Treatment of hydrophobia.—Bleeding even to syncope, and large doses of opium, have been employed, together with camphor, musk, mercury, and almost every other potent remedy in the materia medi- ca, without success. To show 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 re- peated 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 the hydropho- bia. 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 treat- ment to that I have proposed in tetanus at page 574. The injection of tepid water into the veins has been practised without success. But from the experience we have had of the safety of throwing even ten pounds of saline fluid at a time into the vascu- lar system in cases of epidemic cholera, there is little doubt that the practice in hydrophobia will be conducted with greater boldness, and probably attended with better effects. * Nouveau Traite de la Rage. CHAPTER IV. EPILEPSY—HYSTERIA—CHOREA—NEURALGIC PAINS. EPILEPSY. This is a convulsive disease which affects the voluntary muscles, and is characterized by the suddenness of the attack, loss of sense and voluntary motion. 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 con- nected 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 sometimes thrust with violence out of the mouth; it is occasionally caught between the teeth, and severely bitten; a con- siderable quantity of phlegm is collected in the mouth, and expelled with violence in a frothy state, with considerable noise. The respi- ration is always hurried and laborious, which is often produced or increased by patients breathing through the clenched teeth, and the frothy saliva. The pulse varies much; in some cases it is very ra- pid, 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, "clonicspasms." 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 reco- ver his senses and power of voluntary motion, either immediately 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 vomit- in0-. Occasionally it happens that one fit succeeds another till the patient becomes comatose, and dies; but comparatively few die dur- ing a fit, unless the disease has existed for a considerable period of time. An epileptic paroxysm is occasionally preceded by a peculiar and painful sensation in a distant part of the body, as in the fingers, toes, or some part of the abdomen, and is described as proceeding in a gradual manner, like something creeping towards the heart, in other EPILEPSY. 579 cases towards the head, when the convulsions commence. This is called the aura epileptica. The attack is also occasionally preceded by certain symptoms which announce its approach to the patient, but which he has usually no time to communicate ; these are, head- ache, 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. It is not entirely confined to man, as I have seen it in horses— in dogs, particularly of the Newfoundland breed—in poultry and pigeons. Causes of epilepsy.—Epilepsy appears to be occasionally here- ditary. 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 in 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 intoxicating liquors. Indigestible articles of food, and constipation, by occasioning irrita- tion in the stomach and bowels; the irritation produced by worms in the intestinal tube, are also very frequent causes; as is likewise excessive venereal indulgence. This complaint has been attributed to tumours in the brain, and projections of bone arising from the in- ner table of the skull. Appearances on dissection in epilepsy.—A great variety of or- ganic lesions has been discovered in the brain and spinal marrow of epileptics. Congestion of the vessels of the brain; thickenings and indurations of the membranes; inflammations; exostoses; tubercles and tumours of different kinds, and in different parts of the brain— sometimes situated externally to the membranes; at others occupy- ing 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 dis- ease 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 discovered, or any lesion in any part of the body. So that, notwithstanding all the attention which has been paid to the investi- gation 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 ner- vous system, produced by a variety of causes, sometimes by mental emotions, at others, by various irritations affecting the digestive 580 EPILEPSY. organs; and very frequently 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 epileptics 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 garments must be loosened, particularly stays and neckcloths ; 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 pos- sible, and light nourishing 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 men- tal, which can possibly have the effect of disturbing 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; occa- sional cupping may be had recourse to, and if there be considerable plethora, a bleeding from the arm may be serviceable, together with keeping the head shaved, and the introduction of aseton 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 an- thelmintics should be exhibited. 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 serviceable 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 frequent cause of epileptic paroxysms. Some individuals seem to be born with very irritable mucous membranes; and I have seen several epileptics so constituted, that the irritation produced by a laxative medicine, or diarrhoea coming on without any assignable cause, occasioned a recurrence of epilepsy. A lady affected in this manner with epilepsy, was recommended by one of the most learned physicians of the present day, to use drachm doses of the powder of mistletoe, which she persevered in without any apparent benefit for some months; at last happening to pass through a country town, and being in want of a supply, an apothecary sent by mistake drachm doses of powdered oak-bark, which proved of more service than any other remedy she had previously taken. The only inconvenience experienced was the subsequent difficulty of getting the bowels opened without producing irritation. Since this case presented itself i [EPILEPSY.] 581 to my notice, I have used astringents several times in similar in- stances with apparent benefit. The ammoniuret of copper has been much lauded in the treatment of epilepsy, 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 authenticated. 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 remarkable 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.* [The experience of the French physicians presents some very con- tradictory results; but the following note, which was communicated by M. Esquirol to M. Ratier, embraces such a mass of evidence that I gladly insert it here. " The Salpetriere," observes M. Esquirol, "contains upwards of four hundred epileptic patients, and I have employed, but unsuccessfully, all the boasted remedies for that dis- ease. More than twenty female patients, of different ages, and offer- ing, for the most part, the most favourable chances of cure, have made use of the nitrate of silver in various doses, from half a grain to eight and even sixteen grains a day, during several months, with- out experiencing the slightest relief. In many of them it produced very severe gastralgia. Two facts have contributed not a little to make me abandon the use of this medicine: a young girl was the victim of jealousy; the menses were suppressed, and she became epileptic. She was put under the use of nitrate of silver for a year without advantage. Soon afterwards the catamenia were re-established, and the epilepsy ceased, and the case was considered a proof of the efficacy of nitrate of silver: but she avowed, on her dismissal from the hospital, that she had never taken a single dose of the medicine, and that the return of the menses was owing to the use she had secretly made of a strong infusion of emmenagogue plants. The second case was that of a stout woman who, before en- tering the Salpetriere, had taken the nitrate of silver in considerable doses during two years. She was brought to the hospital in a state of deplorable cachexy; vomited whatever she swallowed, and suf- fered excruciating pains in the stomach. She died; on examination it was found that the inferior half of the mucous membrane of the stomach had disappeared, and there were four or five perforations through the peritoneal coat. Latterly," continues M. Esquirol, " I have, with much caution, tried on five patients the muriate (hydro- chlorate) of silver, as prepared by M. Pelletier, but without having obtained any positive result. I have observed that moral influences have a power over the brain of epileptics sufficient to retard the pa- roxysms. The hope of cure and confidence in a remedy may produce this effect; and thus the first year that I was entrusted with the cure of [* This appearance, which is unsightly in itself and alarming to the patient, passes off entirely, but by very slow degrees. Its disappearance is said to be much accelerated by the free use of a solution of supertartrate of potash.] 49 582 [EPILEPSY.] epileptics, the patients, in the belief that I would adopt some effica- cious treatment, suffered much less frequently from their paroxysms than they previously had done."] Several patients have been under my care, who were able to pre- vent 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 circumstance ; but I can testify to the truth of it. One of these patients was found dead, having, it is sup- posed, died in the paroxysm ; one end of a cord was in his mouth, and the other in the hand, showing that he had been attempting 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 position 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.* [Galvanism has, of late, been employed with great effect in the treatment of epilepsy and other spasmodic diseases. Even in that most helpless complication of epilepsy with congenital idiocy, I have seen the convulsions reduced to a tenth part of their ordinary fre- quency : in one instance they were almost entirely suspended for more than three weeks, in a patient who had previously suffered from two to five paroxysms daily. But on removing the galvanic influence, the paroxysms gradually returned in their accustomed frequency and force. In another case which was treated by Dr. W. B. Simpson, resident physician to the Philadelphia Hospital, the result was still more fortunate : the patient, a stout, middle-aged man, had been struck with lightning, after which he became epileptic; his con- vulsions recurring every day, but without affecting his mind in the intervals. The galvanic apparatus was applied in the usual manner —his convulsions became at once less frequent, and in a few weeks ceased to recur. He was soon after discharged cured. About two years afterwards this man again entered the hospital, asserting that his convulsions had returned : but during a lapse of several weeks, no such recurrence was observed; and.1 could not help suspecting that the patient had reapplied for admission more with a view to indulge his indolent habits than to avail himself of medical aid. In those cases of epilepsy which are not complicated with idiocy or organic disease, in other words, those which depend on mere functional irritation, galvanism seems to promise more than any * An excellent article on Epilepsy, by M. Esquirol. will be found in the "Diet, des Sciences Medicates," but the most profound work on this subject, is that published by Baron Portal, entitled, " Observations sur la Nature et le Traitement de I'Epilepsia. HYSTERIA. 583 other single remedial agent; but to insure its good effects it must be persevered in for several weeks at a time ; and the interval between the removal and the reapplication of the plates, (except to clean them,) should not exceed one or two weeks. I shall not stop to inquire in what way galvanism produces its favourable effects. Dr. N. Chapman remarks, that " the hypothesis from which this practical expedient is deduced, supposes an undue accumulation of electric matter in the brain, at the expense of other parts of the body, and hence the cure depends on equalizing the dis- tribution of it."—A negative point is, therefore, established as near the brain as possible, and & positive one in some distant part of the body. To meet the first of these indications, a blister about an inch and a half* in diameter is placed on the back of the neck near the roots of the hair; and a similar application is made on the inner side of the leg below the knee, or to any other part of the extremities that may be more convenient. To the neck we apply, first, a piece of sponge cut flat and thin, and moistened with water; secondly, an- other piece of sponge of the same shape, and also wetted; and lastly, over the sponge is laid the silver plate, which is kept in its place by adhesive strips. The distant or positive point, being also prepared, as just men- tioned, by vesication, there must be applied to this surface, a piece of sponge, as in the neck; over this a thin layer of muscle or of buckskin, (for either will answer, and the latter is the cleanliest,) and, upon the buckskin, the zinc plate is to be secured by adhesive strips. Each of the plates has a small perforation near the margin, to which a delicate silver wire is attached; so that, by this means, the com- munication between the two plates is effectually insured; the wire passing down the back to the hip, whence it is brought over the groin, and so to the zinc plate at the inside of the leg. "The ap- paratus thus arranged," says Mr. Mansford, " will continue in gentle and uninterrupted action from 12 to 24 hours, according to circum- stances. This last is the longest period that it can be allowed to go unremoved : the sores require cleaning and dressing, and the surface of the zinc becomes covered with a thick oxide, which must be removed to restore its freedom of action: this may be done by scraping or polishing; but it will be better if removed twice a day, both for the greater security of a permanent action, and for the additional comfort of the patient." It may here be added, that galvanism has not only been success- fully used in epilepsy, but also in nearly all the neuroses, and espe- cially the protean forms of neuralgia.] 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 dis- ease almost exclusively affecting females; but males are not entirely [* In young children the vesicated surface may be considerably smaller.] 584 [HYSTERIA.] exempt. I have myself seen several well-marked instances in gentle- men, apparently of very different constitutions and habits; but the attacks came on in all of them under the influence of depressing passions. Phenomena of hysteria.—The invasion of hysteria is sudden and irregular, sometimes periodical. In the slighter forms, the patient, without any assignable cause, bursts into a fit of weeping, which, perhaps, is soon followed by convulsive laughing, which may last for a few minutes; and before composure takes place, the patient gives several loud sobs. One of these fits may quickly succeed another, till the patient falls asleep. In more severe instances, com- plaint is made at first of pain in the abdomen or chest; a sensation is felt as if something were in motion in the abdomen, owing, pro- bably, to flatus; it moves upwards, producing in the epigastrium a sensation of tightness and of suffocation ; and a feeling is experienced as if a ball were ascending to the throat.* The belly is tense; the surface is generally cold; the extremities exceedingly so. The countenance 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 showing 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 di- lated ; and occasionally, the paroxysm has a very close resemblance 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 attended 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, dyspnoea is a very urgent symptom. Dyspeptic symptoms often precede the attack ; and the bowels will, in general, be found in a very bad condition, 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 symp- toms 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 conducted in such a manner as to remedy and not aggravate the more severe malady if it exists. [Mr. Tate, in his Treatise on Hysteria, states that a diagnostic symptom of the disease is pain in the left side. " This," he observes, "is very peculiar: it is usually situated immediately below the left breast, in a hollow formed between the cartilages of the fifth, [* It is this sensation which has received the name of globus hystericus.] HYSTERIA. 585 sixth and seventh ribs: it is generally so circumscribed that it may be covered by a shilling, and is of the gnawing kind."* Mr. Tate supposes this pain to be seated in the intercostal nerve; and although the right side is not free from it, he has observed it in nineteen cases out of twenty on the left side. The same author states his convic- tion that the protean forms of hysteria are referable to irritation of the spinal marrow, especially of its dorsal portion, and originally in- duced by a disordered condition of the uterine function. Since my attention has been drawn to this subject, I have so re- peatedly noticed the pain under the left breast, as to believe with Mr. Tate, that it is characteristic of hysteric affections; and that these " never do occur without a combined error in the nervous sys- tem and the uterine functions."] 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 hysteria; as also those who become impressed with strong religious feelings, unaccompa- nied by a sufficient share of common sense to guide thern. Women very pregnant, and those who labour under the disorders of men- struation, seem strongly predisposed to hysteria. It appears to affect women of all constitutions—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 opin- ion is, that it is a complicated disease, and that the supporters of these different pathological views are all partially correct. Treatment of hysteria.—This is difficult at all times, and a radi- cal cure in many cases almost impossible, unless we had the power of changing the temper, altering the disposition, subduing the pas- sions, and relieving the mental distresses of the fair sufferers. It is of great consequence, however, to attend to the bowels, and to im- prove the powers of digestion. The diet should be light and nourish- ing ; 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 interesting pursuits; and much is to be done by a proper intermixture of inno- cent and rational amusement. During a paroxysm, the stays and all tight strings should be loosened, and plenty of air admitted into the apartment, and sixty drops of the spiritus ammonie aromaticus, or the same quantity of volatile tincture of valerian, may be given in a wineglassful 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 half an ounce of the tincture of assafoetida,t or a tablespoonful of the spirit of turpentine. Opiates [* Page 42 ] ft A more effectual enema of assafoetida, because more easily retained, is made by 49* 586 CHOREA. are, in many cases, serviceable after the bowels have been fully opened. Bleeding has been strongly recommended, and is ofien had recourse to in this disease ; but in pure hysteria, it is scarcely ever justifiable. Bitters, and more particularly the sulphate of quinine, will be found very serviceable in restoring the functions of the sto- mach 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. In severe cases, a mustard plaster should be applied over the whole abdomen, and an enema of very cold water is frequently serviceable. [When the disease can be traced to irritation of the spinal mar- row, counter-irritation should be established in the course of the vertebrae, either by blisters or by tartar-emetic ointment. The latter is preferable, and should be employed according to the directions already given under the head of Spinal Irritation, p. 568.] CHOREA. This is a disease of the nervous system, characterized by sudden involuntary motions of various muscles of the body, without being necessarily connected with fever, or any severe constitutional de- rangement. The appetite is generally unimpaired, and all the func- tions 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 later; and several instances have fallen within my observation, where the disease attacked individuals after the age of twenty-one, and in two cases between thirty and forty. The later in life the dis- ease 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 fre- quently 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 men- tioned, that, however violent the convulsive motions may be, they cease the moment the patient falls asleep, unless in severe cases of longstanding. 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 sto- mach and bowels appear much deranged, as is indicated by hard- ness, sometimes unusual softness and swelling of the belly, together rubbing up a drachm of the gum with four ounces of water, and administering the whole at a single injection.] NEURALGIA. 587 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 decid- edly 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 cho- rea, 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 should be carefully avoided. All means should be had recourse to which will improve digestion, if it be im- paired, 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 is com- plained of, and the administration of a narcotic when there is much nervous excitement, will be found serviceable. Good effects some- times follow the use of the warm, at others that of the cold bath. The oxide of zinc, castor, and many other tonics and antispasmodics, have been at various times in high repute; but of these, the car- bonate of iron, in doses of two drachms four times a-day, will fre- quently cure, or relieve the patient in a remarkable manner. NEURALGIA. 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, but 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 the heart* also, are liable to be affected with neuralgia. [* See the chapter on Neuralgia; and in addition to the evidence there given of the neuralgic character of angina pectoris itself, I gladly quote the corroborative senti- ments of Prof. Chapman of the University of Pennsylvania : " That the disease is a species of neuralgia I am entirely persuaded, commencing, for the most part, in the peneumogastric nerve, and spreading in different directions, as other nerves may become involved. The derangements of the heart and other structures, with which it is sometimes associated, I hold to be coincidences or effects, and not the cause, since, among many reasons which might be adduced in corroboration of this, the disease has undoubtedly prevailed independently of such organic lesions, and conversely, these have existed without occasioning it. Cogently is its neuralgic 588 [NEURALGIA.] [Indeed, there is reason to believe that all the nerves of the cerebro-spinal system, from their origin to their ultimate ramifica- tions, are more or less subject to this disease, and especially the subcutaneous nerves. But the most frequent seat of the intense form of the disease is the head and face, which is attributable, observes Dr. Bennett, "to the number and sensitiveness of the nerves in this situation, as well as their superficial arrangement; and perhaps, also, to their intimate connection with the sympathetic, and conse- quent susceptibility of impression from conditions of the abdominal viscera." But it is the trigeminal or fifth pair of nerves which is generally attacked, and each of its branches is almost equally the subject of this suffering malady. When the first branch is affected, the pain shoots from the supra-orbitar foramen, and radiates to the upper eyelid, the forehead and to the eyeball itself. This is called hernicrania or megrini. It is accompanied by intense pain, heat, throbbing, intolerance of light, and an abundant secretion of tears. When the second, or infra-orbitar nerve, is attacked, the pain extends from the corresponding foramen as a centre to the lower eyelid, aloe nasi, upper lip, side of the nose, teeth, palate and antrum, and even to the tongue. The inferior maxillary nerve is the third seat of facial neuralgia, which commences at the anterior mental foramen, and extends thence to the teeth, tongue, lip and cheek of the correspond- ing side, the pain terminating, as is the case also with the other nerves, in the mesial line of the face. The cervical nerves do not escape; and of the intercostal, that running between the eighth and ninth ribs is most liable to suffer, particularly in women. The lumbar nerves are the centre of neu- ralgic pains of the anus, spermatic cord, scrotum and ureter, and the uterus and vulva in women; and to this cause is attributable most of those pains which are called sciatica and lumbago. The muscles, generally, are subject to neuralgia, whence the painful and bruised condition of the limbs in the early stages of fever; the glands, the parenchymatous and membranous structures and the skin itself, are also the occasional seats of this disease, which thus invades every texture in proportion to the nerves that are supplied to it.] 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 particularlyat 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 faeces, or of gelatinous matter, resembling half-di- gested worms; at other times, they have a frothy, yeasty appearance. Affections of the bladder frequently supervene, particularly if the attack comes on during the menstrual period. This affection is of a different nature from that which is called dysmenorrhoea. In this character sustained by the well-established fact of its proneness to alternate with similar affections in other parts, as sciatica, lumbago, tic-doloureux of the face, gas- tralgia, muscular spasms, paralysis, or at least a loss of sensibility in portions of the body." Lectures on the more Important Diseases of the Thoracic and Abdominal Viscera, p. 158.] NEURALGIA. 589 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 disease in the spinal marrow, or in the nerves themselves. [Partial wounds of nerves, and especially, blows on those of the face, are among the immediate causes. So also are severe atmo- spheric changes, although these mostly act through decayed or sensi- tive teeth, checked perspiration, and sudden and violent emotions of the mind, acting on nervous constitutions. Diseased conditions of the brain, especially at its base, whether from effusion, chronic in- flammation, tumours, &c, and lesions of the membranes of the brain, are also among the many causes of neuralgic pain.] Treatment of neuralgic pains.—In tic dolour eux, I have 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 regulation 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 bark, iron, zinc and other tonics, as also opium, musk, cicuta, hyoscyamus, belladonna and stramonium, have each their advocates. If the pain be periodical, the use of large doses of quinine will generally be found to act promptly and efficiently, as in intermit- tent fever. In fact the doses requisite in the one are precisely adapted to the other. Many severe and long-standing cases have been much benefited by drachm doses of the precipitated carbonate of iron; but to subdue a paroxysm of pain, and produce a long interval of ease, the sedative solution of opium, given in small quantities, (15 or 20 drops,) by injection, or the acetate or sulphate of morphia, in doses of l-4th of a grain, every 3d or 4th hour, will be necessary. Several very bad cases of general neuralgia have fallen under my observa- tion, and these remedies were found beneficial after all others had failed. One case, in particular, may be mentioned : A gentleman who had been frequently liable to partial attacks, was seized with general neuralgia during the period when he was preparing for gra- duation. His general health became much impaired ; and not being acquainted with any medical man in 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 suffer- ings, and by terming his complaint " a graduation sickness." After the 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, had 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 aggra- vated by the slightest touch, that he was obliged to sit with his neck 590 [NEURALGIA.] and shoulders bare. He had almost abandoned the intention of gra- duating. After putting his bowels into proper order, I gave him, while suffering a very severe paroxysm of pain, a dose of the seda- tive 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. Since the publication of the last edition, the attention of the profession has been directed to the external employment of veratria, by Mr. Turn- bull, of London. Five or ten grains of the medicine are to be mixed in an ounce of lard or simple ointment, and a small quantity rubbed carefully on the pained part. I can speak with confidence of the relief afforded by this application in six cases of tic doloureux, but it did not perform a cure in any one. [Neuralgia is extremely common in the United States, and is sup- posed to be more so than in former years, merely because the disease, which was formerly confounded with rheumatism and gout, is now better understood. It appears, for the most part, in a strictly parox- ysmal form; though its first invasion is often marked by a frequent succession of short and feverish paroxysms, which, by perfect rest, mild aperients and diaphoretic anodynes, soon present longer and more perfect intermissions with less of the inflammatory character. The free use of quinine, in the manner above indicated, becomes now our first reliance ; and after the paroxysms are broken, the same medicine should be administered to the extent of eight or ten grains per diem, for three or four days in succession. This plan has, of all others, been most successful in my hands. But it has been remarked that neuralgia is often attended with fever, and sometimes the pain is of so intense and pungent a character as to be agonizing and intole- rable, and especially in the facial forms of the disease. Under these circumstances, local remedies become absolutely indispensable; and of these, free leeching over or near the parts is our most effectual re- source. When the fever runs high and delirium or coma is present, bleeding will be necessary; but I have rarely met with examples of this kind. After local or general depletion, or independently of either, blisters behind the ears, or elsewhere in the vicinity of the pains, are of great service, but they should seldom be applied to the part itself, inasmuch as they aggravate the pain and distress. Direct local applications of opium or belladonna, in plasters, are highly bene- ficial. So also is the tincture of aconite, which, from its activity, should be applied by means of a camel's hair brush, or a soft sponge. The ointment of veratria is another resource: it is formed of one part of the alkaloid with 80 parts of rancid lard, and is applied to the affected part. The iodide of mercury, as recommended by Mr. Scott, is composed of two scruples to an ounce of lard. During the intermission, all the tonics from both the vegetable and mineral kingdom are administered with various degrees of success, depending on the seat of the disease and constitutional peculiarities. Among these preparations are the ferruginous articles, and especially the protocarbonate of iron; which, as it tends to constipation, may be NEURALGIA. 591 made into pills with rhubarb. Spirits of turpentine, in drachm doses two or three times a-day, has been used with advantage by Dr. Ben- nett. Free catharsis has been resorted to by some physicians, and even croton oil is recommended by others. We have already spoken of the external use of aconite. It is also given internally in dose of the eighth of a grain three or four times a day. I have faithfully tried every form of galvanism* and electricity; but, for the most part, with little advantage. The electro-magnetic apparatus, however, is the most convenient of all these appliances and, in my hands, the most successful. It should be resorted to at the very outset of the pain; and under these circumstances, I have known a solitary case in which the paroxysms, though they yet recur at intervals, are invariably removed or greatly mitigated by the electro-magnetism, provided no fever is present at the time.] 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 con- joined 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 antimonial oint- ment. In an obstinate case which lately occurred, much relief fol- lowed 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 whenever the pain is severe, and of giving calomel or blue pill when the pain is referred to the right hypochondriac region. I have been consulted by individuals whose constitutions were injured by the frequent repe- tition of powerful remedies, and by some who never can regain the loss of blood, or recover from complaints 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 he de- nominated painful " subcutaneous 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 nerves, requiring surgical rather than medical aid, I will conclude by recommending the perusal of Mr. Wood's learned and interesting essay. [* See the remarks on Spinal and Ganglionic Irritation, page 568.] CHAPTER V. APOPLEXY—PARALYSIS. APOPLEXY. AporLEXY is generally characterized by loss of sense and volun- tary 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; and practical men are well aware, that at the commencement 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 ter- mination of those cases in which the loss of sense and recollection exists 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, however, are sometimes so slight as to be disregarded. These are vertigo—headache—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 judgment, some- times 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 with- out rigors. Should an individual complain of several of these symp- toms 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 APOPLEXY. 593 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 is very transient. It continues 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 attendants to have been only in a faint, from which he quickly recovered. The variety which may be called the most severe, is that in which the patient has for some time com- plained of some of the premonitory symptoms already noticed, is sud- denly 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 practice, we meet with every variety between these two extremes. During an attack, the limbs are generally flaceid, although occa- sionally 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. The pupils are occasionally dilated; sometimes contracted, but almost always immovable. 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, perhaps, 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 dis- covered that one half of the body is paralyzed: the pulse, if pre- viously slow, now rises to the natural standard; he then recovers his senses, perhaps very quickly, and looks about him* with an expres- sion of surprise; he also gradually recovers his speech, although he may have difficulty in articulating. In some hours, these symptoms 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 motion immediately, patients sometimes continue comatose for some hours, and then recover more or less quickly in the manner already stated, being, however, 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 only of one limb, the use of which may be either never or partially restored. I have seen seve- ral 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 50 594 APOPLEXY. state, from the time of attack till death takes place, without the least appearance 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 com- plaining 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 be- tween the occurrence of the first symptom and recovery, is also very various. The intervals between the attacks are by no means uni- form; 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 symptoms will be excited— symptoms produced by inflammatory action in the brain, or mem- branes 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 predisposed are those of a full plethoric sys- tem, 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 quan- tity of blood generally issues from the incisions. On removing the calvarium, the membranes are sometimes observed to be very vascu- lar, with some fluid beneath the arachnoid; 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 thalami nervorum opticorum. The ventricles are sometimes found distended with coagula; and the cerebellum occasionally suffers. Effusion of a serous fluid, in greater or less quantity, is found in the ventricles. It, however, sometimes happens, that no morbid appear- ance 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 * There is a splendid preparation in my museum, of one large and two small aneurisms of the sylvian artery; the largest of whjch, abqut the size of a hazelnut, 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. APOPLEXY. 595 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 considerable portions of the brain surrounding the effusion in various stages of inflammation, either showing marks of increased action or complete ramollissement. On some occasions, most extensive destruction from inflammation has been discovered in the snbstance 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 obtained, 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 firm- ness, that it resisted every attempt at separation without tearing, and the skull itself was rather more than usually dense. On the upper sur- face of the brain a quantity of serous fluid was effused ; while at the base both of the skull and brain, the blood-vessels were 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 extend much beyond the surface. On cutting into the substance of the brain, the traces of much dis- ease and an evident softening became apparent, particularly in the ganglions of gray substance called corpora striata and optic thala- mi, in which the softening had passed on one side almost into sup- puration; 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 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 evi- dence is rarely found of life having been protracted with the pre- servation of intellect, till the whole centre of the nervous system underwent such a change as that described in the above case. Treatment of apoplexy—Some routine practitioners will be found invariably to bleed in cases of apoplexy, without reference to the period of the disease and the state of the pulse. I have little doubt, 596 PARALYSIS. 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 venesection than if it be quick and weak. The feet should be put into hot water, in which mustard has been mingled ; the garments should be loosened ; the head shaved, and cold cloths applied. Active purgatives must be speedily administered, to be assisted by injections of turpentine, par- ticularly if there be evidence of flatulent distension of the bowels; and blisters are to be applied to the lower extremities. Should a patient be fortunate enough to recover from the immedi- ate effects of the attack, much may be done by subsequent treatment, to present 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 beneficial. Frequent bleed- ing, whether by the lancet or by cupping, cannot be too strongly de- precated; 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 for- mation 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 to 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. Restriction 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 mattress; he should use the patent air-pillows, with the head and shoulders somewhat elevated. PARALYSIS. Paralysis appears to have been generally confounded with apo- plexy by the older writers, who thought apoplexy was a complete paralysis, and looked upon the latter as a partial apoplexy. This affection is a frequent result of apoplexy, as well as of in- flammation 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 marrow ;—2. Paralysis of the nerves of sensation, which take their origin from the posterior part of the spinal marrow;—3. Hemiplegia, which implies the existence of paralysis in one-half of PARALYSIS. 597 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 de- grees ; it may be complete or incomplete; in the latter case the indi- vidual uses the affected limb awkwardly, and it sometimes feels weaker and heavier than the other. Paralysis of sensation may also exist in various degrees. Sensa- tion 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 age 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 premonitory symptoms, similar in many re- spects 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 numb- ness, 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 diffi- culty in going down stairs, and in walking on an inclined plane. By and by he is obliged to use a stick; at length he cannot walk with- out 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. Fre- quently 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. Vio- lent cramps sometimes take place in the extremity, which soon after is found paralytic. The bowels are generally very torpid; sometimes 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 rec- tum is similarly affected. The pulse will be found in different states; frequently quite natural ; but in the affected limb it is generally ob- served to be weaker than in the sound one. The limb generally becomes emaciated, although, to the patient's feelings, it may be con- siderably larger than natural; it is usually colder, although, in rare cases, it is found to be above the natural heat. The mental faculties 50* 598 PARALYSIS. continue in many cases of paralvsis quite unimpaired; in others, they are slightly affected, the patients being sometimes a little inco- herent, or they betray some weakness of judgment; occasionally a state which has been called second childhood is produced, and con- tinues 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 appear- ance 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 his 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 frequent 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 exe- cuted ; whereas, on the other hand, some who only saw him occa- sionally, judging from his appearance, and the lethargy 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 may be produced by disease in the brain and spinal marrow. It is, however, more frequently produced by dis- ease of the spinal marrow. Facts seem to prove that paralysis may be produced by disease of the nerves of the affected limb, without any lesion of the central parts of the nervous system; and I also be- lieve, from the effects of certain remedies, that the disease under con- sideration 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 paralysis, by the duration of the disease and by the pathological condition of the body on which this symptom depends. If the dis- ease 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 any temporary increase of deter- mination of blood to the head which is supposed to take place in the PARALYSIS. 599 act of vomiting. Frictions on the affected part, with or without stimulating embrocations, are said to be serviceable, as well as con- tra-irritation in the course of the spine, produced either by any of the ordinary rubefacient, 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 paralytic affections; but I cannot say that I have ever seen them beneficial. Some employ the hot bath, and others the cold. If it can be commanded, the patient should sleep in a well-aired apartment; and it is of great conse- quence to keep his mind amused without being fatigued. The nux vomica has been much employed pf late years in para- lysis. 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 strych- nia, 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 persisted 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 strych- nia in some cases of paralysis with no benefit, in others with only partial advantage, but in the majority with complete success. He considered that it may be an efficacious, though not a certain reme- dy 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, p. 38. CHAPTER 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 accompanies fever and intoxication, and hypo- chondriasis. There are many degrees and shades of insanity. Some persons may be affected with the most violent delirium and incessant raving, furiously threatening the attendants with destruction, wrong alike in their perceptions and reasoning faculties. Others may have some eccentricity, produced by an error of perception, a wrong impression, or some slight derangement of judgment. Cases are frequently met with in practice where there is diseased perception, 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 person, except the first erroneous perception; all his actions tally with the situation in which he supposes himself to be placed. We meet with others who take up an erroneous impression, the reasoning faculties being perfectly 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 con- clude that he was insane ; nothing is incorrect but the first impression. In some instances, we meet with errors in the reasoning faculties which frequently lead men to ruin their fortunes, and bring an accu- mulation of distress upon their families by following out some castle- building speculation, the absurdity of which is too apparent to every one but themselves. In others, we can only discover a disordered state of the association of ideas, or a disproportionate emotion from INSANITY. 601 the application of slight causes. On other occasions, we find indi- viduals believing the fancies of a wild imagination 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 excite- ment 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, develop themselves differently in different cases:— One patient shows elevation of spirits, 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 particular hallucination,-which will occupy his thoughts more and more completely as the disease advances. Another individual will show 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 robbing him of his property; or his depression of spirits may be owing to religious doubts as to his own worthiness, or to the exist- ence of a future state; or he fancies himself haunted by evil spirits. We sometimes meet with an intermediate condition, where an individual shows his ordinary state of temper and disposition; he evinces neither increased excitement nor depression; while an erro- neous notion, religious, political or professional, haunts his imagina- tion for weeks, months or even years, which shows itself occasion- ally, 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 show a great desire to quarrel, litigate and to take personal revenge for imaginary insults and injuries; but all these propensities may exist separately:—A man may be extremely quar- relsome, but, if properly managed, easily appeased, and may never show 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 endeavour to excite hatred between his keepers,so as to induce the one to murder the other. Others show a most determined propensity to commit suicide, and sometimes follow it out with so much pertinacity, as to elude, at last, the vigilance of the most attent- ive keeper; and, what is very curious, each will have his own reason for the act. The vanity of one has received a blow which has low- ered him in the eyes of the world, and he destroys himself because he cannot live dishonoured, degraded or even laughed at. The fear of another induces him to commit the rash act, with a view of escap- ing from some evil spirits, or of disappointing the machinations of 602 INSANITY. some relatives who have conspired either against his peace, his life, or his property. I have known a few instances also of men com- mitting suicide, who could not survive the loss of a wife or child ; and it would appear that the act was committed under the impres- sion that their departed spirits were to be immediately afterwards reunited. 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 physical powers are frequently not at all affected. Thus a body of insane soldiers under confine- ment, 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 super- venes upon some other disease, or is produced by an injury of the head, some organic lesion in the brain, or by long-continued indulg- ence in the use of intoxicating liquors; when there may be heat of skin, quickness of the pulse and a train of nervous and other symp- toms which need not, at 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 1 believe it may be warded off for many years, and in some cases entirely pre- vented, by proper management; which principally consists in keep- ing 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, keep- ing the passions under control, and the mind properly 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 pre- disposed 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 malady under consideration, par- ticularly 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 re- sults 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. ♦ This I had an opportunity of seeing at Chatham, where a large establishment has been formed for the insane officers and soldiers of the British army. Fort Cla- rence is, I believe, exclusively used for this purpose, and the unfortunates there have the enjoyment of good air and exercise, are well fed, kindly used, and carefully superintended. Long may it remain a monument to the good feeling and benevo- lence which characterized his late Royal Highness the Duke of York, and to the zeal and exertions which Sir James M'Grigor has always displayed to increase the comforts of the British soldier. INSANITY. 60S 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 seems 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. 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 organs, such as ophthalmia, iritis, 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 starva- tion and exposure ; while many become so from excess, particu- larly in stimulants. The asylum at Milan is filled by lunatics from bad feeding, 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 insanity 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 eccentricity predisposes, in irritable constitutions, from the high action into which the cor- responding 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,/ro/7i development, the probable form of the mental affec- tion. 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 pre- servation, and for the improvement of its functions, just as other 604 INSANITY. parts do, as the muscles in fencing or dancing. Practice, in the latter instances, increases nutrition, and consequently, 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 de- rangement 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 numerous victims in the unoccupied classes of society. Local causes act by disordering the brain. Blows on the head, coups du soleil, intense cold, drunkenness, meningitis, &c, show this. Dyspepsia and other disorders of the abdominal viscera excite it secondarily in some instances in predisposed subjects, but, in general, mental causes have preceded. The same remark applies in nymph- omania and erotomania, in which the affection of the generative organs is generally the effect and not the cause of the cerebral dis- turbance. 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 func- tion and every faculty of the mind may be involved in the disease or not, and hence indescribable 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 development in one part of the brain, may be eccentric and singular in his mental mani- festations, and yet his mental health be entire. Before we can say he is mad, we must be able to show a departure from his habitual state, which he is incapable of controlling. 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 un- suspecting 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 excite- ment of function;—one who humbles himself in the dust, and fancies himself unworthy of regard, is an example of the second, or dimi- nished 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, INSANITY. 605 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 affect- ed. 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 comba- tiveness 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 in 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 be- fore 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 suggests itself in the treatment of insanity is, what combi- nation of circumstances ought to exist before a medical man is enti- tled 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 atten- tion 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 pro- pensity 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 public morals, he being insane, or even eccentric, I also think an ap- peal 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 such speculations as none but a madman would think of under- taking, 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 manage his own affairs. Thus he may suppose that his legs are made 51 606 INSANITY. 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 all 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 medical 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 employ 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 religious 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, night and day, for the conversion of some of the highest, the most pious and the most rational members of the Scotch church. There are others who, in the wildness of their diseased imaginations, fancy that a pro- clamation 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 to 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 precincts of an asylum ; but it would not be difficult to show, that they, as well as the followers of Joanna 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, should an insane person be sent to a proper establishment, or treated at home ? After consider- able experience in the treatment of insanity, I am disposed most unhesitatingly to declare, that removal from his own house, if not actually necessary, 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 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 consigning any person to a private mad-house, where the money received for board and medi- cal attendance is an object to the individuals who keep the estab- lishment. In a case where the liberty of the subject and the peace and happiness of so many individuals are at stake, should not pri- vate mad-houses be put down by law? Although, then, a decided preference should be given to a public establishment, yet I am not prepared to say that they might not be improved; and if an investi- gation were instituted by Parliament, it would be discovered, that the duties which the directors of such institutions take upon them- INSANITY. 607 selves, are generally very slovenly, and sometimes very imperfectly performed. It would also be seen, that secrecy is not sufficiently observed ; and that, in some instances, the medical appointments are mere jobs, every interest being sacrificed to gratify the caprice of some idiots who ought to be patients instead of directors. In the treatment, more is to be done by moral management, and by attending 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 by cupping, should, if possi- ble, be substituted, unless the balance of the circulation be much disturbed, when the lancet must be used. In a considerable num- ber 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 tranquillity, 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 in- discriminate employment, as well as from the insufficiency of the doses. I have seen the best efl'ects 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 unmanageable. Large doses of tartar-emetic will sometimes be found useful, having a very powerful effect in control- ling 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 highly 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 keeper any injury; and during the day, to be confined in a large well-cushioned chair, which is fixed to the floor; and even here the soothing system is of decided advantage. The superintendents and keepers should possess great prudence and imperturbable tempers ; and are never, on any account, to be allowed to exercise any harsh- ness, either in action or expression, towards a patient. In many establishments, there is a chair fixed in a box, very much like a sen- try-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 608 INSANITY. it is quite sufficient to make the patient control himself. Every ward should be heated with warm air, which will render fires in the apartments unnecessary. Comfortable clothing and preserving warm feet ought to be strictly attended to. Unless a patient have fever, his food should be substantial, and at the same time nourish- ing ; a dinner 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 beneficial than a minute attention to a proper clas- sification of patients; yet I fear, from negligence and laziness, this is either much neglected, or very imperfectly and irregularly per- formed. 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 con- trived to allow the visits of friends as often as may be wished, with- out the patient's 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 with- out showing 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 remune- rated, and be chosen as much for his honourable and benevolent feeling, probity and straightforwardness, as for his zeal and talents. It would be, perhaps, an additional 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 an- nexed. " Besides what you notice with regard to treatment, every thing demonstrates that employment of 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 time of their lives, idleness would have driven mad. Manual labour and occupation are also of immense consequence, and the moral influence of keepers and superintendents, acquainted with human nature, and interested in their avocation, is prodigious in producing quietude, and accelerating recovery, 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 consist- ency, firm honesty and good feeling as if they were quite in posses- sion of themselves. They are quick in detecting deceit, and when once deceived, they never give confidence again. I mention this, HYPOCHONDRIASIS. 609 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 expe- rience says, never advance a word which you cannot conscientiously stick by when the patient recovers, and you will retain your ascend- ancy. Do not thwart his delusion, but neither give it any counte- nance. Our friend is now satisfied I am right in this, and I have decidedly proved it in practice. Remove all provocatives and allu- sions 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 leech- ing, followed by tepid bathing, and cold to the head while in the bath. Many, of eourse, do not require depletion, but it may be ad- vantageously used when the usual indications exist. General bleed- ing I know little of, and do not like it. After the irritability and excitement of the immediate explosion are over, a great deal of ex- ercise 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 indi- vidual 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, 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, engrafted 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 discovered, on dissection, diseased states of the liver, lungs, kidneys, bladder, heart, blood-vessels, and also of the brain and its membranes. I have been often surprised, while attending hypochondriacs, to 51* 610 HYPOCHONDRIASIS. 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 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 in circumstances such as these. Patients affected with hypochondriasis are not always in the same state; perhaps, without any assignable cause, they become quite well, and again relapse; so that the disease is intermittent and irre- gular, until it acquires some duration and intensity, when it con- tinues, 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 development 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. Hypochondriasis 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 undoubtedly 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 hypo- chondriac. 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 treated accordingly; contra-irritation produced by frictions with antimonial 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 surprised, or put out of temper, on finding that the patient, if wealthy, is in communication with twenty other medical men. DELIRIUM TREMENS. 611 DELIRIUM TREMENS.—MANIA A P0TU. 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. [This affection occurs in drunkards, who, after a long indulgence in spirituous potations, are suddenly deprived of their habitual sti- mulus. The symptoms are extremely varied, from simple nervous tremors with aberration of mind, to the most violent and uncontrol- able mania: but, in a majority of cases, we are able to recognize the three stages mentioned by Dr. Blake, viz: The first stage appears soon after a protracted debauch, and is marked by slight fever, nausea or vomiting, cold, moist skin, great debility, vertigo, loathing of food, melancholy, and broken sleep with frightful dreams. After a few days follows the The second stage is characterized by utter sleeplessness, anxious countenance, constant tremor and delirium, extravagant hallucina- tions, incessant talking, and a violent and menacing manner. The pulse is frequent and full; the face flushed; the tongue dry and furred, and the pupils contracted. The bowels are mostly costive, and the evacuations, when induced, are offensive. This stage lasts from three or four days to a week, yet seldom so long as the latter period. The third stage is sometimes a mere subsidence of the second: the patient drops into a deep sleep, and awakes convalescent. If, how- ever, the disease goes on, the mind continnes maniacal, with in- voluntary struggling; a cold, clammy perspiration, a frequent, weak pulse, and universal tremor; and the patient dies either in a coma or convulsion. It must be acknowledged, however, that, in very many instances, these stages are not manifest; the symptoms being so confused as to admit of no demarkation. Patients sometimes go through the first stage without encountering the second: many, again, escape the third stage; while in other instances, the disease begins with those symptoms which are characteristic of the second stage.] 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 com- bined influence of irritability and general functional disease of the nervous system, with positive weakness of the whole frame. In the other, similar symptoms exist, with irritation and increased action, sometimes inflammation of the brain, the patient having a robust, perhaps 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 general, 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 612 [DELIRIUM TREMENS] patient has had many similar attacks, has been long addicted to the excessive usfe of ardent spirits, 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 pursued from that which I would recommend in a patient whose health had been previously unbroken, and who was not habitually addicted to drinking. If such a person as the last mentioned were seized with delirium and trembling after a soli- tary debauch; if the delirium were furious; the strength greatly increased; the limbs being sometimes spasmodically 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 judicious and timely exhibition of stimulants. The kind of stimulants 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 glass- ful, 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 necessary. A patient labouring under this form of the disease, would, in all probability, be destroyed by the loss of four ounces of blood. In the second variety, which has been quoted, if the disease has not existed long, a bleeding from the arm, in such quantity as the case requires, will be found highly beneficial; but should the disease have gone on for any length of time, the same objections which were 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 instances, local bleeding will be proper, when that from a vein is totally inad- missible. The observations already so frequently and so pointedly made in different parts of this work, with respect to venesection, and the difference in the results to be expected from that remedy accord- ing 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 states of the pulse and tongue exist. Considerable caution is also required in exhibit- ing 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. [Delirium tremens is frightfully prevalent in the United States; and the treatment adopted here differs, in some essential particulars, from that mentioned in the preceding paragraph. It is to Dr. B. H. Coates,* of Philadelphia, that we-owe those pathological views which have led to a new and more successful [* N. Amer. Med. and Surg. Joum., vol. iv., p. 27.] [DELIRIUM TREMENS.] 613 treatment of the disease, and of which we propose to give a brief abstract. Dr. Coates, after describing the well-known effects of alcoholic stimuli on the human system, observes, that delirium tremens is produced by habitual stimulation; but not until the stimulus itself is suspended. " The patient is suddenly interrupted in a long-con- tinued course of hard-drinking. What is then the consequence ? The tremulant fever abates or subsides, from the abstraction of its cause; and the system immediately feels the want of its customary narcotic. It has been gradually changed, until the depressing agent has become necessary to the preservation of an approach towards health: without it the patient is unable to sleep, and his cerebral and nervous system are thrown into a state of the very highest ex- citement. Who can fail to perceive in this the production of an excess of activity, a superabundance of vitality in the brain and nerves, requiring the habitual narcotic to keep it down to the ordi- nary standard." A complete analysis of Dr. Coates's valuable paper cannot be at- tempted in this place; but I shall give, in his own words, the apho- risms deduced from his investigation. " 1. The disease is a delirium and not a mania; and this distinc- tion should be attended to, both for medical and legal reasons. "2. It consists in a heightened activity of the sensorium ; and this appears to arise from a generation in that organ, of an unusual vital power which is not, as in common, exhausted by the narcotic poi- sons habitually used. " 3. The delirium may be combined with many other diseases and injuries, situated in many different parts of the body. " 4. When violent, it obscures and renders imperceptible most of the symptoms of the coexisting disease. "5. It is doubtless necessarily accompanied, as all vital excite- ments are, with an unusual amount of the circulation of the blood in the organ affected; and is, from this cause, sensibly influenced by cups, blisters and emetics. It is not so far checked by emetics as to render these advisable as a leading means of cure. It is not sufficiently under the control of the general circulation to be cured by venesection, or to be sensibly relieved by it without such an ex- haustion as is highly dangerous to life. "6. It is entirely and absolutely under the control of opium, al- though the fevers and other diseases which are liable to accompany it are by no means so. " 7. It admits of very large doses of opium, which are not pro- ductive, either at the time, or subsequently, of any injurious conse- quences, provided they are not repeated after a tendency to sleep is evinced. " 8. The patient must sleep or die. There is no alternative. Yet the physician should personally watch the effect of very large doses of opium. " 9. There is no distinction of stages which need occasion a mo- ment's delay in resorting to opium. " 10. Purgatives are of no use in this delirium; but it is necessary 614 [DELIRIUM TREMENS.] to prevent costiveness subsequently to the administration of opium. Purgatives may be necessary for diseases which exist at the same time; but when this is the case, they are, in general, most advan- tageously postponed till after sleep has been obtained. "11. Gentle stimulants are frequently useful during the conva- lescence ; but these should not resemble ardent spirits ; and an excel- lent and efficient one is capsicum. Nor should any ardent spirits, unless indicated by peculiar circumstances, be given during the pa- roxysm." Without subscribing to all these propositions, I must acknow- ledge that they have very much governed my practice for a number of years at the Philadelphia Almshouse Hospital: and although at different periods, the emetic and depletory plans have been abun- dantly tried, the opiate plan has been attended with the most decided success. The opium is freely administered ; viz.: from one to three grains every hour until sleep is induced: and, in several instances, after in vain giving these doses for some hours, I have made the patient take a tablespoonful of laudanum at once. If, as Dr. Coates observes, the patient can be made to sleep, the chances are in favour of recovery. If, on the contrary, he cannot sleep, death is, in a ma- jority of cases, inevitable. A case that came under my care, during the past year, was that of an innkeeper, who, after several weeks of hard drinking, became violently delirious and unmanageable. I was called to see him late in the afternoon, and directed him four grains of morphia in solution (equal to sixteen grains of opium) to be given in doses of a large tea- spoonful every hour. He took it all by the next morning, but without any sensible effect. I then ordered him a teaspoonful of laudanum every hour. In the evening he had taken five doses, (more than half an ounce,) but in his delirium broke away from his family and came in person to my house. He was with great difficulty got home again, when I administered to him at 9 o'clock, p. m., a large tablespoonful of laudanum. At 12 that night he fell asleep, slept soundly until next morning, and, with slight intervals, through the whole succeed- ing day. This man, who had been in a raving delirium, haunted by robbers and contending with shadows, became quiet, conscious and reasonable, and was soon restored to health. This patient, therefore, took the equivalent of nearly fifty grains of opium in forty-eight hours. In this case, as is much my custom, the head was freely cupped, and after convalescence commenced, a strong infusion of columbo and quassia'was freely administered for several days. Let it not be supposed, however, that opium will, in every instance, control this disease: all that I maintain is, that it will cure more patients than any other remedial agent. I have seen cases in which it was of no ser- vice whatever: and in some others, after it has been used to a great extent, the anodyne effect was not produced until the patient had been walked to fatigue in the open air; after which sleep and reco- very followed. When the head is greatly affected, especially in plethoric persons, a blister should follow cupping; and I have met with a number of [DELIRIUM TREMENS] 615 cases in which venesection was not only admissible but indispensa- ble. The danger arising from the sudden and entire abstraction of spirits is said to be counteracted, in the Boston House of Correction, by administering a strong decoction of wormwood, which is given freely. With, perhaps, one exception, (say the managers,) there have been no fatal consequences from delirium tremens since this practice was introduced.] PART VI. DISEASES OF THE EYE AND EAR. 52 CHAPTER 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 function, 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 en- tirely to the consideration of those strictly medical, which will include inflammation of the different tissues of which the eye is composed, and the lining membrane of the eyelids, 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 gene- ral 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 indi- vidual, whatever particular department he may choose to cultivate and practise, should have previously gone through a good general medical education. Many of the diseases of the eye depend upon a variety of constitutional 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 deli- cacy of hand and quickness of eye which many do not possess; but those which fall under the care of the physician are similar to diseases of other parts of the body, though at first, perhaps, somewhat more difficult 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 estab- lishment especially devoted to diseases of the eye exists, superintend- ed by medical men of eminence in this department. I am happy to have this opportunity of speaking in terms of high commendation of the arrangements of the Eye Dispensary of Edinburgh, under the able management of Drs. Robertson and Farquharson. 620 GENERAL REMARKS ON The Germans are exceedingly and needlessly minute in their classi- fication of diseases of the eye. According to Plenck's arrangement, there are one hundred and nineteeen 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-hundredth part of the distinctions of the Germans. Inflammation of the eye may be divided into external ophthalmia, or inflammation of the conjunctiva in its principal modifications; and deep-seated ophthalmia, or inflammation of the other tunics, in- cluding the disease called amaurosis, which, although not always, is sometimes produced by inflammation. 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 inflammation of the eye, its causes and treatment, before proceeding to consider the individual diseases. The general symptoms differ little from those of inflammation in other parts of the body, and only in as much as they undergo modifications from the peculiar structure and functions of the organ. Inflammation of the eye may be confined to one tunic, whence it often extends to surrounding tissues, and may spread in this manner till the whole organ is affected; or it may attack the whole eyeball at once, although this must be an extremely rare occurrence. The disease may be confined to one eye, or may affect both simultaneously ; or first one eye, then the other may be affected. 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 character, if not invariably, is generally characterized by some peculiar symptom or appearance; thus, inflammation of the conjunctiva may be readily distinguished 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 sensa- tion which would be produced by a grain of sand in the eye, followed by a sense of heat and pain in the eyeball, increased secretion of tears, intolerance of light, and a feeling as if the eyeball were swollen. On making an examination, a network of vessels transmitting red blood is seen, although in a state of health they contain a colourless fluid. If ail these symptoms be present, and continue for any length of time, no individual, however uninformed, can be in doubt respect- ing 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 terminate in the total destruction of vision, unaccom- panied 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 inflamma- tion, and yet the patient complained but slightly of pain. Intolerance THE DISEASES OF THE EYE. 621 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 inflammation, 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 eyelids takes place when the inflammation attacks their lining membrane; they then sometimes become very much tumefied, which is by no means an unfavourable symptom. The observations which have been so often repeated in this work respecting other inflammatory affections, viz.: that symptoms vary much according to constitutions, 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 head- ache, nausea, prostration of strength, constipation and febrile symp- toms. When the internal coats of the eyeball are inflamed, there are generally more pain, headache and fever than in conjunctival inflam- mation. These are termed the constitutional symptoms. Causes of inflammation of the eye.—These causes are nume- rous and diversified; few can be said to be peculiar, the great majo- rity being such as are well known to occasion disease in other organs of the body. They may be divided into two classes:—1. External or local; 2. Internal or constitutional. Among the first are included sand, dust, lime, small insects, the irritation produced by tumours growing within the eyelids, and inversion of the eyelashes. 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 ex- ternal 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 re- collected that an insect had flown into the eye a little before the inflammation commenced, and that it had been killed by the appli- cation 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 application of gonorrhoeal virus, the discharge from a syphi- litic ulcer, or, indeed, acrid matter of any sort. These are powerfully aided by intemperance. There can be no doubt of the influence of climate in producing inflammation of the eye: the colder regions of the world are comparatively exempt from these diseases, while they are frequent and peculiarly severe in warm countries. Many writers have accounted for this circumstance, by attributing it to heat, light 52* 682 GENERAL REMARKS ON 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 circumstances, long-continued exposure, without intermission, to light and heat, even when neither is very intense, must be injurious. Egypt appears to be the country which, of all others, is most favour- able to the production of ophthalmia. The English and French troops employed in that country, in 1801, were harassed by the general prevalence of the disease; and, in the subsequent expedition, the English troops were equally affected. Nevertheless, I am in- clined to believe that these causes are very much overrated, and that sudden atmospheric 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 gene- rally 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 more severely felt by the constitution. It will not require any laboured argument to show that these causes affect the eye by pro- ducing alterations in the balance 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 experienced 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 reflection produced by white sandy roads and white-washed houses, the sensa- tion being quickly removed upon getting into the shade, or walking upon grass. Among the constitutional causes may be enumerated general ple- thora, disordered state of the bowels, suppression of any discharge which had previously existed for a considerable time, including the constitutional discharges peculiar to the female, dentition, general chronic disease of the mucous membranes, the diseased state called scrofula, acute and chronic diseases of the skin, the retrocession or metastasis of inflammation to the eye during the progress of gout and rheumatism. Some of the most severe and intractable diseases of the eye take place during 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, 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, removal from the cause must, in general, be THE DISEASES OF THE EYE. 623 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 eyelid should be completely everted. Cases are sometimes met with, par- ticularly of slight inflammation of the conjunctiva, in which a spon- taneous 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 vapour, warm anodyne fomentations, or astringent washes. These simple remedies, together with due attention to the bowels, and confinement to an apartment moderately lighted, will often have the effect of subduing the inflam- mation. 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 indicated 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, peculiarities of constitution, and habits of the patient. The importance of general bleeding in many cases of ophthalmia, has been long known to the profession ; 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 thirty 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 ex- pense 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 180S, I soon observed sufficient to convince me, that the bad success was owing to injudicious treatment, particularly relating to four most essential points:—1. The older military sur- geons, upon whom the treatment devolved, did not seem to be acquainted with the different seats of the inflammation. I never saw any distinction made by one old surgeon, whose wisdom and knowledge were generally admitted 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 ; 3. They appeared to be unable to discriminate between acute and chronic inflammation, which often led them to apply local stimulants most injudiciously; 4. A great deal of 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 under an old surgeon, the plan of treatment ordered to be pursued, when 624 GENERAL REMARKS ON a man came into hospital, was—" Bleed him, sir, to 16 ounces, and give him salts." If the patient happened to be belter at the next day's visit, an order was given to apply a stimulant, generally the vintim opii. On the following day, if he were worse, the order was —"Bleed him again, sir;" and this alternation of practice,—bleed- ing 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 1 was desired to bleed, and not considering, or perhaps dis- regarding the consequences of deviating from the regular plan, I bled each of them to syncope, which required the abstraction 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, placedhis chief dependence on Dover's powder. To show how much the government was alarmed for the state of the army, it may be mentioned, that a male and female quack were hired to take charge of the cases in a certain 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 pretensions as an oculist. He introduced the practice of everting the eyelids, 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 employment of this operation together with not distinguishing the difference between acute and chronic inflam- mation, as well as between superficial and deep seated inflammation of the eye. One bleeding will, in general, suffice, 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 injurious. The applica- tion 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 leech-bites occasionally produce considerable swelling and inflammation of the eyelids, now and then assuming an erysipelatous character; but it should be recollected, that this will only happen in cases where there is a bad habit of body, in which circumstance their application may be avoid- ed. Cupping the neck may be had recourse to, either when leeches cannot be obtained, or when it may not be convenient or proper to employ them. In conjunctival ophthalmia, particularly when the lining membrane of the palpebra is vascular, the application of the scarificator to the everted lid will be found very beneficial, and is a speedy method of taking a considerable quantity of blood from the part THE DISEASES OF THE EYE. 625 affected; but it is only to be had recourse to in certain cases hereafter to be noticed. A modification of this last practice has been recom- mended by Mr. Crampton, (3d vol. Dub. Hosp. Reports,) which is, to apply leeches to the everted mucous membrane of the lower pal- pebra. The beneficial effects of the most judicious and copious abstrac- tions of blood will, however, soon be lost, unless followed by other important means, such as the keeping up a moderately brisk dis- charge from the bowels, and the use of antimony. Blisters, applied either to the neck or behind the ears, are often 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 abdomen, 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 subacute inflammation of the eye, the employ- ment of the antiphlogistic regimen is indispensably necessary; but I apprehend that practitioners too frequently run into an extreme, by persevering 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 fomenta- tions, consisting merely of warm water, or its vapour, a decoction of chamomile flowers, or of poppy-heads. Whether the 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 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 inflammation 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 acetate 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 eyelids, as well as in ulcer- ation of the cornea. Emetics have occasionally been found service- able in some long-standing cases of conjunctival ophthalmia. Experience has proved that the action of mercury is almost indis- pensable in inflammation of the iris; but it is by no means to be depended upon to the exclusion of general and local bleedings. Notwithstanding the general opinion which prevails against the administration of opiates in the diseases under consideration, I would strongly recommend them in cases where there are great pain and want of sleep, after the employment of proper depletion. The dose must be proportioned to the urgency of the pain, as well as to the degree of constitutional irritation; in severe cases, I have given, with benefit, 60 drops of laudanum, or 30 of Battley's sedative solu- tion; but in either case the dose should be repeated, with half the quantity, in the course of two or three hours, if necessary. 626 GENERAL REMARKS ON THE DISEASES OF THE EYE. So long ago as the year 1807, Dr. Wardrop recommended the eva- cuation of a part of the aqueous humour, by making a puncture in the cornea, in cases of very violent inflammation of the eyeball, 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. CHAPTER II. INFLAMMATION OF THE CONJUNCTIVA. 1. Simple inflammation of the external covering of the eye, includ- ing what is termed by authors ophthalmia mitior et gravior; 2. Sim- ple Catarrhal Ophthalmia; 3. Purulent Ophthalmia, the description of which will be drawn from the disease as it occurs in infancy; 4. Pustular Ophthalmia. simple inflammation op the external covering op the eye. The conjunctiva, 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 inflamma- tion, of some days' continuance, that we see vessels on the surface of the cornea. Symptoms of simple inflammation, Sfc.—A sensation of itching takes place, sooner or later succeeded by pain, resembling that which is known to be produced by sand or dust when applied to the eye; redness heat, tension and throbbing follow, 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 eyeball, 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, bounding or hard pulse, generally preceded by rigors or slight chilliness. If the symptoms are mild, the disease is called oph- thalmia mitior; if severe, ophthalmia gravior. On examining the eye in the acute stage of the disease, the vessels are observed to be superficial and distinct, running in straight lines, leaving the intervening spaces of a slight pinkish colour; and when the smaller branches are also well injected with red blood, the conjunctiva has a uniform red appearance ; 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 con- necting 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 628 INFLAMMATION OF THE CONJUNCTIVA. now under consideration, as well as in those of the affection which has been denominated purulent ophthalmia, the conjunctiva be- comes swollen, having a red, granular, somewhat fungous appear- ance, and considerably elevated above the cornea ; this state is called chemosis, and is frequently confounded with ecchymosis, which also takes place occasionally, not only in chronic, but in acute inflamma- tion of the eye. Chemosis is occasioned by thickening and vascu- larity of the conjunctiva, with an oedematous state of the subjacent cellular tissue. We see, on some occasions, also, an accompanying oedema of the eyelids, 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, $c—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 excite- ment in the system. In severe cases, one prompt and copious bleed- ing will be necessary, followed by the application of leeches, foment- ations, strong purgatives, the solution of tartar-emetic, and blisters, as the urgency of the symptoms may require. It is important to consider 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 tis- sues. Chronic inflammation of the conjunctiva may take place in 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 prac- tice which I would recommend, is to pay more attention than is generally done to the constitution ; the condition of the mucous mem- brane of the stomach and bowels should be carefully investigated in the manner so fully pointed out in the first volume. In chronic inflammation, it may sometimes be found of great service to scarify the eyelids, if there is much vascular turgescence of their lining mem- brane; astringent and stimulating washes must be had recourse to; it is in these cases that the solution of nitrate of silver is found useful, together with the wine of opium and an occasional blister. 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 alternations from heat to cold; it is, in fact, called by the vulgar, "a cold in the eye," and, generally speaking, is to be consi- dered as a mild description of purulent ophthalmia, which disease, in its more aggravated form, is known by the appellation, Egyptian INFLAMMATION OF THE CONJUNCTIVA. 629 ophthalmia—occurring after the application of gonorrhoeal virus to the eye, gonorrhoeal ophthalmia—and taking place in infants, infantile purulent ophthalmia. They are all the same disease, requiring the same treatment, modified by the patient's age and peculiarity of constitution, and by the urgency of the case. Symptoms of simple catarrhal ophthalmia.—After exposure to cold, soreness of the eye is complained of, either preceded or accom- panied by dullness and a feeling of general uneasiness, with lach- rymal discharge, sneezing, and sometimes aching pains in the bones, and some degree of fever. It is a slight inflammatory 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 puriform discharge, and some swelling of the eyelids. The eyelids, though frequently washed, quickly become glued together by the drying of the matter, so that, in making examinations, as well as in cleaning the eye, great mischief is frequently done by forcibly opening the lids, and thereby producing additional inflammation. After the disease is a little advanced, the eye, upon examination, will some- times 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 ulcera- tion 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 treatment 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 palpebrae. 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 eyelids is fre- quently left, at the termination of the disease, in a soft, swollen, spongy condition. Should the ordinary astringents fail, the scissors of the surgeon, or what, perhaps, answers fully better, the application of lunar caustic, may be used once every third day, taking care to evert the eyelid 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 antimony 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 syphilitic, gonorrhoeal, 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 53 630 INFLAMMATION OF THE CONJUNCTIVA. ready to apply the most potent remedies speedily, should they be necessary from the extent and intensity of the inflammation. An interesting case may be mentioned, which terminated very fortu- nately :—A young man came to the hospital with violent inflam- mation 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 expected that the contents of the eyeball would escape in the course of twenty-four hours; but it was neces- sary to mitigate his sufferings, which he described to be agonizing. 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 vascular, 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 mem- brane, which was pushed out by the aqueous humour, forming an appearance like a hernia. From this time the healing process con- tinued; 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 structure of the eye, by producing alteration of texture of the cornea, and sometimes, 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 oph- thalmic 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 INFLAMMATION OF THE CONJUNCTIVA. 631 membrane of the eyelids, has been considered, and, I believe, very properly, as a mucous membrane. It is the principal seat of the disease, and undergoes a change, when inflamed, analogous to that of other membranes of the same class. Symptoms of purulent ophthalmia. — The date of the attack varies. I have several times seen children born with the disease, and have often detected it on the second day, and it may occur at any subsequent period; but, generally speaking, it takes place be- fore 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 bed-side.—A child affected with purulent ophthalmia, is observed to be very restless and fretful, par- ticularly when exposed to light, although it keeps the eyelids 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 eyelids, especially about the inner can thus, attended with a secretion of whitish matter. There"'are generally observed also some heat of skin, and a foul tongue. The eyelids soon appear red and swollen, or the eyelashes are found matted together by a glutinous 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 the 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 forcing open the eyelids, 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 eyelids 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 secre- tion takes place when the eyelids 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 eyelids 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 conjunctiva which covers the eyeball, 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 eyelids are allowed to be glued together for some time, it collects, producing great distension, and when they are opened, a teaspoonful or two of puriform matter gushes out. In neglected cases we discover disease in the cornea, perhaps on the first 632 INFLAMMATION OF THE CONJUNCTIVA. examination, or that it is already destroyed. The externa skin of the eyelids in some cases becomes affected, being red, swollen and of a livid colour, particularly when the infant struggles or cries. 1 he inflammation, in some instances, extends to the lachrymal sac and duct and lining membrane of the nose, from which a similar puri- form fluid is discharged. As the complaint advances, portions of the cornea put on a dusky appearance, become elevated, and, in the course of perhaps twenty- four hours, a process of separation commences. The slough, when thrown off, leaves a ragged 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, \Vhen 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 ex- pelled, and vision is for ever destroyed. In some rare instances, with or without opacity or ulceration of the cornea, the inflammation ex- tends to the deep-seated parts of the eye, and vision may be destroyed 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 aggra- vated by improper treatment—a disease which, when early opposed by proper means, is seldom 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 generally left; but when it ad- vances still further, and the iris is protruded, staphyloma 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 prac- tical 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 con- siderable period by a diseased state of the lining membrane of the eyelids, 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 ou some tissue of the eyeball 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 occasion- ally produced in consequence of mechanical injury inflicted on the conjunctiva by the child's own nails. Purulent ophthalmia is said, INFLAMMATION OF THE CONJUNCTIVA. 633 by some, to be produced by the direct application of acrid matter to the eyes of the infant during parturition. This is very probable, if the mother be affected with syphilitic chancres, or gonorrhoeal discharge; but, on the other hand, I have known many women so diseased, whose children were not attacked by purulent ophthalmia. Others maintain, that it is invariably produced by the peculiar discharge called the whites: but experience completely disproves this assertion; for if it were the case, scarcely one new-born babe could, by possi- bility, 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 treat- ment is easily understood. The only difficulties with which practi- tioners 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 manage- ment 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, compar- ing 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 simulta- neously 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 ex- amined, is too often found to be irreparably lost. General 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 exter- nal canthus of the eyes, for when applied too near the part, the loose tissue of the eyelid becomes swollen, inflamed and ecchy- mosed, creating alarm and an impression in the minds of those most interested, that the abstraction of blood has done harm. This opin- ion 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 dis- ease 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 scammony; 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 toge- 634 INFLAMMATION OF THE CONJUNCTIVA. ther. 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 can thus. 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 eyelids, an operation which ought never to be confided to a nurse. With respect to the operation of scarifying the lining membrane of the eyelids, I formerly had doubts whether it did not occasion- ally do harm; but experience has taught me, that it is one of the most effectual parts of the treatment, not only in the chronic, but in the acute stage. The scarifications are to be made very slightly, as their edges sometimes suffer from subsequent irritation and in- flammation. To procure the full effects of scarifying, the eyelid 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 in- stead 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; and they are often serviceable 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 effects of the remediesin reducing the disease, partly by the dimi- nution of the constitutional-symptoms and quietness of the infant, and partly by the diminution of the discharge, as well as by the child opening the eyes; but in order to ascertain this last point, it is neces- sary 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 circum- stance now under consideration, it is a term not very happily chosen. After acute inflammation of the eye has subsided, the vessels are left in a gorged state; the swelling in the surrounding tissues gra- dually 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 sub- dued the previous action will, if continued, rather tend to increase than diminish it. At the same time,'I have to urge the remark which I made in a former instance, 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 sufficient credit to the restorative powers which a living organ possesses; or, perhaps, INFLAMMATION OF THE CONJUNCTIVA. 635 from their own physiological and pathological dimness, they must always be doing something for appearance's sake. 1 have seen much mischief done by officiousuess; therefore, as soon as the in- flammation is either nearly or altogether subdued, I follow a pass- ive plan with respect to applications, and content myself with keep- ing the eye tolerably clean, and the eyelids 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 two after convalescence has been established, an astringent, nay, even a stimulating applica- tion, may be necessary and serviceable, should the vascularity still exist, or should the mucous 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 ap- plied, or surgical aid obtained and the part clipped or cut off—at first recommended 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 discovery by Sir William Adams. Immediately on the decline of the disease, some insist much upon the benefit 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 consider- able debility prevails, particularly where there is a somewhat exsan- guined 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 pompous practi- tioners, who depend upon mystery, this plan may appear vulgar and unscientific—let such people give a few drops of " Huxham's tinc- ture of bark." The experienced reader will have remarked, that the effect of blis- tering has not hitherto been noticed in the treatment; but it was purposely avoided, to be made the subject of my concluding obser- vations. 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 inflammation of the eyes: the same benefit may be expected in purulent ophthal- mia ; but in young infants, the blistered surface is liable to slough, and death will so frequently follow such an occurrence, that I enter- tain considerable repugnance at applying a blister to a new-born child; and it is impossible 1 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 were honest- ly 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. 636 INFLAMMATION OF THE CONJUNCTIVA. PUSTULAR OPHTHALMIA. This disease appears to be a chronic, or, perhaps, rather a subacute inflammation of the conjunctiva, speedily terminating in the forma- tion of pustules. At the commencement, these pustules have a red or yellowish appearance, slightly elevated, surrounded by a consider- able turgescence of vessels,"varying very much in size, number and situation, and sometimes attended by considerable 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, 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 fe- brile symptoms, and more particularly, should they be situated upon the cornea, where they sometimes leave ulcerations, more active means should be employed. A number of leeches must be applied, perhaps a vein opened, a few strong purgatives exhibited, and re- course 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 treated 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. CHAPTER III. INFLAMMATION OF THE EYEBALL. 1. Inflammation of the Sclerotic Coat.—2. Inflammation of the Iris.—3. Amaurosis. 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 movable on making the con- junctiva slide upon the sclerotic, by pushing the former membrane from side to side with the finger, the eyelid being slightly interposed between the finger and the membrane. The pain complained of in this disease is a rheumatic kind, and more uneasiness is felt in the different motions of the eyeball; it is also, in many instances, vica- rious, with gouty and rheumatic affections 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 inflam- mation. Of these I may mention that I have seen great advantage result from the exhibition of colchicum and Dover's powder. In almost every case of iritis the sclerotic is found to participate in the inflammation.* INFLAMMATION OF THE IRIS. Inflammation of the iris received the denomination 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 inflammation 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 eyebrow is rarely wanting; it commonly comes on in pa- * 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 connected 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 uncomplicated. I must, therefore, refer my readers for more minute inform- ation 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. 638 INFLAMMATION OF THE EYEBALL. roxysms. The constitutional symptoms are very similar to those which occur in other acute inflammations 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 beneath the conjunctiva, but they suddenly disappear before they reach the cornea, leaving a whitish zone round it. This ap- pearance 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. Januin 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 commences at the pupillary margin, and the colour it assumes when inflamed is that which would be produced by a mix- ture 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 peculiar pink colour. The retina sometimes becomes affected. This is indicated by greater sensibility 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-men- tioned 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 complete- ly lost, the pupil subsequently remaining immovable under every change of light. When the effusion is considerable, it is seen hang- ing 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 an 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 frequently happens, and discharging its contents into the anterior chamber, forming 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 INFLAMMATION OF THE EYEBALL. 639 often been remarked that, when the iris of one eye is affected, the disease frequently attacks the other, and sometimes both eyes are affected simultaneously. 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 inflammation 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 circumstance that mer- cury is, nevertheless, exhibited for the cure of the disease which it is 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 familiar 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 mentioned. Subsequently, recourse is to be had to topical bleeding, repeated or not according to circum- stances, and blistering. After the violence of the inflammation 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: perhaps 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 experi- ences 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,) begins to disappear. 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 the 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 640 INFLAMMATION OF THE EYEBALL. found so generally successful, to adopt another from the false assur- ances of its invariable success. Dr. Robertson thinks that mercury can scarcely be praised too highly in this disease, which, when al- lowed to proceed, more especially after lymyh 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 slide on, it is next to 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 iri- tis. 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 its effects before having recourse to the mineral. It is only, how- ever, 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 sufficiently nume- rous and precise to allow him to give a decided opinion with regard to its utility. He would, however, recommend its employment, together ivith 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 eyebrow and forehead, or on the temple or cheek, early in the disease ; or a strong solution of it may be inserted between the eyelids every second or third hour. If no effusion have taken place, the pupil will be regu- larly and considerably dilated in the course of a short time; but if adhesions exist between the iritis 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 dis- appear, from which they infer that belladonna is a powerful remedy in destroying the inflammation; but this is not the case ; the dilata- tion merely indicates the cessation or diminution of the inflamma- tion, towards which it does not contribute. The extract of hyoscya- mus seems to possess the same qualities as that of belladonna; so that, should the one lose its powers, the other may be substituted. INFLAMMATION OF THE EYEBALL. 641 AMAUROSIS. The term amaurosis, as at present used, is employed to denote a partial or 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 progress 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 in- flammation 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 spreading 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 apoplexy. 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—inflamma- tion of the substance of the brain—effusions at the base of the brain -^and tumours pressing on the parts on which vision depends; blows, also, on the supraorbital 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 mentioned. 6. Amaurosis has been known to be occasioned by gastro-intestinal irritation, produced by worms—by indigestible mat- ters—and by particular articles of food. During the time of Bona- parte's political influence on the continent, he prohibited the import- ation 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 vegetable matter, called chicor6e, for coffee. 7. Amaurosis is sometimes vicarious with cutaneous affec- tions, 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 dentition, 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 symptoms of which must be so very va- rious, occurring under such different circumstances. I may mention, however, that.imperfect vision, pain in the eyeball and in the head, flashes of light and illuminated sparks, dark spots, or other optical 54 642 INFLAMMATION OF THE EYEBALL. illusions, appearing before the eye, accompanied with a preternatural state of the pupil, which is generally dilated and immovable, announce the existence of this disease. But this state of the pupil is not al- ways 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 immovable 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 recover- ing vision entirely, and losing it again and again, till at last it be- comes permanently destroyed. 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 person looks at another object, it being some time before the muscles of the diseased eye are able to place it in the same direction as the other. Treatment of amaurosis.—The remedial agents must vary ac- cording to the cause of the disease. It is quite evident that, in the first three causes enumerated—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 de- pends, 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 diseases 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 amaurosis 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 at- tended to. Should the disease be connected with cutaneous affec- tions, and with discharges, bleeding may produce relief, but it will be only 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, un- stimulating diet. Occurring during pregnancy, it will, in all proba- bility, vanish, like many other unpleasant symptoms, after delivery; but a minute investigation should be made in case the amaurosis should depend upon some of the other causes, when suitable reme- dies are to be used. If the disease should ever take place during dentition, leeching and purging will be necessary; but lancing the gum will be found to be the most certain remedy. Nux vomica has been long known to possess considerable powers in paralysis, and since its active principle, strychnia, has been dis- covered, it has been found of more service in the same set of affec- tions. Strychnia has been lately tried in France, in amaurosis, by Lembert, and in some cases with marked benefit. It is evident, INFLAMMATION OF THE EYEBALL. 643 however, that, as a cure is not to be looked for in paralysis of a limb if its structure be destroyed, or the brain and spinal marrow 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 derangements. It has been lately introduced into this country, and has been used in the Royal Infirmary of Edinburgh, by Dr. Shortt and Mr. Liston. The man- ner of employing it is to sprinkle a quarter of a grain daily upon a newly blistered surface on the temple, increasing the quantity gradu- ally 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 in- flammation of the part. The constitutional symptoms occasioned by the strychnia are headache, agitation, and tremors of the whole body ; sometimes shooting pains in the eyes, and occasionally cramps and convulsions have followed. When any unpleasant symptom takes place, the dose is to be lessened 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 Westminster Ophthalmic 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 differ- ence 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 strabismus. 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 spasmodic twitches and general startings. For two days after this, half a grain was applied daily, and on the third day a whole grain was used without any benefit. CHAPTER I'V. DISEASES OF THE EAR. In this chapter I shall treat, and that shortly, of Otitis and Otor- rhcea. otitis. The symptoms of this affection may be considered under three heads, viz.: 1. Common earache; 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. Earache.—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 symptoms, such as violent headache, fits of scream- ing, flushed face, quick pulse, great restlessness, and sometimes de- lirium. 2. Inflammation and suppuration external to the tympanum. —This disease is generally accompanied by more severe symptoms, and unless the inflammation 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 dart- ing 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 or less deafness is produced, with an occasional hissing sound. 3. Inflammation of the internal ear.—The symptoms, both local and constitutional, 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 inflammatory action is acute or chronic, partial or extensive; the tympanum becomes ulcerated and de- stroyed together with the lining membrane of the different parts of the internal ear; the small bones are detached and discharged, 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 DISEASES OF THE EAR. 645 membrane of the brain succeeds, subsequently affecting the brain itself; so that, on 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 disease is very insidious in all its stages, attended with very little pain, and perhaps 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 attack 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 notice such cases, and several interest- ing examples are recorded in Dr. Abercrombie's work on the brain, as well as in that of M. Itard, entitled "Traites des Maladies de l'Oreille." Causes.—All these varieties often take place in the course of ulce- rated sore throats, as only 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 com- mon cause proceeds from the bad tricks which children have of putting pieces of paper, peas, &c., into the external ear. Another frequent cause of the first two 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 cutaneous 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 themselves, sometimes produce serious inconvenience and pain. Treatment.—The treatment of earache 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 membrane be slight, fomenta- tions assiduously applied during the day, and a soft light poultice during the night, together with the use of a small quantity of lauda- num, 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 disease of frequent recurrence, and in none of these instances has it ever returned. Besides fomenta- tions, the application of leeches is serviceable, to be repeated accord- ing to circumstances, and followed by a blister behind the ear if necessary. It is also found advantageous, before dropping in lauda- num 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 mode- rately, if not entirely antiphlogistic; and, in severe cases, a brisk action 646 DISEASES OF THE EAR. is to be kept lip on the bowels: I have 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 expected from the slowness with which the matter will form and escape, owing to its being situated in a hard and un- yielding structure. If allowed to take its own course, a troublsome fungous ulceration sometimes follows, and a copious discharge of matter, which occasionally continues for years. OTORRHffiA. A discharge of offensive matter from the ear is at all times very unpleasant, more particularly so when it is habitual and in large quantity. Sometimes the discharge consists of an increased quan- tity of the natural secretion in a very fluid state ; at other times it is more or less mixed with pus. It may be the consequence of in- creased 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 discharge has existed for some time, it becomes, as it were, necessary to the constitution, and cannot be checked without creating some tumult in the system, which may terminate very un- leasantly. Therefore, certain preparatory measures should be taken efore 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 pur- sued 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 cup- ping-glasses to the neck, followed by a blister, together with smart purgatives. In some instances, in which it might be unsafe to inter- fere with the discharge, the disagreeable fetor may be very much diminished, by injecting a solution of the chloruret of lime or soda, properly diluted. I PAET VII. DISEASES OF THE SKIN. CHAPTER I. GENERAL REMARKS ON DISEASES OF THE SKIN. A knowledge of this class of diseases is so necessary in a prac- tical point of view, that I shall devote as large a space to their con- sideration as is consistent with the plan of this work. The study is important, from the frequency of their occurrence, from the little that is yet known respecting them, and from the connection, 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, Ahbert 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 subject, was the knowledge of what had been previously done by Willan! Willan's great merit consists not only in drawing the attention of medical men to a subject which had been quite neglected, but in classifying the different diseases, and in examining the writings of ancient medical authorities. It is incumbent, however, upon me to state, that the errors of his system are numerous, from carrying di- visions and subdivisions of cutaneous diseases too far, and increasing the number of names, thereby complicating the study without sim- plifying 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 bookworms. Our sole object in classifying and investigating diseases, is to render the treatment more success- ful and certain, which a too minute division decidedly counteracts. The practitioners who, according to my observation, are notoriously the most unsuccessful in the treatment of cutaneous affections, are those who, instead of taking a comprehensive view of the history of the case, and attending to the state of the digestive and other organs, embarrass themselves by making minute distinctions, and by en- deavouring to force every disease into some of Willan's classes and orders. Small-pox, measles, and the other exanthemata, are included in almost all the popular works on cutaneous affections, and classed along with other diseases with which they have no connection: as, for example, with purpura. I have already treated of the exanthe- 650 GENERAL REMARKS ON mata, in the first volume, as fevers attended with eruptiona—but my pathological opinions respecting these and simple cutaneous dis- eases, are in some respects very similar. In almost every instance of cutaneous affection which has fallen under my observation, whether attended by fever or not, I find ample evidence 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 disease of the liver, mucous membrane of the lungs, &c. Erysipelatous inflammation is always the consequence of some internal disease, either functional or struc- tural, sometimes of the stomach and bowels, at others of the lungs, and occasionally of the brain. This will be shown when treating more particularly of erysipelas, which I have placed in this part of the work, and not among the exanthemata, because it cannot be considered a specific disease, having, like small-pox and measles, a definite course, progress, and termination. The principles which shall now be explained 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 erroneous notions, or never think at all, of the nature of the affection. It may be briefly 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; 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 quan- tity, 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. the diseased action is situated in the substance of the cutis vera itself, the inflammation and suppuration extending to the subcutaneous cellular membrane, and in some in- stances 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 dis- tribution, which some think they have seen by the help of the micro- scope between the cutis and rete mucosum. Microscopic obser- vations, like those performed by Mr. Chevalier, 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 optical delusion, in the course of a very extensive set of experi- ments which he performed. He observed that all animal fibres were serpentine; he next proceeded with vegetable substances, and * It gives me great pleasure to notice the work on the Diseases of the Skin, by Mr. Plumbe, of London, and to recommend it to my readers as the best pathological and practical treatise on this class of diseases which is to be found in any language. THE DISEASES OF THE SKIIf. 651 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 substance he ex- amined, it was composed of serpentine fibres. He either wrote, or was engaged in writing a paper upon the subject, when he discov- ered, 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 embar- rassment and chagrin. It is to be feared that considerable errors have crept into medicine, from the incorrect impressions conveyed by microscopic apparatus. Some writers have described papille 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 (papillae) 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 repair 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 denomin- ated insensible perspiration; and the proper performance of this duty must have a powerful influence upon the action of every other organ in the body. 3. It would appear that we are able to introduce many substances into the body by the process of absorption from the skin ; so much so, that even minute quantities of strychnia, applied to a blistered 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. I. Erysipelas, or Rose. 2. Papular Diseases. 3. Pustular do. 4. Squamous do. 5. Vesicular do. 6. Purpura. CHAPTER II ERYSIPELAS. Erysipelas appears to have been noticed by the earliest writers on medicine, 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 useless in theory and injurious in practice. Mankind differ as much in constitution as they do in expression of countenance; and it is well known that peculiarity of constitution produces shades of difference in symptoms and appearances, which defy the.ingenuity of the ablest nosologists; but they, nevertheless, have exerted them- selves in a wonderful manner to accomplish the task, retarding instead of advancing the study of true pathology.. . If all the time and talent that have been misused in devising nosological arrangements had been employed in discovering the nature and seats of diseases, our knowledge of pathology and of remedial agents would, in all proba- bility, have been much further advanced than it is at present. 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 symptoms, appearances and terminations which may seem to indicate corresponding alterations in the treatment. I am induced to follow this plan here, because it has met with the appro- bation of practical men of considerable standing in the profession, who have done me the honour 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, however, in certain constitu- tions, 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 met with in practice in every degree of severity, appearing under the form of the slightest erythematic blush, confined to one spot, or under that of deep and intense inflammation of the skin, extending over the whole body. The inflammation may be severe, affecting not only the skin and subcutaneous cellular tissue, but also involving the muscles, and terminating in extensive suppuration, ulceration and mortification. In some cases the disease spreads ERYSIPELAS. 653 from the skin to deep-seated parts, while in others the inflammation appears to extend from within outwards, sometimes from the perios- teum, 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 phenomena of the disease and the local appearances differ considerably from those of simple erysipelatous inflammation. When the periosteum is prima- rily affected, severe gnawing pain, sleepless nights, &c, will be com- plained of for months, perhaps for years, before the skin partakes of the inflammation. When the fasciee of muscles become inflamed, whether from a puncture or from the application of cold, deep-seated pain, tumefaction, tenderness to the touch, and severe constitutional symptoms, precede the redness of the skin. In contradistinction to erysipelas, these cases have been named, by Dupuytren and others, erysipeloid 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 appearance ; on pressure the redness disappears for a moment, but immediately returns; and, as the dis- ease advances, the part assumes a purple colour. The constitutional disturbance manifests itself in the shape of febrile symptoms and general functional disorder, varying according to a number of circumstances 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 appeared after a long and debili- tating illness, the symptoms will be different from those produced in a person who had been previously in good health. If the inflam- mation 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 situa- tion, 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 membrane lining the nose, mouth and ears; vesicafion takes place, even in slight cases, or the parts become exceedingly hard, more particularly the ears; and if the inflammation be superficial, desquamation of the cuticle, after dimi- nution of the redness and pain, marks the decline of the disease. In cases where the inflammation has been more intense and deeper- seated, 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 inflamma- tion of the 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; ery- sipelas frequently comes on at the termination of fevers of long dura- 55 654 ERYSIPELAS. tion, as well as of inflammations of different organs, more particularly of the brain, lungs, and peritoneum ; it also takes place 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. In whatever circumstances erysipelas may take place, the attack is generally preceded by rigors or chilliness, alternating with flushes of heat, oppression at the praecordia, difficulty of breathing, cough, ex- pectoration, pain in the back and loins, general uneasiness, delirium, a sense of weight in the head, headache, lethargy, and sometimes a state bordering upon coma, with high or low toned febrile action. 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 or stages, as in measles, scarlatina, and small- pox. Erysipelatous inflammation sometimes appears on a part for a few hours, and suddenly vanishes, showing itself perhaps in another situation; or if it do not show itself again on the surface, the consti- tutional symptoms become aggravated, coma or dyspnoea frequently follows, and sometimes even death itself. Causes of erysipelas.—From the prevalence of erysipelas in par- ticular years, a belief is pretty generally entertained of its being con- tagious, which has been much strengthened by the additional fact of the occurrence of a considerable number of cases at one time in par- ticular hospitals. There is much stronger ground for believing that erysipelas is produced by epidemical influence. 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 con- siderable moisture, together with the state of the bowels, and indul- gence in particular articles of food. It is proper to state, that I deny altogether the idiopathic nature of erysipelas, and that I believe it to be an occasional symptom of dif- ferent diseases, which diseases may frequently occur, under atmos- pherical, epidemical, and contagious influences. In a great majority of instances, if the particulars of the cases be inquired into, it will be found that no communication, direct or indi- rect, had taken place with others labouring under erysipelas. Some- times it attacks nurses and others who have had an anxious attend- ance 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 attendance on patients affected with other diseases. 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 an attendant who was attacked with erysipelas when attending a patient labouring under that disease, although the confined, crowded, and extremely filthy state of the apartments, on very many occasions, seemed but too well ERYSIPELAS. 655 calculated to contaminate the atmosphere, and thereby to promote the generation and communication of contagion. If erysipelas were as contagious as is represented, we ought certainly to see erysipelas producing 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 as an epidemic, cannot be de- nied, and on many occasions it is said to spread by contagion in hos- pitals; 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 indi- viduals here and there, frequently at a distance from each other, who have been in separate wards, and who have never come once in con- tact. 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 eruption appears. This goes through a regular course of advancement and recession, 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, in- flammations, and other morbid conditions of the system, till perhaps the end of the third or fourth week; at other 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 con- tagious; besides, erysipelas has no regular and determinate course as the others, which attack the same individual only once in a life- time, while erysipelas may affect a person twenty times. Let me ask if any one has succeeded in producing erysipelas in a healthy person by introducing 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 produced by minute splinters of wood, and punctures made by per- fectly 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. In the first circumstance, fevers, and acute and subacute inflamma- tions, also prevail, particularly bronchitis; In the last, the functions 656 ERYSIPELAS. of the stomach and bowels suffer; irritation of their mucous mem- brane ensues; fevers and diarrhoeas also prevail; and the erysipelas, in both cases, although a frequent occurrence, is a mere symptom. The reason why erysipelas should be occasionally very prevalent in hospitals, 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 prevailed 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 hospitals, than by supposing, as too many have done, that the disease lies in ambush, 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 same state as it is observed to be when a person has died twen- ty-four hours after a blister had fully risen; or, if suppuration have taken place, pus will be found infiltrated instead of serum, in some places distributed generally through the cellular tissue; in others, circumscribed little abscesses exist. In the most severe 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, the disease even extending into the muscles. In subcutaneous cellular inflam- mation, more extensive destruction will be discovered; small ab- scesses will be found, but pus and a 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 their inner coats, and the lymphatics as well as veins containing a puriform fluid. Besides the above appearances, traces 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 found in a state of inflam- mation, and in many instances the fatal termination has been dis- tinctly 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 ERYSIPELAS. 657 examining the abdomen, the commencement of erysipelatous inflam- mation 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 ag- glutination of the intestines to each other. My friend and pupil Dr. Yates, when attending my dispensary, was requested to see a child one month old, on a Saturday evening. He found the abdomen tumefied and tense ; there was an erysipe- latous 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 danger- ously ill, but did not seem to be in much pain. Dr. Yates was informed that it had been taken ill on the preceding Thursday morning, after having passed a bad night; that the bowels were confined; and that she cried violently at times, and gave evidence of 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 following morning. Dissection.—The abdomen was considerably distended. The sur- face of the abdomen and thighs showed the remains of the erysipe- latous inflammation, and there were, besides, much tumefaction and discoloration of the integuments at the lower part of the chest. On opening the abdomen, the intestines, which were moderately dis- tended with flatus, appeared very vascular, as well as that part of the peritoneum which lines the cavity. Flakes of coagulable 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 parietes 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 exuda- tion. The stomach distended with air, was found to adhere to the diaphragm as well as to the liver. The colon was much contracted, and on being slit open, its mucous membrane was found very vascu- lar, much elevated here and there, and coated with a dark, thick mucus. 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 ligament was attached to the peritoneum at the brim of the pelvis, by an interposed mass of lymph. In the thorax, the pleura costalis was very vascular on both sides, and slight recent adhesions were observed with the pleura pulmo- nalis, 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 55* 658 ERYSIPELAS. volume of the Medical Communications. "The child of---- War- wick, 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 exhi- bited, notwithstanding which, his bowels were difficultly 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 semicupium often repeated, were of no avail. He died on the twelfth day from his birth, and the fifth from the attack. Dissection.—On opening the abdomen, we found the appearances very similar to what we had often observed in the true puerperal fever—viz., a purulent exudation covering the surface of the peri- toneum, and an adhesion of many of the viscera to this membrane and to one another from the diaphragm downward, with some ex- travasated 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 inflamed. But though the chylopoietic and spermatic organs seemed to have undergone superficial inflam- mation, there was no appearance 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 to- gether, and their surface covered with inflammatory exudation, ex- actly similar to that found in women who have died of puerperal fever. In males, 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 erysipelas of the head and face, as pure examples of idiopathic erysipelas. In both cases I was able to satisfy the gentleman who had been previously attending, that there was a general affection of the mucous membranes—that of the lungs in one, announced by the dyspnoea, 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 unpromis- ing appearances; proper remedies were applied; stimulants with- drawn : 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 inflammation 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 ERYSIPELAS. 659 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 appearances were discovered indicating the commencement of ulceration. In the year 1823, I was requested to see a woman with erysipe- las of the abdomen, which had commenced about a fortnight after abortion. The whole surface of the belly was affected, the inflam- mation was of a deep purple colour, with sloughing at the umbilicus. Although this woman possessed considerable property, she was liv- ing in a state of abject misery, neglected by a brutal, drunken hus- band, 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 umbili- cus, and the discharge of a large quantity of urine. The woman sunk under her sufferings; and on dissection, the peritoneal surface of the fundus of the bladder was found strongly attached to the peri- toneal lining of the abdomen corresponding 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. This valuable preparation is in my museum. The following abbreviated case of erysipelas is extracted from the pathological work of Tacheron.—A man was seized on 1st Febru- ary, 1808, with anorexy, nausea, headache, severe pain of neck, and difficult deglutition. These symptoms gradually increased for some days, the face becoming swollen, inflamed and painful, with severe diarrhoea. 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 (liss.) in the ventricles, between the membranes 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 pleura on both sides. The middle lobe of the right lung was reddish, hard, and did not crepi- tate; in consistence it resembled liver, and adhered to the portion of the mediastinum next the heart. On cutting into this lobe, a thick, grayish, puriform fluid oozed out; the rest of the lungs being healthy. The pericardium adhered in every part to the heart, but particularly on its right side, where it could not be separated with- out 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 dis- tended 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 660 ERYSIPELAS. its left lobe was covered with lardaceous substance, which entered the substance of this viscus to the depth of two or three lines. The gall-bladder contained polyhedrons 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 re- duced it into a pulp. The kidneys were more vascular than natu- ral." The two following dissections of erysipelatous subjects, are extract- ed from Dr. Hastings' work on the lungs: — "Dissection of case 5th, (page 228.)—The mucous membrane lin- ing 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 membrane lining the trachea, bronchia and air-cells, was highly vascular, and the tubes were filled with a bloody serum. The right auricle and ventricle contained more blood than natural." Pathological remarks on erysipelas.—Doubts have been already stated as to the existence of idiopathic 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 disor- der 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 constitution, by which disease is sometimes removed or translated from one tissue to another: in this instance, from an internal organ to the skin, which has compara- tively a less important 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 enumerate 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 appearance of the erysipelatous inflammation, shows erysipelas to be merely an occasional symptom of some other diseased state of the system. 2. The mitigation of the internal disturbance which frequently fol- lows the appearance of the cutaneous inflammation; and the repro- duction of perhaps worse symptoms 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 ERYSIPELAS. 661 may be mentioned, 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 "Dic- tionnaire des Sciences Medicates," in giving an account of the symp- toms 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 an- nounce an erysipelatous eruption, more than another of the exan- themata, or some other fever. It is thus that a person feels wandering pains in the limbs, spontaneous 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, Renaul- din 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, ap- pears 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 d'une cause interne.) 2. Symptomatic or secondary erysipe- las, which depends upon another affection, and goes through its course with it: as phlegmon, oedema, every kind of continued fever, and different internal affections, sometimes of an acute, sometimes of a chronic nature. 3. Accidental erysipelas, which is occasioned fortuitously by a manifest external cause, acting immediately upon the skin; as the scorching rays of the sun, a superficial scald, the ap- plication of cantharides, or any other acrid and irritating substance, injuries, &c." Cullen has given the following history of the symptoms:—"Ery- sipelas of the face comes on with a cold shivering, and other symp- toms of pyrexia. The hot stage of this is frequently attended with a confusion of head and some degree of delirium; and almost always with 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. i. p. 255.) Although Cullen specifies "erysipelas of the face," yet it is well known that this affection, attacking any other part of the body, is preceded by a similar train of symptoms. Sydenham, in his letter on the plague of 1655 and the following year, observes, " 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 662 ERYSIPELAS. dressed up a statement of the precursory symptoms to suit my own purposes. Cutaneous inflammation, produced by a blister or a scald, will most undoubtedly excite general irritation, and more or less fever. In this case we have ocular proof to guide us; but in erysipelas we have the general commotion of the constitution first, which I have known to continue for ten, or twelve, or thirty days before the ery- sipelas appeared. Cullen himself does not seem to have been well satisfied with the prevailing doctrines respecting erysipelas. In describing the different species of this affection, at page 75 of his Nosology, after mentioning the erysipelas pestilens of Sydenham, he observes, in a note, "This and the following species (erysipelas contagiosnm) 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 all physicians from the middle of the seventeenth century to the present day, and contrary to the senti- ments 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 evi- dences of functional or structural disease of many important viscera; therefore, it is unnecessary to quote cases in proof of this. That this 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 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, (at page 75,) that "one of the most favourable 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 fixes on the extremities, 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 I 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 pneumonia, states that "sometimes the dis- ease disappears on the second or third day, while an erysipelas makes ERYSIPELAS. 663 its appearance on some external part, and, if this continue fixed, the pneumonic inflammation 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. page 171.) From the repeated observations of such facts, I cannot avoid con- sidering 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, by observing the beneficial effects of erysipe- latous inflammation occurring 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 appearance of the cutaneous inflammation ; and the re- production of bad, nay, perhaps, of worse symptoms, than had pre- viously existed, upon its sudden recession. These facts are 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 con- vulsive 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—sometimes with a delirium— sometimes with drowsiness, &c."—The same author again remarks, that " it is rendered very dangerous by improper treatment. 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 wandering with much greater inconvenience. I have also observed, that after being re- pelled in the leg, by an application formed of camphor, red lead, and bole, 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 antispasmodics 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 cam- phorated liniments, has brought ou a vertigo, lethargic disorders and quinsey, delirium and palsy of the tongue; which evils have fre- quently proved fatal to persons in years, and scorbutic habits." "A gentleman," says Dr. Swain, the accomplished translator of Sydenham's works, " who, by the cold air, suddenly struck in the erysipelas of his face, had all 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." 664 ERYSIPELAS. Mr. Abernethy noticed a case of this kind in his lectures. "A stout healthy 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 digestive 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? they powder the part a little, and they give bark, and so on !! " " It has been observed," says Wilson Philip, in his work on Sim- ple 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 re- called but maintained ; for the typhus, which supervenes towards the end of an erysipelatous fever, is less considerable, 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 debili- tated." It may be said that the appearance of the erysipelatous inflamma- tion does not alumys produce mitigation of the internal disease. The simple answer to this objection is, neither does an artificial blister, applied foT the express purpose of translating the diseased action to the surface, which I maintain the erysipelas is intended by nature to effect. In severe inflammation of an internal organ, a blister, how- ever large, has but little effect, if applied before the disease is very much subdued by depletion. In like manner, 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 constitutional relief can be expected. . At the period when the erysipelatous inflammation begins to decline, particularly under improper treatment, it is frequently ob- served that the functions of the brain or lungs, or perhaps both, appear to become suddenly and seriously affected, accompanied by oppression at the prascordia, 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 metastasis. 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 through the contiguous parts. There can be no doubt that a fair translation does occasionally take place in inflammatory complaints, particularly when connected with erysipelas; so much so, that we actually find a variety of erysipelas in the books, termed " errati- ERYSIPELAS. 665 cum." In general, however, attentive observation has long con- vinced me, that in erysipelas, diseased action had existed in the in- ternal organ before the external inflammation appeared, during what may be termed the eruptive fever, and that when the cutaneous in- flammation occurred, acting the part of an effectual contra-irritant, it mitigated, 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 natural and an artificial blister. Before quitting this part of the subject, a few remarks may be made regarding the mitigation of symptoms upon the appearance of the erysipelas, although it is repeating nearly the same observations which were made in the first volume, when treating of the General Pathology of Eruptive Fevers. The relief will not strike the eye of a symptomatical physician, who cannot see the pathological miti- gation of symptoms, because the patient, who may have been pre- viously lethargic or comatose, now complains most vehemently. Formerly there may have been little complaint, and little or no febrile movement; now, however, there may be great anxiety, rest- lessness, 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 effects of a common blister, which very frequently aggravates the patient's suffering, while it is mitigating the disease. 3. The third point on which these doctrines are founded, is the appearances found on dissection ; and a triumphant appeal may be made to those dissections which are already recorded under the proper head. 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 were symptoms indicating violent inflammation of the brain. Immediately before my visit, the diseased part had been scarified, from which twelve ounces of blood were abstracted. The inflammation on the forearm 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 he had no complaint whatever; his eye was bright and lively; the expression of countenance displayed no signs of sinking; tongue parched and furred towards the root; pulse 98, and soft; consider- able 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 56 666 ERYSIPELAS. 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 examined, 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 particularly still, the corpora striata, and especially that on the left side, which was reduced into 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 sub- stance of the middle lobe on the left side. 4. I have now to. bring forward a most important part of the evi- dence 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 erysipelas 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 fatality is the result of bad practice, founded upon erroneous pathological notions, or, perhaps, if one may be allowed 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 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 erysipe- las as they would be of the plague: others, from the dread of typhoid symptoms, and of mortification and putridity, aggravate the disease by improper remedies. The symptoms which are called typhoid are often the consequence of the intensity and depth of the external inflammation, running into extensive destruction of parts, by diffuse suppuration and mortifica- tion. 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 con- sequences to be prevented in subsequent cases? The answer is easy, and the practice simple, provided medical men would use the com- mon sense with which they are endowed, and give up a prejudice that has been inculcated on their minds from the earliest period of their lives—forgetting that there is any thing mysterious in erysipe- las—and learning to treat each case that comes before them upon its own individual merits. Some take large quantities of blood, indiscriminately from every patient, because they have seen the practice successful in one or two instances. ' Others give the most powerful stimulants and tonics in ERYSIPELAS. 667 every case, because they have seen that plan succeed in a few instances. A third set depend upon opiates, or some other one particular reme- dy. A fourth class will be found to draw blood, but not in sufficient quantity, and perhaps they repeat the operation in small quantities without mitigating the disease, while they do great harm by debili- tating the patient; and in order to counteract this they give stimu- lants too soon. Some timid practitioners will be found to do nothing but to keep open the bowels, and sprinkle the diseased part with flour. Often have I had occasion to commiserate the wretched pa- tients, who with dry, parched tongues, were doomed to swallow beefsteaks—and others, consumed by burning thirst, compelled to take wine and even brandy ! Some practitioners make incisions into erysipelatous parts in 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 continuauce or concentration of acute or chronic diseased ac- tion in a vital organ, as seen in the 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 dis- eased 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 only has to be subdued; because it is now fully established 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 symptoms as to make the patient or his friends, nay, even some medical men, aware that his life is in the least dan- ger. I cannot but agree with my late lamented friend Dr. Arm- strong, when he stated that "pure surgery is like a vampire, whose daily food is human blood," and deprecate 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 ignorance of what may be called medical pathology; nay, who even decry every part of the profession but the practice of pure sur- gery. With regard to the great doctors of London, Mr. 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 or- gan 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, as they call it, and the man dies!" General bleeding was practised in erysipelas by Sydenham, and has since been followed by many practitioners; but either they have not been able to support the practice by sound reasoning, or bleed- ing 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 re- 668 ERYSIPELAS. medy 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." " Ve- nesection (says Mason Good) was formerly recommended, and has been so of late hy few toriters, but upon mistaken principles. I can conceive few cases in which it can be serviceable, and the applica- tion of leeches always exasperates the efflorescence." I know no remedy so decide'dly and immediately efficacious as general bleeding, if it be performed sufficiently early in the attack, and in constitutions not greatly debilitated by previous disease or bad habits: whereas, nothing but bad consequences can be expected to result from general bleeding in erysipelas, when the disease, hav- ing passed its first stage, is about to terminate in extensive suppu- ration, or in gangrene, or when it has taken place towards the ter- mination of an acute or chronic inflammation of a vital organ, or at the termination of fevers. General bleeding may be attended also with bad consequences when employed in the following circum- stances: 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 1824,1 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 erysipelatous inflammation, the disease rapidly extend- ing over the abdomen. 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 rest- less at night, being often chilly, with want of appetite, and other symptoms of impaired health. He had been thus affected for per- haps ten days or a fortnight before the slight accident. A vein was immediately opened, and about twenty ounces of blood abstracted, 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, laxa- tives 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 dur- ing laborious occupation as a water-carrier,* was seized in Decem- ber, 1823, with what she called a severe cold. Her voice was al- tered ; she had a cough, severe headache, sickness and oppression at the praecordia, together with constant chilliness. These symptoms * The last of her class—the old "water cadies" of Edinburgh. ERYSIPELAS. 669 existed for some days, attended by loss of appetite 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 alarm- ing, and the night previous to my seeing her, she was delirious. I found her labouring under great headache, general oppression 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 on the disease, or upon the constitution ; but he came immediately to inform me of his proceedings. Another gentleman, who was further advanced in the profession, (Mr. Mun- ro,) returned with Dr. Lucas, and bled the patient till syncope took place. The swelling and redness of the parts immediately disap- peared ; the thickening of the ear only being left, but which 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; she passed a good night. A solution of tartrate of antimony was given to act as a contra-stimulant, but of this she took only two doses. In four days she was convalescent, walking about the house; and made an excel- lent recovery. Many important cases could be quoted showing 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 circumstances already noticed. The application of leeches upon the inflamed part stands next in importance 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, 1 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 predic- tions of many individuals, neither ulceration nor mortification has ever ensued. Medical gentlemen have seen the patients twenty-four hours after the application of leeches, when they could scarcely see 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 sta°-e of erysipelas, and before either hardness of the skin or suppuration has taken place. More blood can be evacuated by 670 ERYSIPELAS. 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, in 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 have seen profuse haemorrhage, on several occasions, from punctures, which could not be restrained. The pa- tients would, I believe, have died of the disease in 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. Dense, surgeon to the forces, and Mr. Marshall, now assistant surgeon in the 87th regiment, and, I believe, my learned and facetious friend, the late 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 exclusively in very slight cases of erysipelas, where there are no headache, delirium, difficulty of breathing or oppression at the praecordia, no pain on pressure in the abdomen, and no diarrhoea. The reader will, therefore, perceive that I neither think it necessary to bleed nor to apply leeches, unless compelled by the constitutional symptoms, or the severe pain in the inflamed part. In many cases, which fall 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 suppu- ration or mortification, but in which there is no tendency 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 into the stomach; and, by the speedy evacuation of which, the progress of the erysi- pelas 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 I cannot speak from my own experience of them. 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 already evacu- ERYSIPELAS. 671 ated—or where dead parts are undergoing the process of separation from the living. The best local applications are warm fomentations in the first in- stance, and should the part show a tendency to suppurate, light poul- tices 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. 1 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 appli- cations, Renauldin 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 Hagendorn, Hoffman and Fabricius ab Aquapendente.* In truth, it will be seen, from the preceding statements, that erysipelas must be treated upon very different 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." I shall continue to quote the opinion of this clever surgeon till he adopts wiser views, should he continue to anathematize me in every num- ber of the Medical Gazette. * Diet, des Sciences Med., p. 267. CHAPTER III. PAPULAR DISEASES. Under this head I shall speak of the diseases which Willan has termed Strofulus, Lichin, and Prurigo, without splitting them into the same number of varieties. Willan has divided strofulus into five species, viz.: S. intertinctus, S. albidus, S. confertus, S. volaticus, S. candidus; but I shall not treat of them separately, because they are not, even according to Bateman, "very important 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 the artificial classification, I should have to treat of Lichen simplex, L. pilaris, L. circumscriptus, L. agrius, L. lividus, L. tropi- cus, 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 fol- lowed 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 seldom, containing a fluid, or suppurating, and commonly terminating in desquamation of the cuticle. STROFULUS. Strofulus is a papular affection of the skin, to which infants aud 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 up at the breast; 1 would therefore strongly recommend, that, in general, spoon-meat should not be ht to be considered whether the dangers arising from the operation are not greater than from allowing the disease to re- main undisturbed. In the first place, we have to consider the chance of the patient dying immediately from the shock, or from haemor- rhage, or subsequently from inflammation, after she has undergone the horrid torture occasioned by an incision from the sternum to the pubis, independently of that produced by exposing and handling the viscera and cutting away the tumour, not to speak of the difficulty 812 DISEA6ES OF THE OVARIA. of restraining the protrusion of the intestines, both during the per- formance of, and subsequent to the operation. " I shall never forget (says Mr. Lizars,) the countenances of my pupils, and the younger members of the profession, when the intestines protruded, and baffled all the efforts of Dr.-------and other gentlemen to confine them. The diaphragm acted with great vigour, and with powerful impetuosity." To give my opinion in the shortest possible manner, I shall sim- ply state, that I regard a recovery after such an operation as almost miraculous, and to be considered more in the light of an escape than a recovery to be expected, particularly if performed with an exter- nal incision through the parietes of the abdomen and peritoneum, from the ensiform cartilage down to the pubis. There is only one case in which an operation should be attempted —when we are consulted early, and find a tumour just above the brim of the pelvis, which is movable, and falls from side to side, when the patient changes her posture—when it is ascertained, after careful examination, both by the vagina and the rectum, that the uterus is, in all probability, sound—when the patient has as yet had no pain or constitutional symptoms, indicating the existence of peri- toneal inflammation, which may lead us to believe there are, as yet, no adhesions between the tumour and surrounding parts—and when the patient appears to have great courage and stamina, and as many lives as cats are figuratively represented to possess. In such a case I would recommend an operation, with an external incision barely large enough to admit the passage of a small hand to examine the disease, and bring the surface of the tumour to the opening, that its size may be diminished by tapping if necessary, when the sac can be drawn out by degrees, very much in the manner represented to have been pursued by Dr. Macdowal, of Kentucky. It is difficult to say what line of treatment ought to be adopted in diseases of the ovaria; but I shall state that which I have found to be most beneficial in these unfortunate cases. It is indispensably necessary to attend to the state of the bladder, by taking care that it be not over-distended, and that any irritation which may occasion- ally arise in this organ be mitigated by camphor and hyoscyamus, together with fomentations applied to the lower part of the abdo- men; the bowels are to be daily evacuated, if necessary, by mild laxatives, assisted by tepid water injections. Considerable relief is often experienced from the repeated application of leeches and con- tra-irritants, which operate not only by mitigating pain, but by stop- ping the advancement of peritoneal inflammation, which is so apt to occur, and also by arresting the progress of the diseased growth. Occasional opiates are also serviceable. The use of diuretics cannot, I think, be upheld in the true ovarian disease, as they can have no effect either in promoting absorption, or preventing a further collec- tion of fluid in the sacs; neither can I fancy that iodine in any of its forms can have the effect of causing absorption of such diseased masses as I have seen the ovaria to consist. The next important question comes to be—Is the operation of DISEASES OF THE OVARIA. 813 tapping these tumours likely to prolong life? Experience obliges me to say, that in general it is not, although there may be executions to this. 1 apping, in such cases, is an uncertain operation, from the obscurity which generally hangs over them; and it may prove the first exciting cause of peritoneal inflammation, which may quickly produce death, or leave extensive adhesions between the tumour and surrounding parts. I have already shown, by the description of two cases in which tapping was performed, how uncertain are the indi- cations for the operation; and I know of one case, where the ope- ration of paracentesis abdominis was performed, under the idea of the existence of ascites, when there was actually no fluid. Feculent matter came through the canula, instead of the watery effusion ; the woman soon expired, and dissection showed that the trocar had penetrated the colon. But independent of these objections, which show, at least, that this operation, simple and slight as it appears to be,should not be recklessly performed, diseased ovaria are generally composed of such a number of cysts, that when a puncture is made, either no fluid at all, or only a small quantity, may be discharged, being the contents of one inconsiderable-sized cyst; besides, I have found that the fluid is quickly secreted, and that the more frequently the operation is performed, the more frequently does it require to be repeated. Thus it will be seen in a case recorded at page 123 of the Medical Communications, 2d vol., that a patient was tapped forty- nine times from first to last, and two thousand seven hundred and eighty-six pints of fluid were drawn off; and it is stated that the secretion went on so rapidly at last that, by calculation, three pints and three ounces were secreted every twenty-four hours. Another case is recorded in the 74th vol. of the Philosophical Transactions, in which the patient was tapped eighty times, and the immense quantity of thirteen hogsheads of fluid were evacuated. Many other similar cases are to be found both in the English and Foreign Transactions, which incline me to agree vvith the opinion of the late Dr. Denman—that the operation of tapping should at least be de- layed as long as possible, partly from its being an uncertain opera- tion, but principally because it is quickly followed by another accu- mulation, so that, in the course of a few days, the patient is in as bad a state as ever. I had nearly neglected to mention another proposal which was formerly made and carried into execution, with the view of effect- ing a radical cure: it consisted in laying open the abdomen, and making an incision into the tumour, to evacuate the matter, and afterwards throwing in a stimulating injection, to excite inflamma- tion in the sides of the sac, in order to produce permanent adhesion, or introducing a tent to keep the wound open until the fluid ceased to be discharged. A case is related by Dr. Houston, in the Philo- sophical Transactions, in which he made an incision two inches long into the ovarium, and evacuated a great quantity of jelly-like matter and hydatids; the wound was afterwards kept open, and the patient is represented to have been cured, although the disease had existed for thirteen years, and occasioned violent pains. In the Memoirs of 814 DISEA8E8 OF THE OVARIA. the Academy of Surgery, a case is to be found of a woman who was tapped for a large tumour in the belly, but nothing came away; an incision was then made into the tumour through the parietes of the abdomen, and thirty-five pounds of gelatinous matter were ex- tracted—next day fifteen pounds more were discharged, but vomit- ing and fever took place, and she died on the thirteenth day. I may add, that Dr. Denman notices the case of a patient who died on the sixth day after the sac was injected. PART IX. GOUT.—RHEUMATISM.—SCROFULA.—DROPSIES. CHAPTER I. GOUT. This disease is sometimes known by the terms Podagra and Ar- thritis. Dr. Cullen has divided it into four varieties:— " 1*/. Podagra regularis, with decided inflammation of the joints, continuing for several days, and receding gradually, with swelling, itching and desquamation of the part." " 2d. Podagra atonica, vvith debility of the stomach, or some other internal part, and either without the expected or usual inflammation of the joints, or with slight and flying pains in them: with dyspepsia or other symptoms of debility often quickly alternating." "3d. Podagra retrograda, with inflammation of the joints, reced- ing suddenly, and followed immediately by debility of the stomach, or of some other internal part." " 4th. Podagra aberrans, with inflammation of some internal part, preceded or not by inflammation of the joints; if so preceded, the external inflammation quickly disappears." Dr. Mason Good has enumerated three varieties of gout:— " Is/. Regular fit of gout," which differs in nothing from Cullen's first variety. "2d. Disguised, lurking, atonic gout," which is nothing more than Cullen's second variety. " 3d. Complicated gout," in which he includes Cullen's third and fourth varieties, under the terms "retrograde, recedent, misplaced gout." Dr. Scudamore, who has written a large volume on gout, urges most potent objections, both nosological and practical, to these di- visions and the definitions attached to them. He divides gout into three varieties, viz.: acute, chronic and retrocedent; and the following are his definitions:— "Acute gout.—Inflammation and pain of the articular, tendinous or bursal structure, usually attacking one part only at the same time, but in succession of attack, affecting different parts together; with preternatural fulness of the adjacent veins, and in certain situations, with oedematous swelling of the integuments, occurring in twenty- four or forty-eight hours from the invasion of the fit; vivid redness of surface which is sometimes shining; entire disability of the af- fected part, with peculiar sensations of burning, throbbing, cutting and pricking, and weight; the action sometimes readily changing situations spontaneously or from slight causes; terminating almost 818 GOUT. invariably without suppuration, and usually with some critical indi- cations of the event." "Chronic gout.—Inflammation and pain more slight, irregular and wandering than in the acute; faint redness of surface; much permanent distension of parts, or continued oedema, and impaired moving power; without critical indications of its terminating; com- monly associated vvith a morbid state of the digestive organs, a lan- guid or oppressed circulation, and much nervous irritation in the system." "Retrocedent gout.—Metastasis, or transference of the gouty ac- tion in the paroxysm from the external part to some internal organ." It may appear a strange confession to come from me as a lecturer on the practice of physic, that I never read Dr. Scudamore's Trea- tise on Gout till actually engaged in writing this article, although I have long known that such a work existed, and that its author had attained a high degree of eminence in practice; but I have several reasons in excuse to plead. It is impossible for a person engaged in practice, and at the same time most anxiously employed in investigating the nature and seats of disease, to peruse every medical work which now-a-days comes from the press. With respect to what had been previously written on gout, I had derived nothing but vexation and disappointment from the perusal. Very early in life, I had frequent opportunities of witnessing the phenomena, progress and termination of gout; and during an attendance on a near and dear relative in the course of long paroxysms of this disease, I was compelled to read aloud, for his satisfaction and my own improvement, all the published works of the day. At last, when it was pronounced by a celebrated writer that, after all, the only thing to be done for gout was "patience and flan- nel," my patient became almost frantic with rage, and declared that, although he was not a physician, he could write more sensibly upon the subject himself, and concluded by desiring me to study nature and not books, if I wished to obtain a knowledge of the disease. I never forgot his advice ; and from that moment I began to make a book by storing facts in my own mind. - When lecturing on gout, I have contented myself by giving a simple statement of all the pathological facts which I had observed, and by commenting on the statements made by Dr. Mason Good in his chapter on this subject; but after seeing Dr. Scudamore's treatise, it behoves me to state, that I have never been more gratified and in- structed from the perusal of any medical work; and as the opinions which I entertain are similar in many respects to those of Dr. Scu- damore, I shall avail myself of many of his facts and observations, because they are drawn from a more enlarged experience. Phenomena of a Paroxysm of Regular Gout. "The gout, (says Cullen, Par. 492,) not only as it occurs in differ- ent persons, but even as it occurs in the same person, at different times, is a disease of such various appearance, that it is difficult to GOUT. 819 render the history of it complete and exact, or to give a character of it that will universally apply." The first attack usually occurs in one of the feet, generally in the bal'ofJ the Sreat toe> which has more or less of the appearance de- scribed by Dr. Scudamore in his definition of acute gout, and which there is no necessity for repeating in this place. The patient often attributes the sensation he experiences to a twist he thinks he has given his foot, or to the effects of a tight boot or shoe. Dr. Scuda- more says, at page 17: " On some occasions, and especially in the first fit, the immediate invasion of the disease is not preceded by any warning." The reason of this I believe is, that the warning has not been taken, as I have never yet seen a case which was not pre- ceded by a distinct announcement of gastro-intestinal irritation. The tongue has always a morbid appearance, being loaded, or having a fiery red colour, or being shrunk and blanched; the bowels are irre- gular; the patient feels loaded and oppressed after eating; there is acidity of stomach and heartburn which is sometimes excruciating, accompanied by occasional vomiting of a very acid matter. The epigastric region cannot bear pressure; the urine is scanty, high- coloured, and becomes thick and muddy after standing. The patient is often observed to be depressed in spirits and drowsy, although he cannot sleep, and the nights are passed with great restlessness. The limbs are affected with numbness, weakness, and a pricking, tingling sensation, with cramps and darting pains along the course of the nerves, more particularly in the extremity in which the disease is afterwards to be fixed. The extremities at times can scarcely be preserved in the natural degree of heat; at others, they become burning hot, particularly the soles of the feet and the balls of the great toes, and these states alternate. There are sometimes general rigors, or rather fits of chilliness, followed by feverishness, during which the face becomes flushed, and there is sometimes headache. These precursory symptoms, and others which might be mention- ed, vary much in different individuals, depending upon idiosyncrasy. I have never known a person subject to gout who was not warned of an approaching paroxysm, by some sensation or symptom which might be said to be almost peculiar to himself. Thus, one will have violent fits of sneezing;—a second, a feeling of heat and pain in his eyes, with a diminution of the lachrymal secretion ;—a third will pre- ceive heat, redness and swelling at the point of the nose;—a fourth will have a bronchialaffection, with cough and slight expectoration; —a fifth will be aware of the approaching attack by a peculiar ap- pearance of the tongue, a feeling of coldness, heat or acidity in the stomach, perhaps an unusual craving for some particular kind of food;—a sixth is made apprehensive by the occurrence of diarrhoea, by unusual sluggishness of the bowels, or flatulent distension of the abdomen;—a seventh will have great irritation about the neck of the bladder, scalding in the urethra, and perhaps discharge of matter, sometimes passing a little blood, and having slight difficulty in mak- ing water;__an eighth will experience an unusual lassitude, inability to apply his mind to any subject, and irritability of temper, at times giving way to sudden bursts of passion, or merely to a feeling of 820 GOUT. peevishness; and a ninth will suffer from palpitation or some other symptom sufficiently striking to arrest his attention. Those who have experienced a few attacks of gout are hence able to take steps which will sometimes either postpone the paroxysm, or mitigate its violence. At length the paroxysm fairly sets in with the following local symptoms:—pain, which soon becomes burning and throbbing, vvith occasional stounds from the affected part up the limb, the retnrn of which the patient constantly dreads; with some degree of swelling, which, as well as the pain, increases rapidly; so that, in a few hours, the parts are much swollen, red, with considerable distension of the neighbouring superficial veins. Even from the first, a great part of the swelling is owing to oedema, for the parts will be found early in the disease to pit slightly on pressure. The redness soon becomes of a bright scarlet hue, and the throbbing, shooting pains, heat and inability to move the limb rapidly increase, so as to be at their acme in a first fit, perhaps in the course of twenty-four hours. First attacks are, in general, although not always, slight, the pa- tient being able through the day to bear his sufferings at least with composure. At night the pain and general fever increase, but decline again towards morning, with a slight relieving perspiration, at which time, perhaps, the patient enjoys a little slumber. The constitutional symptoms which occur during the paroxysms, vary not only according to the severity of the local inflammation and pain, but also to the state of health in which the patient may happen to be at the time. If there be any organic affection, of course the symptoms will suffer modification, which, however, falls to be con- sidered under the head of retrocedent gout. The first constitutional symptom which naturally attracts attention is fever, and in all old- standing cases of gout the disease makes its approach with chilliness and cold extremities, succeeded by some degree of fever and its usual attendants—restlessness, thirst, want of appetite and praecor- dial oppression. The pulse varies; it is generally full and hard, and indicates an inflammatory and plethoric state of the system, unless the patient be reduced in health and strength by the long continuance of previous organic disease or intemperate habits. Even in slight cases, the digestive organs show much functional suffering; besides want of appetite and thirst, the patient experiences abdominal pains, which are owing, perhaps, in nine cases out of ten, either to some indigestible matter lodged in the stomach and bowels, or to their flatulent distension, but which are too often attributed to cramp and spasm, and opiates or stimulants are exhibited, lu many cases, burn- ing pain, or merely a sensation of heat is experienced in the epigas- tric region, where pressure cannot be well borne, accompanied by sour eructations, or vomiting of a very acid and acrid matter, which produces a sense of heat and rawness in the oesophagus. This matter sometimes looks as if mixed with bile, of a green colour; at others, it is limpid and colourless. The tongue is furred, red round the edges, or it is clean, but of a fiery red colour, with the papillee much raised; but a furred tongue is the most common appearance, being either white, or having a yellowish tinge. The bowels are some- GOUT. 821 times affected with looseness, but far more frequently they are torpid, and the evacuations are fetid, and look very vitiated and unnatural, being frequently mixed with mucus, which sometimes appears in shreds. The urine is scanty, high-coloured, producing irritation in the bladder and heat in the urethra, with their attendants, frequent desire to make water, and some degree of difficulty in doin<* so. On standing, a pink or brick-dust sediment takes place in every case during the inflammatory stage. The urine is often mixed with mucus, and is represented to be of greater specific gravity than when in a healthy condition. As the inflammatory symptoms sub- side, the urine loses its high colour, and by degrees ceases to deposit a lateritious sediment; but in its place there is a whitish deposit, as if it were mixed with a small quantity of chalk or magnesia. Dr. Scudamore thinks that the brick-dust sediment depends on the func- tions of the liver; and there can be no doubt that it has a share in the cause, but it is quite as likely to depend upon functional derange- ment of other organs, particularly of the stomach. The nervous system shows marked evidence of derangement, as is evinced by irritability of temper, general sensibility and restlessness, the intensity of the pain, the darting cramps extending along the course of the nerves, even throwing the muscles occasionally into violent spasmodic contractions, as well as by the sudden and instan- taneous translation of the inflammation from one limb to another. In the course of two or three days, the symptoms are found to have undergone considerable mitigation. The patient then com- plains of weakness in the limb, with perhaps slight tenderness of the part. It rarely happens, when gout may be said to be in its infancy, that the inflammation, as it declines in one foot, appears in the other, or in any other joint, which circumstance is so frequently observed in the old-standing cases. The oedematous state of the part continues for some days after the subsidence of the inflammation; and occasionally, desquamation of the cuticle takes place, with much temporary itching. In one hundred and seven cases of the first attack of gout, Dr. Scudamore has given the following comparative statement, showing the parts most liable to be affected: In 70 cases, the inflammation was in one foot only. In 8, the great toe of each foot. In 2, the toe and instep. In 2, the outer side of one foot. In 1, the heel of each foot, the hand, and elbow. In 3, one ankle. In 1, each ankle. In 1, the ankle of one foot, and toe of the other. In 3, the ankle and instep of one foot. In 1, the toe, instep, and ankle of one foot. In 2, instep of one foot. In 1, instep of each foot. In 1 one instep first, afterwards each knee, wrist, elbow and shoulder. In 1, heel of one foot. 69 822 GOUT. In 1, heel of each foot. In 1, each foot and hand. In 1, right thumb, and afterwards in the toe. In 1, right knee. In 2, left knee. In 1, hand and wrist. In 1, back of one hand. In 1, back of each hand. In 2, one wrist. In the early fits of gout, the health improves soon after the local symptoms decline, and 1 have heard many people declare they felt themselves better and more vigorous than they had done for weeks and even months before. The gout may return annually, perhaps, at shorter intervals; on many occasions, however, there is no threatening of a paroxysm for several years; but as the disease goes on, the attacks are generally more severe, the fits longer and the intervals shorter, the parts af- fected more numerous, till at last the constitution becomes broken down. Dr. Scudamore has justly observed, that the frequency of a return of gout is in proportion to the constitutional tendency, and to the unfavourable mode of life of the individual. In subsequent attacks, the constitutional and local symptoms are similar in character to those already described, but are more marked in point of severity, of longer duration, and the constitutional nature of the disease becomes more and more manifest. The precursory symptoms are also rendered more apparent by becoming more severe with each returning fit. But we are assured by Dr. Scudamore, that even confirmed gouty subjects are sometimes attacked at the very moment when they most congratulate themselves on the possession of health and strength; and he has seen some fits thus sudden and unexpected, in the sequel very tedious and severe. There is no disease, except, perhaps, rheumatism, in which such a complete appearance of metastasis or translation of the inflammation takes place as in gout; the disease having been frequently observed to originate in the toe of one foot, at the very time it disappeared in the other. There can be no doubt of the fact, although, in many cases, I have been able to satisfy myself, that the inflammation in both feet had previously co-existed; but when it became more painful, and a greater annoyance in one foot, the attention was attracted from the other. In the same manner, a metastasis sometimes appears to take place from the great toe, or from any other joint, to an internal or- gan ; but this, I am also persuaded, is often a deception, and can be explained in a similar manner. Phenomena of Chronic Gout. When the constitution is considerably injured by long-continued indulgence in luxury and bodily inactivity, or is worn down by re- peated attacks of acute gout, the disease assumes a less violent, but still more dangerous form, which Dr. Scudamore has called "chronic," GOUT. 823 aTo^ic^m" "atonic'"-and Dr' Mason Good, "disguised, lurking, This form of the disease is generally a consequence of previous acute attacks. The local inflammation, pain and redness are com- paratively slight; there are more permanent distension, cedema and helplessness of the affected limb than in the acute form; but the con- ditions of the digestive organs, of the circulating and nervous sys- tems, are more embarrassed and oppressed. The disease is more bearable in this than in the acute form, because the patient does not suffer that extreme agony occasioned by intense local inflammation; but there is, nevertheless, more danger, from the importance of the parts whose functions are very seriously impeded, which sooner or later terminates in structural lesion; and it is invariably observed that the paroxysms are more frequent and irregular. According to Dr. Scudamore—" The state of the constitution in chronic gout embraces a great variety of symptoms, which are mo- dified by the temperament and habits of the patient; by the situation and degree of local disease; and also by the seat and nature of the internal visceral derangement. Indeed, so many anomalies so often arise in this impaired state of the health, partly depending on internal causes, and partly on the painful or uneasy state of the affected tex- tures, that probably no description would be adequate to include all these shades of sympathy; and it may be sufficient to delineate a general outline."—(P. 327.) Some patients are severely distressed with dyspeptic symptoms, such as uneasy sensations in the stomach and bowels, nausea, a crav- ing desire for food, oppression and flatulent distension after every ordinary meal, which are much increased if the stomach be incau- tiously loaded. Some experience cramps, others heartburn, and some a peculiar coldness in the stomach, which they compare to that which would be produced if it contained ice. The cramps are owing, I am persuaded, in a great majority of cases, to efforts made by the stomach and bowels to expel crude and indigestible matters ; as well as to distension from flatus, and are not commonly, at least, of that mysterious nervous character which is generally imagined. Although the patient's appetite seems natural, yet he is not nourished by his diet; he neither experiences increased strength nor vigour, but on the contrary, suffers additional constitutional and local irritation, and even feverish action. His mind becomes weak and irritable, often hypochondriacal; he is haunted by imaginary evils during the day, and by disturbed, or even frightful dreams at night; and the sleep is, in general, broken and unrefreshing. Palpitations are common, not only in the region of the heart, but in the course of the abdominal aorta, even when the heart's action is quite tranquil and natural. The body becomes more susceptible to the impressions of atmospher- ical vicissitudes; the limbs become emaciated and weak when the abdomen is, perhaps, growing larger; the bowels are sometimes cos- tive, sometimes loose; the stools always possess an unnatural fetor, sometimes having a white appearance, showing a diminution of biliary secretion ; at other times they are dark-coloured, and very fre- quently mixed with mucus. I have even seen the mucus tinged with 824 GOUT. blood, and attended by all the usual symptoms of dysentery. There is considerable irritation about the rectum, no doubt often produced by the enlarged and painful condition of the haemorrhoidal veins, which occasionally discharge blood, sometimes in considerable quan- tity; and many gouty people are so much relieved by periodical haemorrhage, not only from the anus, but from the nose, that they consider it necessary to health; and I have known several cases in which apoplexy took place, when the natural haemorrhage ceased to recur. The urine has much the same appearances as in the acute form of the disease. A chronic cough and expectoration are fre- quently met with, and depend upon the state of the bronchial mem- brane. The calcareous depositions which are so frequently found about the smaller joints, and which go under the name of "chalk stones," are more frequently formed in this species of gout than the acute. The humoural pathologists believed them to consist of indigested gouty matter thrown upon the joints, and changed into their peculiar state of hardness by the heat and pain of the joint, but they are now known to be a compound of uric acid and soda. "These gouty con- cretions, (says Dr. Scudamore,) occurred only in a few individuals of particular gouty idiosyncrasy, and are found in various situations from within the synovial membrane of the joint even to the layers of the cutis. I have found them in the living subject, filling the bursae, and condensed to great hardness; in the sheaths of tendons, feeling almost stony; in the cellular membrane, either in hard or soft lumps; and under the cuticle, pressing for escape. In one gouty person who comes under my frequent observation, the concretions near the surface have caused numerous ulcerations both in the hands and feet, and the chalk-like matter is constantly secreted." Phenomena of Relrocedent Gout. It sometimes happens, that, during a fit of gout, the external in- flammation suddenly disappears, or, at least, becomes very much mitigated, while the patient is affected with lethargy, stupor, coma, apoplexy; or with severe pain in the head, and other symptoms in- dicating inflammation or some other cerebral affection. At other times, on the recession of the gout, difficulty of breathing, With tightness in the chest, great oppression at the praecordia, and a sense of suffocation, followed by cough and expectoration, take place; or violent palpitation, pain and constriction in the region of the heart, accompanied by oppressed breathing, cough, &c, indicating disease of some part or parts of the viscera of the thorax. In another set of cases, the translation takes place towards the abdomen with symptoms of gastritis, hepatitis, enteritis, peritonitis or dysentery; and, in some cases, the urinary organs are involved. Dr. Scudamore thinks " the transference is most disposed to affect the.stomach or intestines, or both in succession. The symptoms which attack the stomach are exquisite pain and spasm, with vomit- ing. If the intestines be more distinctly affected, enteritis, in its worst forms, is produced; and vomiting, which is a usual attendant, GOUT. 825 is more or less urgent, according as the seat of disease is near or dis- tant from the stomach. In either case, the danger is pressing; and unless relief be speedily rendered, death soon closes the scene." Dr. Cullen (Par. 532) observes, that " the stomach, which has so universal a consent with the rest of the system, is the internal part that is the most frequently, and often very considerably, affected by the gout. The paroxysms of the disease are commonly preceded by an affection of the stomach; many of the exciting causes act first upon the stomach; and the symptoms of the atonic and retrocedent gout are most commonly and chiefly affections of the same organ." Dr. Mason Good (vol. 2, p. 630, 2d ed.) makes the following ob- servations: " It sometimes happens, however, that while the general constitution of a podagric patient is tolerably sound, one or more of the internal organs form an exception to the general rule, and are less healthy than the rest. And as, upon an excitement of gouty inflam- mation in a gouty habit, the inflammation seizes ordinarily upon the weakest part of the body, it makes its assault upon such organ rather than upon the hands and feet; or, if it commence in the latter, is readily transferred to it; constituting the third of the varieties before us, and which has usually been called retrograde or misplaced gout. And if the general system should, at the same time, be below the ordinary tone of health, when the paroxysm is thus excited by the force of some occasional cause, the organ affected may evince great languor and painful inertness, as in the second variety, rather than acute inflammation, as in the first. The sensation in the sto- mach, instead of being that of a fiery coal, is that of a cold lump of lead ; in the head it changes from maddening pain to oppresive horror, in which the patient suddenly starts from sleep almost as soon as he has begun to doze from the hideousness of the ideas that rush across the mind, and from the distracting dream. "The fit is sometimes transferred to the bladder, in which case there are acute pain at the neck of the organ, strangury, and a dis- charge of thin acrid mucus from the urethra. The rectum has also occasionally been the seat of metastasis, and has evinced various species of affection, as simple vehement pain, spastic constriction ; or haemorrhoidal tumours. When thrown upon the lungs, it mimics the symptoms of a peripneumony." There is a great deal of good sense and sound observation displayed in the above passages, but it is mixed up with some absurdly mysteri- ous expressions, which may throw young practitioners off their guard, and therefore must be noftced. When Dr. Mason Good speaks of the second variety of retrograde gout, in which the organ affected is represented to be " below the ordinary tone of health, evincing great languor and painful inertness, instead of more violent symp- toms as in the first variety," one accustomed to see much of disease, and to open the bodies of those who have fallen victims to it, would be led to imagine the author was not aware that inflammation may exist in various degrees of intensity; and that, modified by some peculiar but unknown causes, inflammation of similar intensity and extent will give rise in one subject to violent symptoms, while in another they have such an opposite character, that although the 69* 826 GOUT. patient is observed to labour under some degree of suffering, yet the symptoms are not so striking as to attract the same degree of atten- tion. These passages would lead one to imagine that the author of this learned and laborious work was not aware that inflammation of different tissues gives rise to a different cast of symptoms as to vio- lence, which is particularly exemplified in the serous and rrfucous membranes, which last are so very frequently involved in gout. I must enter a strong protest against the expression used when speak- ing of retrocedent gout, viz.: "When thrown upon the lungs, it mimics the symptoms of a peripneumony." Dr. Scudamore states "that Dr. Home, of Edinburgh, in his lectures, relates the case of a gentleman who exposed himself to the influence of wet and cold when the gout was slightly present in the feet: and, on the same afternoon, enteritis followed, which in twelve hours proved fatal. He also states that Dr. Parry informed him, " that in the same winter he has seen two instances of extravasation in the brain, from the removing of gout in the extremities, by immersing the feet affected in cold water." Unless from similar rash practice, or from imprudence on the part of the patient, I conceive that such sudden translations of the inflam- mation, or, what is the same thing, sudden alterations in the balance of the circulation, during the paroxysm of gout, are among the rarest occurrences to be met with in practice, unless, indeed, there have been previous disease in the organ to which the translation takes place. A person of gouty habit may be seized, after exposure to cold and damp, vvith slight inflammation of the brain, lungs, or of any other organ, when his bowels are constipated and his system plethoric; gouty inflammation of a joint may supervene, and mitigate for a time the internal disorder, the attention of the patient and of the physician being then exclusively attracted to the external inflammation ; and subsequently, upon the subsidence of the inflammation in the joint, or from mismanagement, such as plunging the foot into cold water, the internal disease may reappear, perhaps with increased violence, or, what is all the same, when the patient is weaker, and not so well able to stand the remedies as he would have been a few days pre- viously. Or it happens that an individual may be affected with a permanent organic disease of the heart or lungs, and may be at times seized vvith gout, when lie will be every moment in danger of the inflammation receding from the joint. I once casually met with a gentleman, in many respects a hypochondriac, and who was so con- sidered, at least according to his own account, by his medical attend- ant. He had a very foul tongue and acidity of stomach, which he said had been his constant companion for years; he also added that he had a tightness about his chest, .which was certainly increasing; and that he never had a good night's rest, in consequence of frightful dreams. I satisfied myself from the state of the pulse, and that of the heart's action, that he had an enlargement complicated with dila- tation of that organ. In the course of a few months afterwards, he was seized with gout, and died during the attack from retrocession; his death was attributed by his medical friends to "spasm of the lungs;" whereas, all the symptoms immediately preceding death GOUT. 8^ • appeared to accord with the opinion which I had formed to myself. I anxiously looked forward to the examination of the body of this patient, and took an opportunity of urging its propriety, but received the following reply—" What would be'the use of opening a man who died of gout ?" In the year 1830, I attended a gentleman who, after an illness which I knew to proceed from extensive disease of the heart, with which he had been slightly affected for several years, was seized with gout in the lower extremities. The external inflammation was very unsteady in its seat, sometimes affecting one joint, sometimes another; but whenever there was little external inflammation, he became instantly affected with difficulty of breathing, occasioned by bronchitic inflammation or violent palpitations, with constriction and sense of suffocation. Twice the translation took place to the brain; on one occasion he became frantic, talked loud and abused those about him; and on another, he exhibited a strong tendency to coma. At these times relief was produced by the application of leeches, but principally by causing external irritation. At last, after spending a quiet night, with much refreshing sleep, taking nourishment at proper intervals, and when every thing appeared to be going on well, he became affected with difficulty of breathing, and died in a moment. Immediately previous to the fatal event, he expressed his own satis- faction at the relief he had experienced and the prospect of a speedy recovery. I made every effort to obtain an examination of the body, but failed, in consequence of a promise he had extorted from his wife; but there could be no doubt that there was hypertrophy with dilatation of the heart, disease of the valves, and that there had been bronchitic inflammation. Causes of Gout and Pathological Observations. Dr. Scudamore has written a considerable number of pages on the causes of gout, to which I beg to refer my readers for a great deal of very valuable information, as it would be inconsistent with the plan of this work to enter so much at large into the subject as he has done in his treatise. The first question that naturally suggests itself is—Whether or not the disease is . hereditary? According to Dr. Cullen, it is expressly defined to be—"Morbus her edit ar ius, oriens sine causa externa evidente" &c. Guided by nature instead of books, I have observed that gout is more an acquired than a hereditary disease. Dr. Scuda- more instituted an investigation to ascertain the fact, and of one hun- dred and thirteen patients, the number of those in whom the disease was hereditary from the father, amounted to - - - 32 __________.__________mother, - 9 ____________________father and mother, 3 Of those whose grandfather only had gout, the disease completely hopping over one generation, - - - 6 ■_________._______grandmother only, 1 _________.____-------uncle only, - 3 ____________________aunt only, - - - - 1 Gout not known either on the father's or mother's side, - 58 828 GOUT. From this statement, it appears that the cases of acquired gout, in which no family reference could be traced, were to the rest as fifty- eight to fifty-five; and in the examples contrasted with those imme- diately hereditary, as fifty-eight to forty-four. My own experience corroborates the above statements, but it is generally viewed as a hereditary disease; and this has arisen, I imagine, from the habit which too often obtains among medical men, of drawing general conclusions from one or two facts, such as the following. A gentle- man in affluent circumstances, very fond of the pleasures of the table, and taking little exercise, will generally be found to be afflicted with the gout; and because his son, living exactly under the same cir- cumstances, perhaps enjoying greater indulgences, and being fully more indolent, also has the gout, it is marked down immediately as a strong proof of the hereditary nature of the disease. But if the case were somewhat altered, if the father, however gouty he might be, were to experience a reverse of fortune, and his son were ob- liged to break stones on the road, or to earn his bread by any other kind of severe labour, then there would be about a hundred chances to one, that, to whatever diseases he might be heir, he should never have the gout. Gout is notoriously a disease of the rich, or rather, I should have said, of the affluent and indolent, who induce a constitutional ple- thora by living in a too luxurious manner, pampering the appetite, and overloading the stomach with different articles of food at each meal—who do not take sufficient bodily exercise, or attend to the state of their bowels—and who stimulate their systems in every pos- sible way, till at length their bodies may be said to resemble a house filled with highly combustible materials, which requires but the ad- dition of a small spark to set it in flames. Dr. Scudamore observes that, in Scotland, gout is much more rare than in England, and that in Edinburgh, where the habits of the people approach the nearest to those of London, it is seen most frequently; while in Glasgow the gout is very rare, even among the highest classes, which he ascribes partly to the greater activity of the people and the better regulation of general habits; but he gives a sly hint, that the exemption may be owing also to the use of Glasgow punch, which is a more general beverage at the best tables than wine !! The truth undoubtedly is, that gout is comparatively rare among the middling ranks in Scot- land, and that it is not nearly so frequent among the rich as in the same class of society in England; and one cannot help feeling proud at being connected with a country whose population, from the high- est to the lowest, are bent upon giving their children a better educa- tion than they themselves have received. Many a man in a humble walk of life is delighted with the thought that one of his sons may possibly some day fill a pulpit, or be physician to some great em- bassy, or raise himself, by integrity and assiduity, to be a first-rate London merchant, or be sent to India, and become a rich nabob. These are far greater sources of delight to the humble Scotsman, than pampering his own appetites. It is thus he raises the moral and intellectual character of his country, and prevents himself from being teased and tortured by many a bodily infirmity.—A word re- GOUT. 829 specting the Glasgow people and the Glasgow punch. I know that nith ls wTl mad,G b7 Df- Sc"damore is generally believed, but the truth is we do not often meet with gout in Edinburgh in any class of society; and however unfrequent it maybe in Glas-ow I am quite sure the habits of all classes of society in Edinburgh will at least stand a comparison vvith those of the inhabitants of that flour- ishing city. The gout attacks males much more frequently than females • but some of the most severe and tedious cases of sout I ever attended happened in females; and during the course of the summer of 1830 a female had a severe attack, which was protracted for three months' She was very little benefited by any mode of treatment, till the parts affected were literally covered several times with leeches, after which she speedily recovered. With respect to age, it has been remarked from the time of Hip- pocrates downwards, that it is a disease which, if it ever do occur is rare before the age"of puberty. I have known one case in a boy' the son of a scientific friend, who, no doubt, had'an attack of gout at an early age. As a general statement, the correctness of the fol- lowing paragraph from Dr. Scudamore may be depended on :—" I have not myself witnessed more than one example of a first attack before twenty, nor any after sixty-five." I have seen the gout attack individuals of every kind of tem- perament, complexion and disposition; and, with respect to severe study, I am sure this is much overrated by writers as a cause of gout. " This cause, (says Dr. Scudamore,) comprising not only want of exercise, lateness and irregularity in the hours of rest and sleep, but also its consequences, weakness of the stomach, and inactive bowels, by its effects on the nervous system from the over-action of the brain, produces that form of irritative debility which increases the susceptibility of the frame to disease, and consequently to gout, if such be the predisposition of the individual." I admit that people of studious habits, who eat and drink a great deal more than the wear and tear of the body require, will be liable to gout; but I do not consider it in any way connected with the over-action of the brain, which is certainly more conducive to health and longevity than indolence of mind, all other circumstances being the same. For example, I know one gentleman most intimately, with a strong here- ditary title to the disease, who, for many years, has had his mind intensely engaged in scientific pursuits. During that period, he has scarcely ever enjoyed more than five hours sleep in the twenty-four —and has often been two or three days and nights without being in bed, sometimes, indeed, four or five—his constant habit is to sit over the " midnight lamp" till two, three or four o'clock every morning; and yet, were he going to insure his life, he could obtain a policy at half the premium he could have done twenty years ago, vvith all the difference of age. He has preserved himself by rarely drinking any thing stronger than good table-beer; avoiding loading his stomach; and regulating the quantity of solid food to the exercise which he has enjoyed, the state of his bowels, and the degree of mental effort which he knows he must make after dinner. It may be mentioned 830 GOUT. as a hint to others, that when he has to apply his mind most assi- duously, he prepares himself for the exertion, not by taking a very hearty meal and a more liberal allowance of wine, but by eating less than usual and taking no stimulant whatever, although he can, when necessary, enjoy his friend with a good dinner and a bottle of wine, as well as any other person. All excesses in eating and drinking are bad for the animal system, and render it liable to disease; but overloading the stomach vvith different kinds of food at every meal, is, I am persuaded, far more frequently the cause of gout than over-drinking. Nevertheless, every habit which tends to produce plethora, combined vvith irrita- tion of the stomach and bowels, may be considered as a cause of gout. There are some kinds of wines which, taken even in a mode- rate quantity, gouty subjects always feel—these are, more particu- larly, champagne, and claret. Upon the whole, then, I look to a diseased state of the mucous membrane of the stomach and bowels, as produced by all the above causes, either singly or combined, in addition to a plethoric state of the system, as being the cause of a gouty paroxysm. I believe that the seat of the gouty inflammation is in the nervous filaments of the part affected: but various opinions have prevailed upon this last point. Boerhaave considered a morbid texture of the nerves and capillaries to be the disease. The humoural pathologists supposed that it depended upon an acrimonious state of the fluids which are separated, and thrown off by a process of nature; and they con- sidered the inflammation in the extremity to be a sign of a revulsion of the humours, and therefore regarded it as a mark of health. Dr. Cullen was of opinion that, "in some persons, there is a certain vigorous and plethoric state of the system which, at a certain period of life, is liable to a loss of tone in the extremities. This is, in some measure, communicated to the whole system, but appears more espe- cially in the stomach. When this loss of tone occurs while the energy of the brain still retains its vigour, the vis medicalrix nature is excited to restore the tone of the parts; and accomplishes it by ex- citing an inflammatory affection in some part of the extremities." (Par. 533.) Thus it will be perceived that here, as well as in fever, he makes strength to depend upon weakness, and weakness upon vigour and plethora of the system. According to the views which I have taken of gout, it should be regarded simply as an inflammation of the affected part, produced by an effort of the constitution to remove disease from internal parts to the surface of the body. Therefore, the inflammation of the toe is not to be regarded as a disease, but only as the occasional symp- tom of a disease, which may be one either of function or of struc- ture. This is proved by taking a retrospective view of the causes of gout, and the marks of constitutional disturbance which always precede the inflammation of the part—by the production of a great increase of internal suffering, sometimes even death, from the sudden recession of the external inflammation—and by the universal belief of those who have either seen the disease or experienced its suffer- GOUT. 831 ings, that a gouty paroxysm clears the system of something which had been acting injuriously upon it for some time. The body may be in a very high state of predisposition to take on gouty action, but it requires some additional accidental circum- stances to bring it into operation; this is what is called an exciting cause, of which there are many; but the following are the most fre- quent. Exposure to cold and wet, particularly when the body is in a state of fatigue; long-continued coldness of the extremities; con- stipation; indigestible matter taken into the stomach; a cold drink when the body is heated; a particular act of intemperance, more especially, indulgence in the use of certain kinds of wines; excessive evacuations; suppression of periodical discharges; the influence of the passions, a strain, or pressure from a tight boot or shoe, &c. Treatment of gout.—In the treatment of gout, it is to be feared that much mischief is frequently done by large and repeated bleed- ings under the idea that this disease depends upon an internal affec- tion of an inflammatory nature. Injurious consequences have also followed from the opposite course of never bleeding; the practitioners treating the symptoms as the disease, which they supposed to possess some peculiar and mysterious character, rendering all interference hurtful, even dangerous, and therefore dooming the patient to Dr. Cullen's remedy of patience and flannel. Many highly respectable men still entertain this opinion ; and it becomes an important inquiry to ascertain how this should have come to pass. Many people are still guilty of pinning their faith to the sleeve of Cullen, never once calling their own good sense into action. Heroic remedies, if not loudly called for by threatening symptoms, undoubtedly do mischief, by interfering with the salutary operations of nature. Many prac- titioners, I am sorry to say, treat every disease which comes before them according to its name and not according to sound pathological principles, including the consideration of age, constitution, habits and duration of the disease. Some patients are therefore bled who do not require it, and the consequences are injurious; others are bled who cannot bear it, and who ought to be treated by cordials, and the result is fatal; many patients are over-purged with drastic medi- cines, to the aggravation of the disease, while others are bunged up with opium. Some patients are highly nourished and over-stimu- lated, because the doctor thinks gout a disease of debility, which, in all cases, requires nourishment; and as the heart is unable " to pump the blood to the brain, which may produce fatal syncope," the strongest stimulants are necessary to effect that end. Such prac- titioners never alter their practice; they have one steady method of treatment for all cases. There are also reasons why the public in general entertain a dread of interfering with the course of a gouty paroxysm. It may be a prejudice handed down from father to son, and the notion very probably owes its existence to statements made to that effect in medical writings. But the principal reason appears to be that many people ruin their constitutions, and some even die suddenly, from being in the habit of going on indulging their appe- tites because they know they can relieve themselves very speedily during a paroxysm, by the use of colchicum or the eau medicinale. 832 GOUT. There is a very satisfactory method of explaining why gout should be imagined, by people unacquainted with medicine, to be ultimately conducive to health, and to rid the constitution of something noxious. Observing people perceive, that some constitutional ailments, such as indigestion and its attendants, always precede a gouty paroxysm; and that after the fit subsides, these no longer exist. Now this is no doubt correct, that the external inflammation has the effect of relieving the internal disease. But there is another circumstance which is not observed, or which is lost sight of, and that is, that per- sons who have suffered the agony attending a paroxysm of gout, subsequently, for a considerable time at least, avoid all causes which they know will expose them to the return of such a torturing visitor; they also attend to their bowels, and take more exercise. I know many, even highly predisposed persons, who have thus warded off the disease for years. Regarding the disease according to the views I have endeavoured to point out, the treatment is generally quite simple. In a first paroxysm of gout, and in all slight cases, little consti- tutional treatment is necessary further than keeping the bowels gently open by any mild laxative exhibited every six or eight hours, and restricting the diet to very small quantities of farinaceous food, or merely allowing thin gruel or arrow-root; and the best ordinary drinks are whey, barley-water, or toast-water. The patients are to be kept cool and quiet, and if the pain and inflammation of the affected part be slight, a tepid, evaporating lotion, composed of three or four ounces of tincture of camphor to a pound of water, is to be applied to the part, by means of linen several times folded and kept constantly welted. This does not differ from the lotion recommended by Dr. Scudamore, which consists of one part of alcohol to three parts of the mistura camphorae, and which he says he has used vvith great satisfaction to himself, and with the best success, and he recom- mends its temperature to be from 75° to 85°. In more severe cases, however, venesection may be required, but should never be adopted upon slight grounds, even if the patient be plethoric. The circumstances which serve to render general bleed- ing necessary, are, symptoms threatening an apoplectic attack, or showing the existence of inflammation in some internal organ; and, as Dr. Scudamore justly remarks, " in the circumstances in which bleeding is a proper remedy, its early employment is a point of much importance. When delayed, it will be found that the depres- sion of strength resulting from the excessive irritation of the nervous system counteracts its advantages in a great degree." The pulse, in some measure, affords a guide; if it be full and hard, accompanied with a hot skin, thirst, and scanty high-coloured urine, general bleed- ing can rarely do harm, and is absolutely necessary if inflammation of any internal organ exist. The quantity of blood which ought to be abstracted is regulated by circumstances that have been already fully considered when treating of many other diseases ; but so cau- tious should we be about opening a vein, that I would strongly recommend, in the first instance, the application of a considerable number of leeches to the affected part, particularly if much local GOUT. 833 inflammation exist. This practice is recommended because it seems to be following the course pointed out by nature. In determining the number of leeches that may be necessary, it is much safer to err by applying two or three too many, than too few, because, if a suf- ficient quantity of blood be not drawn, the advantages from the depletion are counterbalanced by the additional irritation from the bites. But we must always keep in view, in the treatment of gout, that the disease is produced by constitutional causes, and is not to be altogether relieved by local means. The practice of leeching the part affected is noticed by Cullen, and has, in some measure, received his sanction, although, it would seem, he had not often employed it. In par. 563, he says: "I believe, however, that bleeding by leeches upon the foot and upon the inflamed part, may be practised and repeated with greater safety (than general bleeding;) and I have known instances of its having been practised with safety to mode- rate and shorten paroxysms; but how far it may be carried, we have not had experience to determine." Emetics have been extolled by some, but are only to be adminis- tered if indigestible food is suspected to be lodged in the stomach, and when there is distressing irritation from slight nausea, and'hot acid eructations. Mercurial preparations are to be occasionally given in conjunction with laxative medicines, particularly if the stools show either a de- ficiency of bile, or are dark-coloured and fetid. It is immaterial whether we use calomel or the blue pill; sometimes, indeed, when the liver seems implicated, a slight mercurial course is necessary. In cases where there is a burning heat at the pit of the stomach or other signs indicating inflammation, or even a high degree of irrita- tion of the mucous membrane of the stomach and bowels, a sufficient number of leeches must be applied, or cupping had recourse to, followed by rubefacients or blisters. I have often seen considera- ble benefit in cases which indicated, not only the existence of ab- dominal, but also of thoracic disease, by producing two or three successive crops of eruptions, by means of the tartar-emetic oint- ment. Opiates are highly serviceable in allaying pain and producing sleep, and have been in greater favour with practitioners than any other class of remedies; but they are inadmissible before the bowels have been sufficiently relieved—when the patient is threatened with apo- plexy, or any other cerebral affection—and, indeed, when there is local inflammation of any internal organ, unless they be conjoined with the remedies necessary for its cure. When opium disagrees, hyoscyamus may be substituted. Many years have not elapsed since the eau medicinale was in high repute, but it has now shared the fate of the Portland powder and of all other pretended specifics for gout. The colchicum autumnale has been highly recommended during paroxysms of gout, and has been used with the best effects, not only in alleviating the immediate sufferings of the patient, but in breaking the severity of the disease; but it has no claim to the title of a spe- cific There is considerable difference of opinion among practical 70 834 GOUT. men as to which preparation of colchicum is the most efficacious. Some recommend the powder of the bulb; others that of the seed; many prefer the wine of the seed ; while others extol the acetic preparation. I have used all the preparations, but find a saturated infusion of the seeds in wine to answer better than any other. It is to be exhibited, according to the age and constitution, in doses from twenty to a hun- dred and twenty drops, conjoined either with the same quantity of tincture of hyoscyamus, or with a half, or even a third part of the sedative solution of opium, which will be found to answer better than laudanum. In some cases, when the stomach is exceedingly irritable and when the colchicum cannot be retained, leeches may be applied, or a blister over the epigastric region, and a pill with two, three or four grains of calomel and two of opium, may be exhibited. In treating a case of the gout with colchicum, it is by no means to be trusted to alone, as if it were a specific ; it is necessary to attend to the state of the bowels, and allay local inflammation in the same manner as if colchicum were not employed. Alkalies are very serviceable when there is acidity in the stomach, or when there is much irritation in the urinary organs, particularly when the urine is high-coloured, and deposits a red, sandy sediment. If it be necessary, at the same time, to give any laxative medicine, we may use Henry's calcined magnesia, in which are conjoined antacid as well as aperient properties. During paroxysms of those forms of gout which have been termed "atonic" and " retrocedent," we must treat each case according, not only to the organ affected, but to the nature or kind of the affection. We must be careful not to confound mere functional disorder with inflammation, an error which young practitioners are very liable to commit, but which is not attended with fatal consequences nearly so often as mistaking inflammation for the other class of affections. In cases where pain and inflammation are shifting about from place to place, it is a good plan to leech such parts, as well as to pro- duce contra-irritation on the chest if respiration be at all affected or the patient troubled with palpitations: and on the epigastric region, if there be evidence of much gastro-intestinal irritation. Should inflammation attack any organ, it must be treated upon general prin- ciples, always, if possible, making use of leeches or applying cupping- glasses instead of venesection, unless the patient be young and ple- thoric, or there be signs of local congestions or unusual determinations of blood to any particular organ. Management of Gouty Subjects during the Intervals. As soon as a gouty paroxysm begins to subside, it is our duty to make the patient aware of the usual progress of gout in undermining the constitution, in order that he may the more readily submit to directions which he is to receive for his future management. It ought to be impressed upon him that medicines can be of little comparative service, unless he live abstemiously and alter many of his habits. Perhaps the point of most importance is a proper regulation of the diet, so as to make it correspond to the degree of his daily exercise. GOUT. 835 I am aware how impossible it is to prescribe a proper diet for each individual, until we come to know his peculiarities of constitution and previous habits, but there are certain general directions which it is advisable to give in all eases, in the first instance, at least, which can be modified and changed afterwards according to circumstances. At breakfast the patient may be allowed one large breakfast-cup of milk, tea, coffee or chocolate, according to his taste, with an egg and bread and butter. Meat and fish should be interdicted at this meal, which should be taken at eight o'clock in the morning, to ensure his rising early; as well as for the purpose of regulating the hours for the other meals. From that time he should take nothing till dinner, which should be about two o'clock; when he may be allowed" a moderate quantity of animal food, not exceeding from a quarter to half a pound, cooked in a plain way, perhaps on a gridiron is the best, with as much stale bread as he chooses, and a small quan- tity of any of the ordinary vegetables that agree with him; but he must dine upon one dish, particularly for some time after a paroxysm. At any subsequent period, should he wish to partake of two articles at one meal, the quantity of each must be regulated in such a man- ner that the stomach is never over-distended. Should he take fish, it must be eaten without melted butter, a good substitute for which is meat gravy; and the reason why vegetables should be avoided as much as possible, is that they tend to produce acidity and flatulency in the stomach and bowels, when their functions are in a weakened state. For drink, I believe that good^sound table-beer will be found to agree very well with the generality of people, if it be not hard or too weak, and if it be taken in moderate quantity. If beer should disagree, a dessert-spoonful of brandy in a tumbler of water will be found a very good substitute. With respect to wine, the use of it depends entirely upon former habits; were old gourmands deprived altogether of their usual stimulus they would quickly sink; but in younger subjects, when the constitution is as yet unbroken, it will be well to advise the patient to avoid the habitual use of any stimulant whatever. At 7 o'clock in the evening, the patient should have an- other meal, consisting of the same articles as at breakfast; and if he take any thing afterwards, which I do not, however, think necessary, it may be a teacupful of gruel at ten o'clock, on retiring to rest. He should sleep in a large, well-aired room, with sufficient clothing to make him feel comfortable, but not to produce perspiration, the continuance of which tends to occasion constitutional debility, per- haps more than any other circumstance whatever. It should be as- certained, when the patient goes to bed, that his feet are comfortably warm; if not, friction should be used, or he should be supplied with a bottle of hot water; whereas, if they should be too hot, which is sometimes the case, they should be bathed for some minutes in milk- warm water. A gouty person, in particular, should not sleep on a feather bed nor should he indulge in the use of soft pillows, more especially if there be any tendency of blood to the head, when his head and shoulders ought to be considerably elevated. The bowels should form a chief object of attention ; they must not be allowed to be constipated; but the opposite extreme is fully, if not more inju- 836 GOUT. rious. Many individuals are injured by the pernicious habit of taking some strong physic now and then; but it will be invariably observed that the bowels become afterwards more torpid. All lax- ative medicines, which operate violently or produce watery stools, should be avoided. Patients should be furnished with different kinds of pills, of which they should regularly take such a quantity as will produce one, or at most two evacuations daily, or a teaspoonful or two of Henry's calcined magnesia, sometimes by itself, at others joined with six grains of rhubarb and three or four of ginger. During the day care must be taken to preserve the feet in a pro- per degree of warmth ; and the patient should at first be very cau- tious not to use too much exercise, which will not only weaken the body and derange the functions of the stomach, but will injure the limb which has been recently the seat of inflammation. By degrees the exercise maybe increased, but should never be violent or carried to such an extent as to create fatigue. Till his health is completely established he should avoid exposure to night air, and at all times carefully protect his body against the influence of atmospheric vicissi- tudes. At any period that digestion becomes impaired, which will be indicated by a loaded tongue and a sense of fulness and distension after meals, patients should not depend so much on drugs for relief as on the restrictions of diet, but I do not mean to undervalue the effects of medicines. Every practical man must be aware how ad- vantageous are a blue pill or a grain or two of calomel and a small quantity of extract of colbcynth when the tongue is loaded with a white or with a yellowish fur. These, with the addition of from ten to twenty drops of nitric acid in four ounces of infusion of quassia, compound infusion of gentian, or in water along with two grains of the sulphate of quinine, once, twice or thrice a-day, are often bene- ficial. In some constitutions the occasional use of the warm bath will be found serviceable, while in others the cold bath will best agree. There is almost no individual so situated that he cannot ob- tain the advantages frequently found to result from the shower-bath, which may at first be used warm, and afterwards gradually made more and more cold as the strength increases. CHAPTER II. RHEUMATISM. Most authors describe two, others three varieties of rheumatism, viz.: the acute and chronic rheumatism and rheumatic gout, which last is so termed from its resemblance to both diseases. The follow- ing is Dr. Cullen's definition of acute rheumatism:—"A disease produced by an external cause which is, in general, known, attend- ed with pyrexia; pain about the joints, following the tract of the muscles, attacking the knees and larger joints in preference to those of the feet or hands, increased by external heat." Dr. Mason Good has given the following definition: " Pain, in- flammation and fulness, usually about the larger joints and sur- rounding muscles; often wandering; urine depositing a lateritious sediment; fever a cauma" (inflammatory). acute rheumatism. Although the diseases cannot certainly be identified, yet there are many strong points of analogy between gout and rheumatism. Few men can be long in practice without meeting with cases which have some resemblance to gout, and some to acute rheumatism, so much so, that it is a common enough circumstance to hear practical men speak of" rheumatic gout." Some, indeed, maintain that gout and rheumatism are only varieties of the same disease; while others allege that, although they are not exactly the same, yet the one often passes into the other. Acute rheumatism generally attacks young people, or those rather below than above middle age, after long exposure to cold and mois- ture, as sleeping in damp sheets, remaining long in wet clothes, par- ticularly after fatigue, or from changing winter clothing too early in spring, to which people are often tempted by a few successive days of warm weather. Symptoms of acute rheumatism.—After exposure to some of the above-mentioned causes, the patient complains of rigors or chilliness, with a general feeling of numbness, pain or aching: febrile symptoms soon follow, when the skin is pungently hot and the pulse quick, full, hard and bounding, even in weakly subjects, and will be found to beat from 100 to 140, perhaps even higher. As the febrile symp- toms increase, the pain becomes more acute; it is generally an aching 838 RHEUMATISM. or gnawing pain, with numbness and powerlessness, and it some- times even possesses the pungent, hot, lancinating character of gout. The pain is sometimes general, but some one joint is more intensely affected than the rest; and we also see translations of the disease take place, which are so frequently observed in gout. In acute rheumatism, the parts affected usually become red, swollen and tender to the touch, although in some cases it is observed that the redness and swelling are slight in comparison to the degree of pain. The least motion aggravates the pain, as in gout, and it often shoots with great severity, either along the course of the muscles or the nerves and their ramifications. Sometimes local pain exists before the general febrile commotion, although this is rare, unless a patient with chronic rheumatism, from imprudent exposure or other causes, excites the acute form of the disease. The pain and febrile symptoms abate and increase irregu- larly; generally speaking, however, the patient is most tormented at night, which circumstance is observed in almost all other diseases. The muscles often feel hard, rigidly contracted and sore to the touch; the intercostals are occasionally affected in such a manner as to re- semble in every respect an attack of pleurisy, which has been already noticed, when treating of that disease, under the term " Pleurodinia." The muscles of the abdomen are occasionally painful to the touch, without hardness of the part, so as to resemble peritonitis. The muscles of the back are often affected, the complaint being well known by the term " lumbago." Another affection, either of the sciatic nerve or of the muscles which pass from the trunk to the lower extremities, sometimes takes place, which is called " sciatica." These latter affections, however, very frequently occur without fever, unless during the night, and are usually described under the head of chronic rheumatism. In acute rheumatism the tongue is generally loaded, often red, particularly round the edges, and fissured; the appetite is destroyed; the thirst excessive; the urine scanty and high-coloured, depositing a' heavy sediment, as in gout. There are sometimes nausea and vomiting, with considerable internal heat, particularly in the epi- gastric region, with irregular, generally costive bowels and fetid evacuations. At others there are headache, with intolerance of light, and sometimes even inflammation of the eyes, which is well known to attack a particular part, viz. the sclerotic coat. On other occasions, symptoms of cerebral irritation or inflammation take place; and it is well known that dissection has frequently and unequivocally revealed an inflammatory condition of the membranes of the brain. But the pericardium of all parts is the most liable to the occurrence of inflammation during the course of rheumatic affections—a most insidious disease, under any circumstances, but more particularly so when the attention of both patient and practitioner is attracted to the pained joints. The skin is generally dry and hot in acute rheu- matism, but is sometimes bathed in a clammy sweat. In the consideration of all diseases, after becoming acquainted with their phenomena, the most important point is to determine their na- ture and seat. With respect to acute rheumatism, some allege that RHEUMATISM. 839 it is a disease of the sanguiferous, others of the nervous system. My own opinion is, that both systems are deeply implicated, but that the real nature of the disease is inflammatory. All the symptoms prove this position, for even in the weakest subject the pulse is quick and strong; the fever is undoubtedly inflammatory; the affected part generally possesses all the characters of inflammation; and blood, when drawn from a vein, shows an inflammatory crust. It would be interesting if we knew whether the inflammation were situated in the cellular substance, in the muscles, nerves, blood- vessels or lymphatics. That the inflammation is not seated in the cellular substance is rendered probable from its rarely terminating in suppuration, ulceration or gangrene. I cannot pretend to deter- mine the seat of the inflammation; but from the quick translations which take place and the resemblance which rheumatism in many points bears to gout, it is very probable that it involves the nervous filaments more considerably than any other tissue. But I have seen cases which presented symptoms similar to those of rheumatism, in which, after death, the lymphatics of the limb were found inflamed and filled with a puriform fluid. Many French pathologists have come to the conclusion that rheumatism is nothing more than acute inflammation of the lining membrane of the arteries. Treatment of acute rheumatism.—Many Writers insist much upon the importance of a proper diagnosis between gout and rheu- matism ; but practical men know how difficult this is in many cases, how impossible in some, and I might add unprofitable in many, as both diseases must be treated very much upon the same principles, with this exception, that rheumatic subjects bear bleeding better than gouty, and that in them it is generally more beneficial. The following diagnosis has been drawn between the two diseases: Gout. Gout is a disease which rarely attacks the young;.males are more frequently affected than females/ Gout is more connected with some in- ternal disease, more particularly with disorder of the viscera connected with indigestion. Gout generally infests the smaller joints. In gout, the pain is burning, pungent and lancinating. In gout, the external inflammation is a bright, intense red: the swelling takes place rapidly and the part is much more sensible and tender. The young are as liable to this disease, if exposed to its causes, as those more advanced in age, and females as well as males. Rheumatism frequently attacks peo- ple in perfect heahn, and is always to be traced to cold and moisture, although acute inflammation of an internal organ may be produced at the same time with the original disease, or may be subse- quently engrafted on it by translation or otherwise. Rheumatism attacks the larger joints. The pain is generally gnawing and numb, occasionally pungent and lancina- ting. In rheumatism, the inflammation is said to be less intense, and the swelling not so great or, at least, so rapid. It is said also that rheumatism shows more regular exacerbations towards night than gout; and that the pulse is more full, hard and bounding, which characters it often pre- serves for a considerable period after the subsidence of the external inflammation. 840 RHEUMATISM. A great deal of discussion has taken place in the profession re- specting the treatment of rheumatism. One set of practitioners depend entirely upon venesection: another upon purging ; a third upon exciting long-continued profuse perspirations; a fourth upon the exhibition of bark alone ; and a fifth upon a course of mercury to produce salivation. It is no wonder, therefore, under such empiri- cal treatment, that an attack of the disease used formerly to continue violent for such a long period of time. Formerly an attack of acute rheumatism, vvith its sequela?, generally confined the patient for twelve months, that is to say, before he regained his ordinary state of health, and few got off with less than six months' confinement to bed. Of late years, more common sense pervades the profession, and each case is now treated more upon pathological principles. The best remedy we possess for the cure of acute rheumatism, is vene- section, provided the patient be plethoric or have an unbroken con- stitution, and the disease be in its early stages. The general inflam- matory diathesis which prevails, the local inflammation in the parts, the highly inflammatory state of the blood and the knowledge which we have derived from post mortem examinations—all proclaim the propriety of general bleeding, in severe cases, in the circumstances already mentioned. The precise quantity of blood to be taken, can only be determined by watching its effects upon the constitution. We frequently, however, meet with people of nervous, irritable ha- bits of body, and others who have been much injured by dissipation, in whom venesection will, in general, prove injurious ; and I may add that it will often produce bad effects even in the strongest con- stitutions, unless it be followed up by proper after treatment. The good effects of the tartrate of antimony in small but frequently repeated doses, so as to keep up slight nausea without producing vomiting, cannot be praised too highly; but the patient should be lightly covered with bed-clothes, so as not to excite perspiration. I have often employed antimony with great success in cases where general bleeding was inadmissible; but if there be considerable plethora, and a strong, hard, bounding pulse, antimony will have a better effect when veneseciion is premised. Local bleeding by leeches has very good effects, and ought never to be neglected when the inflammation runs high. When leeches are employed, however,a considerable number should be used; and I make it a rule, after the leeching is commenced, to chase the dis- ease, as it were, from joint to joint without intermission, pursuing other means of treatment at the same time. In many cases, decided and immediate advantage will be derived from the employment of colchicum, combined with the sedative solution of opium, or with large doses of the tincture of hyoscyamus, precisely in the same manner as has been recommended in gout. It sometimes succeeds after the failure of antimony ; but in general I like to try the latter before having recourse to the colchicum. It is highly necessary, throughout the whole course of the disease, to keep the bowels moderately open; but violent purging is by no means necessary, and is often injurious. If the tongue should be loaded with a white or yellow crust, two or three grains of calomel, RHEUMATISM. 841 combined with four or six of rhubarb, or four grains of colocynth, may be given at bed-time, and the operation assisted next morning by castor oil or an injection. The old plan of sweating patients for ten or fourteen days, by means of large and repeated doses of Dover's powder, warm di- luents, and a load of bed-clothes, is, I hope, now very generally abandoned, as it is attended with the same injurious effects as too frequently repeated and indiscriminate bleedings. I can say nothing, except in condemnation, of another plan too indiscriminately followed, viz., the calomel and opium treatment. I have often seen the tongues of patients swollen and ulcerated, and profuse salivation produced without the least sign of amendment. The Peruvian bark was formerly highly extolled in acute rheu- matism, and has been used and approved of by many celebrated physicians of the last age. Dr. Haygarth came to the conclusion that "bark does not cure an ague so certainly and so quickly as it does the acute rheumatism." It is impossible to reconcile such a statement with the opinions maintained by others respecting the same medicine. " The Peruvian bark (says Cullen, par. 469) has been supposed a remedy in some cases of this disease; but we have seldom found it useful, and in some cases hurtful." I formerly tried bark in all its forms, and my experience exactly corresponds with that of Dr. Cullen; in fact, I have never seen it useful, except in one case, when it was employed after copious venesection. There can be no doubt, however, that cases may occur in which the sul- phate of quinine will be found beneficial, where the bark in sub- stance would prove injurious, and the infusion, or any other pre- paration, too weak to have any effect whatever; and there is much good sense and discrimination in the following passage from Cullen. Speaking of bark, he says,—" It appears to me to be fit in those cases only in which the phlogistic diathesis is already much abated, and where, at the same time, the exacerbations of the disease are mani- festly periodical, with considerable remissions interposed." With regard to stimulants, such as gin and brandy punch, and a bottle or two of port-wine daily, which are so generally prescribed by some, I shall say nothing. It is to be regretted that the laws appli- cable to medical men in China cannot be had recourse to in this country.* Blisters ought never to be employed in acute rheumatism, at least in the early stages, unless there be evidence of the existence of peri- carditis, or inflammation of some other internal organ. Fomentations are seldom serviceable, and the warm bath is often injurious in acute rheumatism, from the increased pain produced by the motion which it requires. The sulphurous vapour bath, how- ever has been much praised by several individuals, but in looking at a table of M. Gale, 1 find nothing to recommend it. The plan was tried in sixty-five cases, of which twenty-five only were cured, thirty-two were stated to have been much relieved, and eight derived no benefit from the remedy. • * Vide Penal Code of China, by Sir George Thomas Staunton, 1812, page 319. 842 RHEUMATISM. The diet should be antiphologistic during the acute stage, and farinaceous and unstimulating for some time after, until the pulse ceases to be full and bounding. After the patient has been for some time convalescent, when the limbs are stiff, and the joints somewhat rigid, good effects will be occasionally produced by general cold bathing; but the health and strength must be in other respects quite restored, and all the functions natural. Frictions vvith a hair glove are to be used and persevered%in. chronic rheumatism. This form of rheumatism sometimes succeeds the acute disease and may be confined to one part of the body, or may be general. The patient complains of a dull, gnawing pain, increased on motion, with little or no fever or local inflammation. There is frequently swelling about the joints and occasionally contraction, and the muscles are sometimes rigid. The pains are often relieved by the application of heat, but are always aggravated by exposure to cold, damp air, and occasionally also by the application of heat, so that frequently pa- tients pass painful and restless nights. In this form of the disease, the warm water and the vapour bath, together with rubefacients are found more beneficial than in acute rheumatism. The Russian plan of treatment is said to be decidedly superior to any other, which is to expose the patient fo vapour at a very high temperature, in a room where the evaporation of water is produced by dashing it upon stones intensely heated. After this has been persevered in for some time, the patient still remaining in the same apartment, small quantities of cold water are dashed upon the parts affected; the body is afterwards well rubbed. I am told by a gentleman who has undergone the process, that the relief is very decided. If there be any fever, the antimonial treatment will be found beneficial, as well as colchicum; and, in several cases, I have seen permanent advantage produced by the combined effects of the wine of colchicum and tincture of hyoscyamus. It has been already mentioned, that rubefacients are sometimes serviceable, and it may be now stated, that excellent effects have been occasionally observed to follow the application of blisters, but more particularly the contra-irritation produced by antimonial oint- ment and moxas, a remedy in great repute on the continent. Train oil, obtained from the liver of the codfish, is highly extolled by Dr. Percival.and has since been used by other individuals, particu- larly by Dr. Bardsley, who exhibited from one to three tablespoonfuls daily. I have seen it tried, and persevered in for some weeks at a time, without observing any benefit whatever from its use; and I can only wish a few doses were exhibited to those gentlemen who have the patience to prescribe it for others. The arsenical solution and bark have been recommended, when the disease shows any tendency to periodicity. Of late years acupuncturation, which is said to be an eastern RHEUMATISM. 843 remedy for this disease, has been employed in various parts of Eu- rope for the cure of chronic rheumatism, and with most astonishing good effect; the operation is said to produce little or no pain, and no haemorrhage. A single puncture has been found sufficient to remove an ache of some years duration; generally from two to six sharp- pointed needles are used at once, and are pushed, at a little distance from each other, into the affected part to the depth of half an inch, and in fleshy parts, even of an inch; each needle is allowed to remain for about five minutes before it is withdrawn. It is observed that the pain sometimes leaves the part into which the needles have been introduced and flies to another; but we are told to follow it with the instrument. Lumbago and sciatica appear to me to be more decidedly of a nervous nature than any other, and are to be treated in the follow- ing manner:—viz., by gentle laxatives, frictions and rubefacients, and the frequent use of the hip-bath. But what answers fully better, is to pour a small stream of very hot water over the part affected, the patient being placed in a comfortable posture, either sitting on a bidet, or any convenient article to receive the water, which should be heated to 130° or 140°. In fact, it should be so hot that the finger cannot be kept immersed for any time. Acupuncturation may also be necessary in sciatica, which is the most intractable of the two affections, although commonly not so severe. I have seen the best effects produced, even in old-standing cases, by wearing a chamois- leather jacket and drawers in all the forms of chronic rheumatism. It is of the utmost consequence to regulate the diet, as relapses may be frequently traced to indigestible articles of food. It is said that individuals previously liable to attacks of lumbago and sciatica, have escaped further annoyance by wearing a piece of stick-sulphur in their breeches pockets; and it is well known that the internal use of sulphur is a popular remedy for all forms of rheumatic complaints. rheumatic gout. I do not consider it necessary to give a description either of the phenomena of this disease or its treatment, as it is sufficient for all practical purposes to refer to what has been already said respecting gout and rheumatism. CHAPTER III. SCROFULA. Dr. Cullen has given the following definition of scrofula:— "Enlargement of the conglobate glands, especially in the neck; the upper lip and columnar nasi and lower part of the nostrils tumid; the face florid; the skin soft; the abdomen enlarged." Dr. Mason Good, who applies the term " struma" to this class of affections, gives the following definition:—" Indolent, glandular tumours, chiefly in the neck; suppurating slowly and imperfectly and healing with difficulty; upper lip thickened; skin smooth; coun- tenance usually florid." The belief is almost universal that this class of diseases is here- ditary, and that it is confined to an unhappy few, who transmit it from father to son, from one generation to another, far more regu- larly than they transmit their money or virtuous reputation. I must confess my scepticism upon this point, as many instances might be quoted where both parents were strongly marked with all the appear- ances described as scrofulous, nevertheless their children were very healthy. On the other hand, cases are often seen where the parents had no vestige of the complaint, and yet the children were scarcely ever without some of the affections generally denominated scrofu- lous. Many authors, aware of these circumstances, observe that it is true the parties are not born with the disease, but only with a greater aptitude to receive certain morbid impressions, which may bring the latent disposition into action. This is a very plausible salvo, but it is too vague to be received as medical evidence. They also say, that a remarkable circumstance attending scrofula is, that it does occasionally pass over one generation, and appear again in the next, so that " the grandfather and grandson shall be both scrofu- lous, while the intermediate person, who holds the most intimate relation of father and son, and connects the two others, shall be ex- empt from any attack of the disease. My opinion with respect to glandular affections denominated scrofu- lous, is, that they are generally engrafted on the constitution by im- proper food and deficient clothing;—by neglect or bad medical treatment during the period of dentition ; the progress of scarlet fever, measles and other eruptive fevers, as well as during the ordinary eruptions and affections of the throat. And lastly, that they are pro- duced by mismanaging swollen and inflamed glands during their early stages. Hence it is a disease with which some of the members SCROFULA. 845 of almost every family in this climate are at one time or another affected. We see glandular affections in persons of every variety of colour of the hair, eyes and appearance of the skin, and in every variety of constitution. I have, therefore, long ago persuaded my- self that they depend upon gastro-intestinal irritation, which point of pathology has been clearly established with reference to the most scrofulous of all scrofulous diseases, viz., that which is termed " tabes mesenterica." This view is much strengthened by the following circumstances:—Scrofula is a frequent disease among the poor, and those who are fed upon large quantities of weak broth, coarse, ill- baked bread, or hard, indigestible puddings. From these causes the disease is often seen in charitable establishments for children; and I have also seen it traced to English boarding-houses, where the children are crammed with hard pudding before they are allowed even to smell meat, and are told " that the young ladies and gen- tlemen that eat most pudding shall have most meat."—Poor children! Another important fact may be mentioned, that scrofulous affections can be produced in a short space of time in many of the domestic animals, by unwholesome feeding. Thus I have seen them purposely produced in poultry, rabbits and pigs, by such means. A pig is called " measly," when it is affected with a very general disease of the glands throughout the body, which is well known to depend upon the manner in which it has been fed. It has been my belief, for many years, that many of the affections called scrofulous, may, in a considerable number of instances, be traced to the exanthemata. In order to obtain precise facts upon the subject, I requested Dr. Robertson, Surgeon to the Edinburgh Eye- Dispensary, to preserve a list of all diseases of the eye usually de- nominated scrofulous, as well as those accompanied by glandular and cutaneous affections, usually attributed to scrofulous action, in order to ascertain how many were attributed by the parties themselves or their parents to the exanthemata and hooping-cough. Dr. Robertson accordingly directed his attention to this point, and, in the course of twelve months, informed me that almost all the cases Were attributed by the parties themselves, or their friends, to those diseases. This investigation took place nine years ago; and Dr. Robertson informs me that he has seen nothing in his extensive experience, since that period, to weaken the effect which it made upon his mind. It may be added, that the result of my daily practice confirms and supports the views already stated. There seems good ground for the following statement, made by Mr. Lloyd, in his valuable Treatise on Scrofula, p. 7.:—"Among the symptoms indicating a disposition to scrofula, it has been already observed that a fair complexion and light hair and eyes are gene- rally mentioned; but I believe there are no legitimate grounds for such distinction. Indeed, I am fully convinced, from a very exten- sive investigation of the subject, that persons of every variety of com- plexion are alike subject to this disease; and that it is only necessary to place them in circumstances favourable for its development, to have it fully established." The reasons will now appear evident why scrofula is a disease that 71 846 SCROFULA. no one can properly define; every physician having a definition of his own. The term is applied too often to diseased states of the system, with the nature of which the physician is entirely unac- quainted; and it is too frequently used for the purpose of concealing professional ignorance, when he is puzzled and foiled in the treat- ment of disease. I most heartily coincide with the sentiments expressed by Mr. Lloyd in the following paragraph: "In describing the symptoms indicating a scrofulous diathesis, all the authors with whom 1 am acquainted have fallen into the error of describing the state of a patient, after the disease has given local evidence of its existence, instead of informing us of the temperament or habit of body of the patient antecedent to this period; a circumstance which I cannot but consider as of the highest importance in our pathological research. Thus they enumerate among the symptoms of a scrofulous diathesis, or which only denote a tendency to scrofula, ' a thickened, chapped upper lip, the thickening extending to the alas of the nose,' 'tume- scence and redness of the tarsi,' with weakness of the eyes in general, 'tumid belly' and 'enlargement of the lymphatic glands, particularly those of the neck.' These, it is true, (continues he,) afford very decisive evidence of the existence of the disease, but should not be ranked among the symptoms indicating only a disposition to it. All the other symptoms illustrative of the same point, which have been adduced, are either dubious or uncertain; as fair and shining skin ; light hair and eyes, females being more subject to it than males, or males, than females; both of these contradictory positions having their respective advocates." (Page 3.) I have many cases annually under my care illustrative of these statements, and proved not only by the previous history, but by the effects of proper remedies. For, as the functions of the stomach and bowels become more impaired, the inflamed and tumid appearance of the eyes, nose or lip become more and more evident, until, per- haps, ulceration takes place. But as the condition of these functions is improved, the above described state of parts disappears. All parts of the body are liable to be affected by scrofulous degene- ration ; thus it is seen in the brain, lungs, heart, liver, spleen, kidneys, muscles and bones, and also in serous and mucous membranes. I cannot do better than extract the following description of scro- fula, when left to itself, from Dr. Cullen's " First Lines on the Practice of Physic," (par. 1743, et seq.) "Frequently the first appearance of the disease is the tumid and chapped lip above men- tioned. Upon these occasions, the first appearance is that of small, spherical or oval tumours, movable under the skin. They are soft, but with some elasticity. They are without pain and without any change in the colour of the skin. In this state they often continue for a time, even for a year or two, and sometimes longer. Most commonly they first appear upon the sides of the neck below the ears, but sometimes also under the chin. In either case, they are supposed to affect in these places the conglobate or lymphatic glands only; and not at all the salivary glands, till the disease is very greatly advanced. The disease frequently affects, and even at first SCROFULA. 847 appears in other parts of the body. In particular it affects the joints of the elbows and ankles, or those of the fingers and toes. The ap- pearances above the joint are not commonly, or elsewhere, small movable swellings; but a tumour almost uniformly surrounding the joint and interrupting its motion. "These tumours, as I have said, remain for some time little changed; and from the time they first appeared in the spring, they often continue in this way till the return of the same season in the next, or perhaps the second year after. About that time, however, or perhaps in the course of the season in which they first appear, the tumour becomes larger and more fixed ; the skin upon it acquires a purple, seldom a clear redness; but, growing redder by degrees, the tumour becomes softer and allows the fluctuation of a liquid within to be perceived. All this process, however, takes place with very little pain attending it. At length some part of the skin be- comes paler; and, by one or more small apertures, a liquid is poured out. " The matter poured out has at first the appearance of pus, but it is usually of a thinner kind than that from phlegmonic abscesses; and the matter, as it continues to be discharged, becomes daily less purulent, and appears more and more a viscid serum, intermixed with small pieces of a white substance resembling the curd of milk. By degrees the tumour almost entirely subsides, while the ulcer opens more and spreads broader; unequally, however, in different directions, and, therefore, is without any regular circumscription. The edges of the ulcer are commonly flat and smooth, both on their out- side, and their inner edge, which seldom puts on a callous appear- ance. The ulcers, however, do not generally spread much or be- come deeper; but at the same time their edges do not advance nor put on any appearance of forming a cicatrix. "In this condition the ulcers often continue for a long time, while new tumours, with ulcers succeeding them in the manner above de- scribed, make their appearance in different parts of the body. Of the first ulcers, however, some heal up, while other tumours and ulcers appear in their vicinity or in other parts of the body; and in this manner the disease proceeds, some of the ulcers healing up, at least to a certain degree, in the course of summer, and breaking out again in the succeeding spring; or it continues, by new tumours and ulcers succeeding them, in the spring season, making their appear- ance successively for several years. " In this way the disease goes on for several years; but very com- monly in four or five years it is spontaneously cured, the former ulcers being healed up, and no new tumours appearing; and thus, at length, the disease ceases entirely, leaving only some indelible eschars, pale and smooth, but in some parts shriveled; or where it had occupied the joints, leaving the motion of these impaired or entirely destroyed. , , . ,. •, • . " Such is the most favourable course of this disease, and with us it is more frequently such than otherwise—but is often a more vio- lent and sometimes a fatal malady. In these cases, more parts of the body are at the same time affected, the ulcers also seeming to be 848 SCROFULA. imbued with a peculiar sharp acrimony, and therefore becoming more deep, eroding, spreading, as well as seldomer healing up. In such cases, the eyes are often particularly affected. The edges of the eyelids are affected with tumour and superficial ulcerations; and these commonly excite obstinate inflammation in the adnata, which frequently produces an opacity in the cornea. "When the scrofula especially affects the joints, it sometimes pro- duces there considerable tumours; in the abscesses following which, the ligaments and cartilages are eroded and the adjoining bones are affected with a caries of a peculiar kind. In those cases, also, of more violent scrofula, while every year produces a number of new tumours and ulcers, their acrimony seems at length to taint the whole fluids of the body, occasioning various disorders and particularly a hectic fever with all its symptoms, which at length proves fatal, with sometimes the symptoms of a phthisis pulmonalis. "The bodies of persons who have died of this disease, show many of the viscera in a very morbid state, and particularly most of the glands of the mesentery very much tumefied and frequently in an ulcerated state. Commonly, also, a great number of tubercles or cysts, containing matter of various kinds, appear in the lungs. "Such (says Cullen, par. 1750,) is the history of the disease; and from thence it may appear that the nature of it is not easily to be ascertained." Treatment of scrofula.—In describing the treatment of scrofula, I shall confine myself to that which is necessary in glandular affec- tions and superficial ulcerations, as the diseases of the eye and the lungs have been already considered, and as those of the bones belong more to the province of surgery. Nevertheless the constitutional treatment that I shall recommend, is equally applicable to all forms in which the disease occurs. We are told by almost every author «' to correct the bad habit of body," and improve the state of the constitution; but, as far as I am aware, we have never yet been told a proper method to bring about this desirable event, or, indeed, in what the bad habit of body consists. Mr. Lloyd appears to me to have arrived nearer the truth in this respect than any other writer, but how much of his information has been drawn from Mr. Aber- nethy it is not easy for me to say. " From repeated observations, however, (says Mr. Lloyd,) I am convinced that there is always a disordered state of health antece- dent to those changes in the structure of parts, which are called scrofulous diseases, whether they are the effect of an acquired or of an hereditary tendency; and, therefore, that our treatment must be always founded on the same principles: so, of course, it must be modified according to any particular circumstances which may attend particular causes."—(Page 26.) In other places of hie work, he attributes this condition to more or less disorder of the digestive organs, which, he says, will always be found to have existed for some time previous to the appearance of the disease in any particu- lar part. This will be distinctly observed in the following paragraph, (at page 33.)—"From the nature of the constitutional disorder that attends and precedes this disease, we might be induced to believe SCROFULA. 849 that the disease entirely depended upon the disorder of the digestive organs, produced by various causes acting immediately on them, or mediately through the nervous system." Nevertheless, Mr. Lloyd has failed to show what the true nature of the disorder is, or its pre- cise seat, or, I may add, a more successful mode of treatment than his predecessors. Dr. Cullen states, in paragraph 1753, that " for the cure of scrofula, we have not yet learned any practice that is certainly or even gene- rally successful. The remedy which seems to be the most successful, and which our practitioners specially trust to and employ, is the use of mineral waters; and, indeed, the washing out, by means of these, the lymphatic system, would seem to be a measure promising suc- cess." A great number of specifics have been recommended for the cure of scrofula, the chief of which are bark, mercury, steel, mineral waters, barytes, lime-water and muriate of lime; but experience has shown that they are not worthy of much confidence, and some of them are represented to have been injurious. I was once very much amazed on hearing the answer given by a physician in my presence to a lady, who was desirous of knowing how long her little girl was to be compelled to take the solution of the muriate of lime. She stated that it was a very nauseous medicine, and that it had done the child no good, although she had taken it regularly for six months. The physician replied that it would probably require three or four years before it would produce any beneficial effects, and lhat it must be regularly taken. Whether the physician spoke believing what he said to be true, I cannot pretend to say, but he looked grave enough. Judging from the condition of the tongue, from the appetite, the increased thirst, the tumefaction of the abdomen, the degree of flatu- lency, the occasional pain in the belly, the irregularity of the bowels and the appearance of the feculent matter, I persuaded myself, many years ago, that scrofulous affections were produced by disease in the digestive organs, and that that disease, whatever else it might be owing to, consisted principally in extensive irritation and inflamma- tion of the mucous membrane. But I had little notion that fre- quently there were extensive ulcerations, till I was repeatedly con- vinced by dissection that it was the case—since which time I have treated the disease in the following manner, and with much success. If, along with considerable gastro-intestinal irritation, there be much fever at night, the strength being as yet unbroken, leeches ought to be applied to the abdomen, in such number as the symp- toms, strength and state of the constitution require; the bowels should be kept gently open, but drastic purgatives are on no account to be exhibited. Contra-irritation should be produced on the abdo- domen by means of stimulating embrocations, or by what is still1 better tartar-emetic ointment; and if an opiate be required to allay the irritation of the bowels, perhaps the best remedy will be a few grains of Dover's powder. It is, probably, in such circumstances that lime-water has been found beneficial, as it is a remedy of con- siderable power in this particular state of the mucous membrane. 850 SCROFULA. The diet must be rigidly attended to, and varied according to cir- cumstances. When the tongue is loaded and red round the edges, or universally red, the patient should be restricted to gruel, arrow- root, whey and the like, as the digestive powers will not be able to assimilate any other kind of food. Soups and animal jellies, which are so often had recourse to, prove very injurious, and aggravate the evils which it is our object to prevent. But when the marks of irri- tation in the stomach and bowels subside, when the tongue becomes clean, and the stomach more vigorous, a small quantity of chicken, or any other kind of meat, should be allowed, care being always taken that the patient shall take no more than the stomach can easily manage. If he do, the mischief will be soon announced by acidity, heartburn, troublesome distension of the stomach and a feverish night. For some days after such an occurrence, the articles of diet mentioned above should be used. Calomel or blue pill is to be administered only when the tongue is furred, although there can be no objection either to an occasional grain or two of calomel or of blue pill, to act as a gentle laxative. The great error of the system pursued by Mr. Abernethy and his disciples, arises from their giving the blue pill indiscriminately, owing, perhaps, to their not being aware that the mucous membrane is the seat of the irritation, and that inflammation and ulceration sometimes take place. The warm bath is to be used every second night, and on the alter- nate days the body may be sponged with warm water and vinegar, which last is the best remedy when the patient is either very weak or when the health and strength are becoming restored. By and by, sponging with cold water, the shower-bath, or sea-bathing may be substituted. Air and exercise are indispensable parts of the treatment, but the patient should not be exposed to a raw, cold, damp atmosphere, at least till recovery is far advanced, and not even then, unless the body be sufficiently protected by warm clothing. Flannel should be worn next the skin, and during the winter and spring months a leather jacket and drawers should be used in addition to, but outside of, the flannel. There can be no reasonable objection against the occasional em- ployment of mineral acids and tonics, provided they be not persisted in too long, or exclusively trusted to as specifics, or used at times when leeching and contra-irritation are actually necessary. I cannot avoid doing Mr. Lloyd the justice of transferring the fol- lowing judicious passage from his work to these pages:—"When there is what is called a weak stomach, with loss of appetite, I have often seen the different tonics, as cinchona, steel and the mineral acids, of the greatest service; but I am sure, as I have said before, that they possess no specific power over scrofula. Moreover, I feel certain, that a great deal of mischief is often produced by the exhi- bition of these medicines in conjunction with a stimulating diet, and that diseases which niight otherwise be speedily relieved, are, by these means, rendered fatal to the patients. Too often have I seen medical men, when consulted about children with swelling of the SCROFULA. 851 glands of the neck, or other scrofulous affection, at once declaring them in a delicate state of health, prescribe a generous diet, as full meals of meat, with porter and wine, with the use of bark, steel, or some other strengthening medicines as they are called, merely be- cause the disease was scrofula. Too often have I seen this plan pur- sued in cases where, on more accurate examination, I have found the patient requiring a plan of treatment directly the reverse."— (Page 41.) And in another place, alluding to the same treatment, he says, " It is true, however, that when children are first put on this treatment, they appear to the common observer immediately to im- prove in health. A species of fever is produced, the cheeks become fuller and flushed, and the exhilarating powers of the stimuli height- en the spirits of the child, so that the delighted mother feels greater confidence in her doctor, and expects soon to see her child perfectly recovered. But too soon, however, these favourable appearances are generally proved to be fallacious by the discovery of some fresh swelling, or by the child evidently becoming weaker and more irri table. It is equally true, too, that when children are put on a differ- ent plan of treatment, they often, for the first ten days or a fortnight, become paler and perhaps weaker; but after this period, if there be no important visceral disease, it will always be found that, the irrita- tion of the disease subsiding, they gradually recover strength and flesh, though, perhaps, taking only half the food which they were accustomed to before."—(Page 42.) These passages merit the greatest attention from those practitioners who still follow the line of treatment which Mr. Lloyd condemns; and for further particulars, I beg to refer the reader to the chapter on Tabes Mesenterica, in the first volume of this work. It is now necessary that I should notice a remedy which has been found of great service in reducing enlarged glands, provided their structure be not destroyed by diseased action. This remedy is iodine and its various preparations, the effects of which are very wonderful in bronchocele, although its administration in scrofulous affections of the glands has not been attended with the universal success which was at one time anticipated. Nevertherless, it is a preparation which is in many instances highly serviceable, but which requires judgment and discrimination. Iodine is of no service if there be much gastro- intestinal irritation, or a loaded tongue, or if the gland be in a state of inflammation. Hence it is that it has been found so beneficial in chronic indolent swellings, as in bronchocele, and that its operation has been observed in many cases to be more rapid when its use is conjoined with local bleeding. Preparations of iodine are to be used in the manner already described when treating of diseases of the uterus. Local treatment of the scrofulous affections of the glands.—It is to be apprehended that serious injury has been inflicted on indi- viduals by the absurd plan of trying to "put back" glandular tumours by cold applications of various kinds. When the tumours are small and not painful, little need be done except covering the part with flannel, or rubbing them with an ointment containing iodine. But should there be any inflammation, warm fomentations, 852 SCROFULA. or poultices ought to be applied, and an opening made as soon as fluctuation is discovered. Dr. James Hamilton, jun., the professor of midwifery in this university, has great merit for being among the first who insisted upon the advantage of making an early opening; and he used to take particular pains to show that so far from leaving a mark, an early puncture was the best means for preventing such a disagreeable circumstance. By making ihe incision, we shall prevent the formation of those small apertures which so frequently run into extensive ulcerations; and we always find that the longer the part is inflamed, and the more distended it becomes, the subsequent ulcer- ations are more extensive, indolent and difficult to heal. When the gland is deep seated, there is a greater necessity for letting out the matter. But should the glandular swelling be very much inflamed and tender from the first, or become so at any time before matter is formed, leeches are to be applied to moderate the violence of the inflammation, and prevent the abscess from becoming so large as it would undoubtedly do if left to run its course. In the event of our not being called till ulceration has taken place, besides attending to the constitutional treatment already so fully described, we must have recourse to the application of various remedies. Some cases of indolent ulcer assume a healing tendency under the application of the black wash, or a solution of the acetates of lead or zinc, but it should be applied warm, and not persisted in for more than two or three days. In other cases, whether the sores are either indolent or irritable, lunar caustic will be found to have the best effects; and the reason why it has failed so often is, that proper constitutional remedies have not been employed at the same time. In some cases, immediate benefit will be derived from the application of an ointment of the acetate of copper, in the proportion of two, four or six grains of the acetate to a drachm of simple cerate. From ex- perience, I can speak highly of the effects of pressure. In a case of deep and extensive scrofulous ulceration of the mamma, of above fourteen years standing, the part assumed a healing tendency in a few days after the application of a graduated pressure, and was completely cicatrized in rather less than six weeks; and I could mention manv other successful cases. CHAPTER IV. DROPSY. GENERAL REMARKS. An unusual collection of serous or watery fluid in any part of the body, is called a dropsy; and is observed to take place in the cellu- lar tissue and in serous cavities. Hence we find it in the general cel- lular membrane, which is extended over the surface of the body— in the lungs, where the air-cells and blood-vessels are enveloped by a loose cellular tissue—within the membranes of the brain—in the pericardium—and in the cavities of the pleura and peritoneum. Dropsy has therefore received distinct appellations, according to the locality of the effusion; and, in noticing these circumstances, Dr. Cul- len observes, (par. 1645,) that "although the particular instances of such collection are to be distinguished from each other according to the parts they occupy, as well as by other circumstances attending them, yet all of them seem to depend upon some general causes, very much in common to the whole. Before proceeding, therefore, to consider the several species, it may be proper to endeavour to assign the general causcof dropsy." I shall pursue the same course as Dr. Cullen, who, although he seems to have directed considerable attention towards the acquirement of an intimate knowledge of the morbid alterations found in different organs in dropsy, yet was too anxious to insist upon a loss of tone in the absorbent extremities of the lymphatics and laxity of the exhalent vessels as causes, to allow sufficient influence to internal organic disease, or to a general ple- thora or inflammatory diathesis. " In persons in health (says Dr. Cullen), a serous or watery fluid seems to be constantly poured out or exhaled in vapour, into every cavity and interstice of the human body capable of receiving it; and the same fluid, without remaining long or being accumulated in these spaces, seems constantly to be soon again absorbed from thence by vessels adapted to the purpose. From this view of the animal economy, it will be obvious, that if the quantity poured out into any space happens to be greater than the absorbents can at the same time take up, an unusual accumulation of serous fluid will be made in such parts; or though the quantity poured out be not more than usual yet if the absorption be any ways interrupted or diminished, from 'this cause, also, an unusual collection of fluid may be occa- sioned. 854 DROPSY. " Thus, in general, dropsy may be imputed to an increased effusion or to a diminished absorption." (Par. 1645.) He considered that increased effusion may happen either from a preternatural increase of the ordinary exhalation, or from the rup- ture of Vessels carrying, or of sacs containing, serous or watery fluids. The ordinary exhalation may be increased from an inter- ruption which resists the free passage of the blood from the arteries into the veins, which interruption increases the force of the arterial fluids in the exhalents from which the effusion takes place. This interruption may be owing to the following circumstances; disease of the heart, particularly certain conditions "in the right ventricle of the heart itself," which prevents it from receiving the usual quantity of blood from the veins to obstructions in the vessels of the lungs, preventing the entire evacuation of the right ventricle, and thereby hindering its receiving the usual quantity of blood; "thus, (says he,) a polypus in the right ventricle of the heart, and the ossification of its valves, as well as all considerable and permanent obstructions in the lungs, may be considered as causes of dropsy." (Par. 1649.) The only additions which can be made to these last observations are, that it is now well known every kind of organic disease of the heart and of its valves may give rise to dropsical effusion, if the patient be not cut off early in the complaint; and there can be no doubt, also, that all considerable and permanent obstructions to the circulation in the lungs will occasionally give rise to dropsy; but, in a practical point of view, it is important to know that chronic bron- chitis is the diseased condition of those organs on which it most fre- quently depends. But in either of these cases, there is something more to account for the dropsical effusion, than the mere obstruction to the circulation—the functions of the lungs are embarrassed, and the blood itself does not undergo those changes which are necessary to constitute health. Dr. Cullen supposed that " it may serve as an illustration of the operation of these general causes, to remark, that the return of the venous blood is in some measure resisted when the posture of the body is such as gives occasion to the gravity of the blood to oppose the motion of it in the veins, which takes effect when the force of the circulation is weak; and from whence it is that an upright pos- ture of the body produces or increases serous swellings in the lower extremities." (Par. 1650.) It appears more probable, however, that the collection of serum in the lower extremities is rather to be attributed to the fluid gravitating from superior parts to those most depending, than to an increased effusion from the vessels aris- ing from the posture of the body, and the weakness of the circula- tion. " Not only (continues Dr. Cullen) those causes interrupting the motion of the venous blood more generally, but further, the interrup- tion of it in particular veins, may likewise have the effect of increas- ing exhalation and producing dropsy. The most remarkable in- stance of this is, when considerable obstructions of the liver prevent the blood from flowing freely into it from the vena portarum and its DROPSY. 855 numerous branches, and hence these obstructions are a frequent cause of dropsy." (Par. 1651.) "Scirrhosities of the spleen and other viscera, as well as the scir- rhosity of the liver, have been considered as causes of dropsy; but the manner in which they can produce the disease, i do not perceive, except it may be when they happen to be near some considerable vein, by the compression of which they may occasion some degree of ascites ; or, by compressing the vena cava, may produce an ana- sarca of the lower extremities." Dr. Cullen also thought that, even in smaller vessels, the interrup- tion to the motion of the blood, in particular veins, has a similar effect: "Thus a polypus formed in the cavity of a vein, or tumours formed in its coats, preventing the free passage of the blood through it, have had the effect of producing drospsy in the parts towards the extremity of such veins." (Par. 1653.) "But the cause most frequently interrupting the motion of blood through the veins, is the compression of tumours existing near to them; such as aneurisms in the arteries, abscesses and scirrhous or steatomatous tumours in the adjoining parts. To this head may be referred the compression of the desending {ascending) cava by the bulk of the uterus in pregnant women, and the compression of the same by the bulk of water in the ascites; both of which compres- sions frequently produce serous swellings in the lower extremities." (Par. 1654.) The statements contained in the above paragraphs appear to me to be far too mechanical. When an obstruction takes place in the liver, it proceeds either from abscess, tubercular formation or scir- rhous degeneration ; consequently, the functions of the organ must be embarrassed to a greater or less extent; the mesenteric blood which passes through it cannot undergo the necessary changes, and must therefore operate prejudicially on the system at large. Besides, if dropsy were owing to the mere mechanical obstruction, preventing the blood from flowing freely through the vena portarum, ascites only should be the consequence, and not general dropsy. With respect to Dr. Cullen's observations concerning the compression produced by the gravid uterus, and that occasioned by the bulk of water in ascites, as being the frequent causes of cedema in the lower extremities, it may be further remarked that, in many cases, the embarrassed func- tions of the kidneys will be found to be the cause of the effusion; and that, by increasing the flow of urine in the former, the swelling in the extremities will permanently disappear, although the uterus goes on for months increasing in bulk as well as in weight. In some of the most exquisite examples of dropsical effusion, confined to the cavity of the abdomen, which have fallen under my observation, no oedema of the lower extremities took place. I have often made a similar remark, in cases of enlarged ovaria and other uterine tumours, in many of which the pressure must have been more considerable than either during gravidity or ascites. Dr. Cullen seems to have forgotten that, in the case of mere ob- struction in any one particular vein, unless it be the trunk leading from an extremity, the blood which ought to pass through it will find 856 DR0P8Y. its way by some other route. The crural and iliac veins have been found not only obstructed, but diseased, in cases of phlegmasia dolens, in which, instead of cedema of the limb, a general inflammatory af- fection is produced in it; and although the nature of the disease has not yet been fully investigated, all the phenomena in the limb are different from those accompanying cedema. "It may be supposed (says Dr. Cullen, par. 1655), that a general preternatural plethora of the venous system may have the effect of increasing exhalation; and that this plethora may happen from the suppression of fluxes or evacuations of blood, which had for some time taken place in the body, such as the menstrual and haemorrhoidal fluxes. A dropsy, however, from such a cause, has been at least a rare occurrence, and when it seems to have happened, I should sup- pose it owing to the same causes as the suppression itself, rather than to the plethora produced by it. " One of the most frequent causes of an increased exhalation, I apprehend to be the laxity of the exhalent vessels. That such a cause may operate, appears probable from this, that paralytic limbs, in which such a laxity is to be suspected, are frequently affected with serous, or, as they are called, oedematous swellings. " But a much more remarkable and frequent example of its opera- tion occurs in the case of a general debility of the system, which is so often attended with dropsy. That a general debility does induce dropsy, appears sufficiently from its being so commonly the conse- quence of powerfully debilitating causes, such as fevers, either of the continued or intermittent kind, which have lasted long; long-con- tinued, and somewhat excessive evacuations of any kind; and, in short, almost all diseases that have been of long continuance and have at the same time induced the other symptoms of a general debility. "Among other causes inducing a general debility of the system and thereby dropsy, there is one to be mentioned as frequently oc- curring, and that is, intemperance in the use of intoxicating liquors, from whence it is that drunkards of all kinds, and especially dram- drinkers, are affected with this disease. "That a general debility may produce a laxity of the exhalents will be readily allowed: and that by this especially it occasions dropsy, I judge from hence, that while most of the causes already mentioned are suited to produce dropsies of particular parts only, the state of general debility gives rise to an increased exhalation into every cavity and interstice of the body, and therefore brings on a general disease." It appears to me that the illustrations which Dr. Cullen has used in proof of the laxity of the exhalent vessels, which he considers the chief circumstance in the pathology of dropsy, and therefore terms the hydropic diathesis, are most unfortunate. If they were correct, we should invariably see paralytic limbs oedematous, which is far from being the case. With respect to fevers, whether continued or intermittent, which have lasted long, we may certainly expect occa- sionally to see dropsical affections, not so much from debility, how- ever, as from changes in the structure of internal organs: and, lastly, as to intemperance, and especially dram-drinking, these habits no DROPSY. 857 doubt produce general debility, and likewise dropsy, in consequence of the diseased conditions of the stomach, liver or kidneys, which they occasion. Dr. Cullen also considers that dropsy may be produced by a pre- ternatural abundance of serum in the blood-vessels, which may be sometimes owing to drinking a large quantity of very cold water, or to absorption from a moist atmosphere, or to a fault in the digestive and assimilating powers in the stomach and other organs. Besides these, he mentions other causes which are more likely to produce inflam- mation than dropsy—as the rupture of the thoracic duct, and a con- sequent effusion of chyle and lymph into the thorax; and a rupture or erosion of the kidneys, ureters and bladder of urine—" whereby the urine has been poured into the cavity of the abdomen, and pro- duced an ascites." (Par. 1&61.) From these theories I turn vvith pleasure to the pathological work of Dr. Blackall, and the still more useful and splendid production of Dr. Richard Bright, of London. Dr. Blackall seems to have been the first author who drew the attention of the profession in a particular manner to the coagulable state of the urine, and to the prevalence of an inflammatory diathesis in some kinds of dropsy. He proved by dissection that the pleura, the peritoneum and pericardium are often unequivocally inflamed, covered with false membrane, and adhering to adjacent parts;—that the liver and kidneys are frequently enlarged and otherwise diseased; —that the lungs sometimes show marks of inflammation ;—that the lymphatic vessels themselves are found unusually thickened and dis- tended in dropsical bodies, so much so, that he alleges sueh subjects are much preferred for anatomical preparations;—and, lastly, that the cellular membrane, in dropsical parts, frequently presents an unusual resistance to the knife, and that the cells contain an effusion some- what transparent and coagulated. Dr. Blackall thinks that the inflammatory nature of dropsy is so far made out by the following facts : " 1. The serum of the affected cavities has been often found opaque in various degrees, discoloured and containing pieces of lymph; and in one instance, even the fluid of the cellular membrane coagulated spontaneously. "2. In addition to these appearances of the dropsical fluid, which argue a secretion often different from that of mere relaxation, the membranes likewise are sometimes greatly inflamed and disfigured. " 3. Many of the remedies are antiphlogistic; and there is a cer- tain stage in almost every case of the disease, in which tonics do material injury. " 4. The frequent buffiness of the blood, and that, too, sometimes of a peculiar kind, is not to be overlooked in this investigation; and it is worthy of much notice, that whilst the blood and the secreted serum are accused of being too watery, the urine, which commonly contains little or no albumen, is loaded with it in a great and un- natural proportion. This phenomenon could hardly be expected as the result of too thin a condition of the fluids, and a deficiency of coagulable matter; on the contrary, it is a very strong proof, if not °72 858 DROPSY. of its excess, at least of some newly-acquired properties with regard to separation, and of an altered texture. I add, as a fact on which we cannot too often reflect, that where the urine is most loaded, coagulates by the lowest heat, and most firmly, the blood is likewise most buffy, and the whole system bears the greatest marks of inflam- mation." That part of Dr. Bright's work relating to dropsy, is divided into three parts. In the first, he gives twenty-four cases of dropsy illus- trative of the coagulability of the urine,* with a number of very in- teresting dissections in which a peculiar diseased condition of the kidneys was discovered. In the second, eleven cases illustrative of the disease of the liver connected with dropsical effusion are noticed. And in the third, four cases illustrative of some of the appearances observable where the disease is connected with the viscera of the thorax. In the first part, Dr. Bright, besides mentioning the great and tan- gible causes of dropsy—as diseases of the heart, lungs and liver; the pressure of tumours; the obliteration of veins; and certain inflamma- tory appearances of the pleura and peritoneum—makes the following observations respecting the alteration of structure in the kidneys, and its connection with albuminous urine : " There are other appearances to which I think too little attention has hitherto been paid. They are those evidences of organic change which occasionally present themselves in the structure of the kidney; and which, whether they are to be considered a6 the cause of the dropsical effusion, or as the consequence of other disease, cannot be unimportant. Where those conditions of the kidney to which I allude have occurred, 1 have often found the dropsy connected with the secretion of albuminous urine, more or less coagulable on the application of heat. I have, in gene- ral, found that the liver has not, in these cases, betrayed any consider- able marks of disease, either during life or on the examination after death, though occasionally incipient disorganization of a peculiar kind has been traced in that organ. On the other hand I have found that, when the dropsy has depended on organic change in the liver, even in the most aggravated state of such change, no diseased structure has generally been discovered in the kidneys, and the urine has not coagulated by heat. I have never yet examined the body of a patient dying with dropsy, attended with coagulable urine, in whom some obvious derangement was not discovered in the kidneys. Whether the morbid structure by which my attention was first di- rected to this subject, is to be considered as having, in its incipient state, given rise to an alteration in the secreting power, or whether the organic change be the consequence of a long-continued morbid action, may admit of doubt; the more probable solution appears to be, that the altered action of *the kidney is the result of the various hurtful causes influencing it through the medium of the stomach and the skin, thus deranging the healthy balance of the circulation, or producing a decidedly inflammatory state of the kidney itself, that when this continues long, the structure of the kidney becomes per- [* See Albumin aria, p. 721.] DROPSY. 859 manently changed, either in accordance with, and in furtherance of, that morbid action, or by a deposit which is the consequence of the morbid action, but has no share in that arrangement of the vessels on which the morbid action depends. " The observations which 1 made respecting the condition of the urine in dropsy, are, in a great degree, in accordance with what has been laid down by Dr. Blackall in his most valuable treatise. "Where anasarca has come on from exposure to cold, or from some accidental excess, I have, in general, found the urine to be coa- gulable by heat. The coagulation is in different degrees; it likewise differs somewhat in its character; most commonly when the urine has been exposed to the heat of a candle in a spoon, before it rises quite to the boiling point, it becomes clouded, sometimes simply opal- escent, at other times almost milky, beginning at the edges of the spoon, and quickly meeting in the middle. In a short time the coa- gulating particles break up into a flocculent or a curdled form, and the quantity of this flocculent matter varies from a quantity scarcely perceptible floating in the fluid, to so much as converts the whole into the appearance of curdled milk. Sometimes it rises to the sur- face in the form of a fine scum, which still remains after the boiled fluid has completely cooled. There is another form of coagulable urine which, in my experience, has been much more rare; when the urine on being exposed to heat, assumes a gelatinous appearance, as if a certain quantity of isinglass had been dissolved in water. I have, indeed, met with this in one or two cases only. "During some part of the progress of these cases of anasarca, 1 have, in almost all instances, found a great tendency to throw off the red particles of the blood by the kidneys, betrayed by various degrees of haematuria from the simple, dingy colour of the urine, which is easily recognized; or the slight, brown deposit, to the completely bloody urine, when the whole appears to be little but blood, and when not unfrequently a thick, ropy deposit is found at the bottom of the vessel." And again he states: " In all the cases in which I have obtained the albuminous urine, it has appeared to me that the kidney has itself acted a more important part, both functionally and organically, than has generally been imagined." Case I.—In the first case, published by Dr. Bright, of anasarca with coagulable urine, there were marks of pericarditis; the heart was large and firm; a triangular and solid deposit of bone was found in the angle between two of the aortic valves; the left lung adhered, and was in every part converted into a gray hepatized structure, very few portions admitting partially the entrance of air; the right lung was oedematous, and surrounded but not compressed by effusion of serum • there were some marks of former inflammation on the peri- toneal coat of the liver; the spleen was dark-coloured, with a slight adventitious covering like that on the liver. The kidneys were completely granulated throughout; externally the surface was rough and uneven ; internally all traces of the natural organization nearly gone except'in the tubular parts, which were of a lighter and more 860 DROPSY. pink colour than usual. The granulated condition of the kidney was in an advanced stage of the disease. Case II.—On dissection the kidneys were both found of unusual size, certainly half as large again as most commonly seen, but the right was the largest. On an external view they were obviously granulated, with a large proportion of yellow granular matter; on taking off the proper tunic, this was more distinctly seen ; and on cutting in, the whole of the cortical structure seemed to be converted into a yellow substance in appearance like fat in many parts; though' in other parts the change had not gone so far. In this case the urine was coagulable. Case III.—In this ^ase, which was connected also with some de- gree of coagulability of the urine, the kidneys were found in the following condition. Externally, somewhat misshapen from the tubercular character of their structure; the form did not depend upon any disease analogous to true tubercles, but upon a general change in the substance of the kidney, some parts projecting, of a white colour upon a pinkish ground, the small star-like vessels running over them. The size was but little altered ; the proper tunic adhered very closely. Internally, the whole cortical structure was of a pretty uniform yellowish colour, vvith many small, opaque, and indistinct yellow spots. Case IV.—The urine coagulated by heat was of a brown colour, apparently from a mixture of the red particles of the blood : and the kidneys afforded, on dissection, throughout the whole cortical struc- ture, a curious specimen of disease, apparently the commencement of granulation ; they were rather large and soft; their general colour was pale, and on taking off the tunic, the whole surface was seen speckled with-minute yellowish bodies; on making a longitudinal section, the same bodies were seen pervading the whole cortical substance, assuming, near the surface, somewhat of the striated arrangement observed in the structure of the kidney at that part, and irregularly disseminated through the other parts. Case V.—The urine coagulated strongly by heat; and the kid- neys were found large, very dark on their upper surface; on the lower mottled vvith yellow; no elevated granulation to be seen ex- ternally, but many small yellow specks. Internally, the substance was remarkably pale, and had assumed the appearance of a fatty substance, with some traces of a granulated structure throughout: this, however, depended in part on a flaky opaque matter thickly disseminated; and this same appearance became very obvious over the whole external surface after the kidney had been kept in pure water for a day or two. Case VI.—The kidneys afforded very fine specimens of the con- firmed granulated change. They were rather large and bulky; the granulation was seen externally over every part of the surface, even DROPSY. 861 before the tunic was removed. The granular bodies were small, of a yellow colour, and the surrounding substance more pink. On cut- ting longitudinally through the kidney, it was seen that the whole cortical substance was composed of the same altered structure, and the striated arrangement near the surface was almost lost. Dr. Bright gives no account of the state of the urine, as he did not see the patient. Case VII.—The urine was scanty, and coagulated very considera- bly on the application of heat, becoming first milky and then loaded with a great number of flakes; and on dissection the kidneys were found small, rather lobulated, of a semi-cartilaginous hardness, com- pletely granulated; the small whitish or yellow granules projecting with red, intervening spaces, so as to form a scabrous surface, both appearing and feeling rough. On making a longitudinal section, the kidney cut with the resistance of a scirrhous gland ; the tubular part was drawn much nearer to the surface than is natural; the cortical part indistinctly granulated throughout, of a grayish drab mixed with purple. Case VIII.—The urine was of a deep yellow colour, clear, and coagulated in a very marked manner by heat, assuming a white cur- dled form ; and on dissection the kidneys were observed to be very small and hard in consistence, feeling most cartilaginous; their pre- vailing colour was purplish; on their external surface they were dis- tinctly granulated in texture; and on making a longitudinal section, the same was perceptible throughout; it was remarkable that the cortical portion was exceedingly thin, so that the distance between the termination of the tubular part and the external surface was much less than in the healthy organ. Case IX.—The urine was scanty, and when first passed, was clear, but of a dingy brown colour; it became turbid on cooling, grew clear on the application of a gentle heat, and by raising the tempera- ture nearly to the boiling point, it coagulated in a very marked degree, so that it put on the appearance of thick treacle-posset. On examination of the body after death, the kidneys presented most decidedly the granulated structure; this was somewhat marked ex- ternally, the lighter points of the granulation being smaller than Dr. B. has often observed; and, on cutting into the substance, it was seen that the natural structure was destroyed throughout the whole cortical part, which was mottled as in the two last cases; but this morbid structure appeared in its most advanced stage around the tubular parts. Qase x.__At first the urine was scanty, and coagulated decidedly, though not to the extent usually observed, and in the progress of the disease it always continued very scanty. Sometimes it was tolerably clear but became turbid on cooling; at other times it bore the dingy colour which usually denotes the presence of blood; almost always it retained its coagulability, but in general this was limited to a dense 72* 862 DROPSY. deposit of brownish flakes, the whole fluid not becoming milky or curdled. On dissection, the kidneys were contracted and hard, and on removing their tunic, the surface was scabrous ; but the projecting roughness was of a pretty uniform gray, purplish colour, and the same was observable on making a section. Case XI.—The kidneys were most decidedly diseased. They did not feel so firm as natural, were almost white in external appear- ance, rather large and lobulated, without any signs of granulation, and only showing a few star-like vessels distributed on the surface ; otherwise of nearly one even surface, and on most minute inspection no mark of structure, as usually seen on the surface of the healthy kidney, was discoverable. On making a complete longitudinal sec- tion, the same gray-white colour pervaded all the cortical part, vvith little sign of natural structure; the faint appearance which did exist preserved those marks of lines proceeding towards the surface, which are often more evident in the healthy kidney. The tubular part was also faintly coloured. In this case Dr. Bright could not ascertain the state of urine. Case XII.—The urine was scanty and of a slightly dingy colour, coagulating decidedly by heat; and on dissection, the kidneys were found disorganized throughout, smooth in their external texture, rather lobulated, of a pale yellow colour, with a few superficial vessels; and on being examined internally, the same gray yellow colour per- vaded the whole cortical part, with some more opaque yellow spots irregularly intermixed. The tubular structure pale and indistinct; in a word, approaching more to the condition of the kidneys men- tioned in the last case than any others. Case XIII.—The urine coagulated, was turbid, and became dingy as from a slight admixture of blood. On dissection, the kidneys very pale and rather soft, discovered externally nothing but the natural structure, rather more marked than usual, but internally was plainly to be traced a motley granulation, very small and faint in its colour and markings. Case XIV.—The urine coagulated by heat more or less during the course of the disease, had a dark brown tinge, being a mixture of the red particles, and at length became quiet red, depositing a quan- tity of ropy mucus. On dissection, the kidneys presented a very curious appearance. They were easily slipped out of their investing membrane, were large and less firm than they often are, of the darkest chocolate colour, interspersed with a few white points, and a great number nearly black ; and this, with a little tinge of red in parts, gave the appearance of a polished fine-grained porphyry or green stone. On cutting longitudinally into the kidney, this structure and these colours were found to pervade the whole cortical part; but the natural striated appearance was not lost; and the external part of each mass of tubuli was particularly dark; the whole mam- millary processes were also of a dark colour. On being cut through DROPSY. 863 ''nd left for some time, a very considerable quantity of blood oozed from the kidney, showing a most unusual accumulation in the organ; and, indeed, it seemed to be from this cause that the peculiar appear- ance and colour arose, the very dark spots being the effect of blood either extravasated, or in vessels greatly gorged. The immediate cause of death in this individual seems to have been oedema glottidis. Having now extracted from Dr. Bright's work the principal dis- eased appearances in the kidneys, I shall proceed to give short ex- tracts from the second part, of some of the appearances of the liver and gall-bladder, connected with dropsical effusion. " Although (says Dr. Bright), I am strongly impressed with the belief that many cases of dropsy have been supposed to depend on disease of the liver, when the kidneys have, in fact, been chiefly in fault; yet there is little doubt that, in many other cases, the liver is the real cause of the dropsical effusion, frequently showing most ex- tensive disease when the kidneys are quite healthy. " I have already remarked, when relating the cases of anasarca, connected with organic disease of the kidneys, that the liver has sel- dom been perfectly healthy, though the deviation from the natural structure has often been so slight, as to render it doubtful whether it should be noticed amongst the morbid appearances ; and in describing this state, I have sometimes used the expression that the liver showed a tendency to granulation. The fact is, that the liver, in these cases, has usually preserved its natural figure; the acute margin has been perfect, and the general size has not been augmented; the perito- neum has been quite transparent, and attached only in the ordinary degree to the viscus ; the texture of the liver has neither been unna- turally firm nor morbidly flaccid; but, on examining the surface, it has been evident that the colour was less uniform than in perfect health; the whole was marbled, consisting of very small light spots in a darker ground; but on making a section perpendicular to the surface, though the same general variety of colour has been observed, yet in some parts of the section it has been doubtful whether the darker or the lighter part should be considered as the groundwork; in general, however, by attentive observation, it will be found, that in the centre of the lighter spots small depressions or openings are visible, and that the darker parts appear to be the connecting medium of the lighter parts, which seem to be the acini of the glandular struc- ture. Although, in most cases, these appearances scarcely attract attention, yet in other cases they become more obvious, either the white portions becoming larger in proportion, or the whole viscus appearing to have lost a little of its natural pliability, to have become hard, and to break down with a slightly granulated fracture. I have scarcely, in any instance, seen this derangement of the liver go far- ther except in the case of Stewart, where most decided morbid change had taken place. The liver had assumed more of a lobulated form than in health, and the acute margin had become rounded. In all these cases, the secretion of bile is tolerably natural, the gall-blad- der being well supplied with bile of a sufficiently dark yellow colour Besides this more common appearance of the liver in the class of 864 DROPSY. dropsies of which I have been treating, the liver has occasionally de- viated a little in its consistence from its natural state, being either too firm or too flaccid; but where this has been the case, the deviation has only been such as is constantly occurring in cases where neither effusion nor any other marked symptom of disease has arisen during life. From the very prominent place which the disease of the kid- ney has appeared to hold in these cases, I have been inclined to con- sider the derangement of the liver as a secondary effect, or at least a subordinate disease, though not impossibly the state of both these organs depends on the same general constitutional affection; and I have sometimes even thought that the tendency to granulation, where it existed, maintained a certain relation in its progress to the disease of the kidney. "There are, however, hepatic derangements, unaccompanied by obvious disease of other organs, which may probably with justice be considered as laying the foundation of dropsical effusions. And of these, I shall now detail a few examples, in which it will be seen that the morbid appearances presented by the liver are very various, arising, as it would seem, from morbid actions, essentially differing from each other." Case XXV.—"Liver contracted, and throughout of a morbid structure, apparently by the deposition of minute portions of a yel- low matter. The surface, covered by a very fine peritoneum, quite transparent, even more thin than usual, presenting a rough, granular, and therefore uneven surface, of what might be called liver-coloured red and yellowish gray. On being cut into, the same structure of a less red colour pervaded the whole. The liver was thicker and rounder than natural, and rather smaller; and on pressure broke down easily, with a brittle or crisp fracture, uneven and granular. The gall-bladder, opaque and thick, containing the usual quantity of bile. The common duct was pervious, but at its entry into the duo- denum, was contracted in a nipple-like projection, with an orifice not much larger than to admit the point of a pin. On opening the gall- bladder and letting out the deep-coloured viscid bile with which it was filled, a number of small yellow bodies, larger than millet-seeds, and soft, adhered to the villous surface of the gall-bladder, chiefly on the side where it is attached to the liver." The urine, in this case, did not coagulate on the application of heat. Case XXVI.—"The liver externally tuberculous, of a light yellow colour nearly approaching to that of a lemon, with deep fissures in the surface, apparently arising from partial contraction taking place in the substance of the organ, and partly depending on the contrac- tion of the thin adventitious membrane which covered the perito- neum. The whole liver was enlarged about one-third above its natural size; it was greatly increased in firmness and specific gravity; it felt firm and hard; cut with considerably more resistance than boiled udder, to which it might be said to bear some general resem- blance ; and on examination, its whole structure was composed of bright yellow granules distributed in a transparent pinkish ground, DROPSY. 865 the two parts bearing about an equal proportion; and although on the surface the pinker part appeared the basis, yet in the section the yellow rather seemed to be so. The two parts did not separate, or in this respect resemble one body imbedded in another; nor was there any appearance of tubercular structure in the substance of the organ. The gall-bladder very much contracted, containing a small quantity of dirty-looking bile." Urine not coagulable by heat. Case XXVII.—"The substance of the liver hardened throughout, the structure nearly resembling scirrhus, with bands of thickened cellular membrane like ligamentous matter pervading every part, and in some parts forming one-third of the whole structure; although when seen externally the liver appeared tuberculous and knotty, yet when examined internally there were no tubercles. The outside was smooth, though not even, and on pressure between the fingers, gave almost the resistance of cartilage. A piece of the substance taken without the peritoneal and adventitious membrane, was still so hard as not to be broken down by the same pressure; there were some adhesions, old but web-like, between the liver and diaphragm. The gall-bladder was contracted, and covered by the false membrane; it contained bright yellow bile, and the ducts were pervious." Urine not noticed. Case XXVIII.—"The liver was drawn up under the diaphragm to which it was fixed by a firm old adhesion; it was stiff and rigid, and being covered with the adventitious membrane, bore no resem- blance to a natural liver. It was contracted in size, and throughout every part extremely hard, so as to cut with difficulty, and almost vvith a cartilaginous resistance. It was of a speckled yellow green, with lighter bands running through it, but these bearing a small pro- portion to the whole. It was compared by some to a decomposing coarse-grained sand-stone, and would not break down under any ordinary pressure of the fingers. The gall-bladder of tolerable size, and moderately filled with viscid yellow bile, which, when seen in the mass, appeared of its full dark colour; indeed, I should say that it was by no means unhealthy bile. There were five gall-stones in the bladder the size of peas which appeared like inspissated bile." In this case, there was evidently chronic peritonitis, and the omen- tum was dense and hard. The kidneys were healthy in structure. The urine did not coagulate by heat. Case XXIX.—"The liver was found to have undergone nearly the same change as that described in Case XXVII.—The kidneys were large, and in a very unhealthy condition, quite dissolved and watery in their texture, vvith light yellow stripes through the cortical substance. The urine was high-coloured, coagulating a little on the application of heat, so as to become, for a short time, turbid, and then let fly a flaky deposit, leaving the fluid clear." Case XXX.—" The liver was drawn up almost entirely within the concavity of the diaphragm, to which it was attached by several 866 DROPSY. very firm cord-like organized adhesions. This organ, throughout its whole substance, was quite changed in structure, as if in progress of becoming uniformly tubercular; its whole structure changing into small round masses of the size of large peas, not much altered from its natural colour, but capable of being picked out, leaving imperfect cavities. The gall-bladder was very small, and at least twenty times its natural thickness, opaque yellow, but containing a small quantity of bile ; the ducts pervious. There was, besides, considerable disease of the peritoneum and intestines, and the spleen was four times the natural size. The kidneys, though large, were not unhealthy." The state of the urine is not noticed. Case XXXI.—" The liver was rather contracted in size, of a yel- lowish drab-colour externally, the whole granulated in appearance, so as nearly to resemble a coarse-grained sand-stone, of which the component granules projected slightly on the surface, and were gene- rally about the size of small lupine seeds, varying a little in colour— gray, brownish and yellow. The liver was somewhat tough, and gave considerable resistance to the knife: the altered structure per- vaded the whole, and the rounded bodies were formed into clusters, many of which were of a light yellow colour; and this was particu- larly remarkable near the acute margin. The gall-bladder was dis- tended with watery bile. The kidneys had a few vesicles in the substance of the cortical portion ; otherwise their structure and con- sistence were perfectly healthy; and on stripping off the tunic, they presented a smooth and yielding surface." The state of the urine is not noticed. Two or three other cases are subjoined in Dr. Bright's work, but I shall pass them over. I hope the appearances already described, of alteration in the structure of the kidneys and liver, will be a guide to my readers in making similar investigations; and will induce them to peruse the work of Dr. Bright, from which they will derive much pathological and practical information. My attention has long been attracted to diseases of the liver, peritoneum, heart and lungs, in connection with dropsy; and my portfolio contains many drawings in illustration of these appearances; but it is only within these few years, since Dr. Bright's work ap- peared, that it was directed to the morbid structure of the kidneys. Since the publication of the last edition of this work, several cases have fallen under my observation, in which the kidneys presented the exact appearances so beautifully delineated by Dr. Bright. Some of these cases were dropsical, others not. These disorganizations of the kidneys are, for the most part, however, connected with dropsical effusions, and are announced by scanty secretion of urine of low specific gravity, containing a large quantity of albumen and a dimi- nished proportion of urea. At the same time, I must state the fact, that I have several times seen the urine coagulable by heat, the specific gravity low, (109°,) along with general dropsical diathesis, and yet the patients recovered perfectly; which could not have taken place had the kidneys been disorganized. I cannot but conclude, therefore, that the urine may be in this condition, and dropsical effu- DROPSY. 867 sions may take place from functional disorder of these organs, as well as from organic lesions. The profession owes much to the labours of Dr. Bright, and it is deeply to be deplored that other hospital physicians, with similar ad- vantages, have not made the same good use of their opportunities. General remarks on the symptoms of dropsy.—In this place, it is my intention to give a slight sketch of the general symptoms which accompany dropsical complaints, reserving those which are peculiar to effusions in the thorax, abdomen, &c, 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 spe- cific gravity ; muscular emaciation ; general debility ; febrile symp- toms particularly towards night; want of appetite and indigestion, and sometimes nausea, vomiting and diarrhoea. In some cases there are cough, difficulty of breathing, particularly in the horizontal pos- ture, and occasionally expectoration. Sometimes there are a sense of suffocation, violent palpitation and startings during sleep. The pulse is sometimes slow, at others quick, often irregular and intermit- ting; the tongue is sometimes furred and moist, at others parched and red and sometimes it is preternaturally clean and florid. Occa- sionally 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 re- medies employed 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 insurmounta- ble obstacles are experienced in investigating and deciding what or- gan 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 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 cel- lular 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 wast- ing much valuable time, because the disease may exist after the re- moval of its cause, or be even incurable, and the patient may yet be enabled to live a considerable number of years with tolerable com- fort following his business, provided the attention of the practitioner be directed to certain consequences, the occurrence of which is con- 868 DROPSY. stantly 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 conse- quent occurrence of apoplexy. Of the 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 peri- cardium 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 inflammation 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 cerebral affections coming on in the progress of these diseases, 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 ful- filled in two ways. 1. By evacuating by means of a surgical ope- ration, 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 some- times manifestly injurious to the patient. Against the third indication—"restoring the tone of the system, the loss of which may be considered in many cases as the proximate cause of the 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 ad- vantage, 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 fol- lowing such treatment, except under the above restrictions. I have met with several medical men in extensive practice, whose invaria- ble method of treating dropsy is by giving digitalis and large quan- tities of strong gin-toddy, containing an English pint, and sometimes even two of the spirit, in the course of twenty-four hours. 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 DROPSY. 869 of the urine, as indicating an affection of the kidneys, which affec- tion almost always terminates in inflammatory action, to the destruc- tion 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 observed, 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 dis ease—and also by the state of the pulse. Should the condition of the pulse and other circumstances contra-indicate venesection, 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 practitioners 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 dis- ease has too frequently led to the adoption of the opposite mode of practice already noticed. I have seen several cases in which chronic bronchitis existed with dropsy, whether as cause or effect, I could not in some instances dis- cover; but in all, great and permanent advantage was obtained from venesection. Purgatives stand next in importance to blood-letting. In all cases it is necessary to keep the bowels open; and, in many, we are ob- liged to depend on the use of free purgation, when the constitu- tion is not sufficiently strong to stand the effects of venesection; con- sequently, 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 make such asser- tions, 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-con- tinued purging is fully as debilitating as venesection, and in point of fact, I have seen several individuals die under the action of purga- tives, to all appearance from syncope. I had the satisfaction lately of curing a case of ascites of some standing. The disease came on after child-bed, and the abdomen was very much distended, when the woman was sent from a dis- tance for my advice. After exploring the chest, and ascertaining that all the organs were sound, I had confident expectation of curing her without tapping. There was no fever or pain, neither was the urine coagulable. She was first put under the action of a combina- tion of calomel, squills and digitalis, and kept under it for several weeks without much amendment. Afterwards, powerful doses of 73 870 DROPSY. elaterium were employed, and with the happiest effects. The woman returned home perfectly cured; I have since heard of her, and she continues well. 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 sub- sequently 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 supertartrate 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, apparently 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 will 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, remain; and, indeed, in several lingering instances, which I have treated by these means, so far successfully as to get rid of the drop- sical effusions, the symptoms afterwards became more urgent, and the disease more active. The principal diuretics employed are squills; foxglove; acetate of potash; supertartrate of potash; infusion of fresh brooms; can- tharides; oil of turpentine; and balsam of copaiva. Of these, the squills and balsam of copaiva I believe to be the best; Dr. Bright pre- fers the former, which he finds to act best in combination with hyo- scyamus, 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 sub- stances to form an important part of the treatment, by diminishing the irritation of the kidneys, as well as by allaying the general disturbance. The propriety of tapping is very questionable, unless we are con- vinced 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 advantage; but I believe it will, in general, be only temporary; and, in many constitutions, inflammation, ulceration of a bad cha- racter, and even mortification, sometimes ensue. Emetics were formerly in great repute in the treatment of drop- sies, owing to the high encomiums passed upon them by the illustri- ous 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 Sydenham, still, perhaps, they have been abandoned by practition- ers of the present day without sufficient examination. DROPSY. 871 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 may be expected to prove beneficial, in order to prevent the; loss of much valuable time. 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 detect disease of the heart or chronic bronchitis—very fre- quent causes of dropsy—in which the action of mercury will cer- tainly not be so serviceable as if the liver were diseased. Dr. Bright has shown that dropsies frequently depend upon disease of the kidneys, in many cases of which mercury may prove decidedly 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 repeated in proper doses, three or four times a day. But Dr. Bright assures us, that the cases which have proved most suc- cessful in his own practice, have generally 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 reme- dies entirely interrupted by the mercurial action and he has like- wise 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 remarkably 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 contra-irritation, produced by other means, have been occasionally 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. 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 the pat'ient be thirsty, and is interdicted from taking a drink, additional sufferin0" and many a sleepless night are the consequence; whereas, if he be&encouraged to drink, he may subsequently experience great uneasiness from the over-distended state of the stomach. In prac- tice we often take advantage of the thirst to introduce a sufficient quantity of the supertartrate of potash into the system. I believe that some who interdict liquids, do so for no better reason than be- 872 DROPSY. cause 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.: an- asarca; hydrothorax; ascites. ANASARCA. The term anasarca implies a preternatural collection of serous fluid in the cellular texture; and when partial, it is often called cedema. This form of dropsy generally comes on slowly, unless it succeeds 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 even- ing, 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. Sometimes there is considerable fever and dry skin ; and the heat of the parts affected is sometimes increased, although, in general, it is diminished, and occa- sionally mortification takes place. Treatment of anasarca.—This must be conducted upon the prin- ciples 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 abdo- men, and also with general cedema. In the commencement of hydrothorax, the symptoms which particularly indicate this form of the disease, are, in general, so slight as not to attract much attention, and may continue so for a considerable period, although other cir- cumstances denoting bad health may 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 annoy- ing cough. The feet are observed to be swollen towards the even- ing ; the extremities become more and more oedematous as the disease advances, when the patient frequently complains of palpita- tion, increased dyspnoea, 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 vvith increased dyspnoea. The surface shows signs of impeded circulation; the cheeks and lips in DROPSY. 873 particular become livid or deadly pale; and the pulse, if it have 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 corresponding lower ex- tremity. Stethoscopic signs.— Before the discovery of auscultation, practi- tioners 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 respiratory murmur 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 depend- ed on without having recourse to auscultation and percussion; the thorax will be observed to be more rounded than natural, and the intercostal spaces 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 principles already laid down in the general re- marks on dropsical effusions. In cases of threatened suffocation, or even when the dyspnoea 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 never- theless entertain some hope, if the effusion be confined to the chest, and have been produced by inflammation of the pleura, uncompli- cated with disease either of the heart or lungs, and if the patient's strength be good. When treating of chronic pleurisy, in the first volume of this work, a successful case of empyema is noticed where the operation of paracentesis thoracis was performed by Dr. Pit- cairn, of Edinburgh ; and there are many others on record. ascites. Ascites, or dropsical effusion within the abdomen, may exist either alone or complicated with hydrothorax and general anasarca. The symptoms, as in the 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- \ S74 DROPSY. coloured urine, dry, parched skin, &c. After these symptoms have continued for some days, the abdomen will be observed 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 insidiously, the enlarge- ment of the abdomen being often, for a considerable time, attributed to corpulency; and the other symptoms, such as restless nights and loss of appetite, to want of exercise and debility. At length the secretion of urine becomes almost suppressed, when symptoms indi- cating a cerebral affection sometimes take place and create alarm; or, along with scanty^urine, the legs become oedematous, and excite, for the first time, a correct notion as to the nature of the patient's complaints. In all cases of ascites, the most careful examination should be made respecting the state of the thorax, as it is much more likely we shall 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 aus- cultation and percussion, for we cannot judge with any degree of certainty from the dyspncea or the posture of the patient. In ascites there may be great dyspnoea from hurried circulation, or from the effusion 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 con- siderable enlargement; and when treating of diseases of the uterus, it was stated how difficult it occasionally is to determine the exist- ence 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 dis- ease. With respect to tapping, it should be avoided as long as pos- sible. We should be guided chiefly by the sufferings produced by the distension as well as by the difficulty of breathing. I have been frequently on the point of directing the operation 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 cannot leave off, as the effusion subsequently takes place with greater rapidity. The successful case of ascites cured by elaterium, noticed at p. 501, was sent to Edinburgh expressly for the operation. When the operation is finally determined upon, care should betaken, in my humble opinion, to have the patient under the influence of diuretics for some days before it is performed. Contra-irritation has appeared to me to be more serviceable in ascites than in some other forms of dropsy. [APPENDIX: CONTAINING UPWARDS OF ONE HUNDRED MEDICAL PRESCRIPTIONS.] * F*™an? °f-lheSJ Pr.e**iPHon* are referred to by corresponding numbers in the lexi. i tie classification is one of mere convenience. CATHARTICS. No. l.—Seidlitz Powders. R. Tart, sodse et potassae, gij. Supercarb. sods, gij. Make a powder, to be dissolved in a gill of cold water. R. Acid, tartaric, pulv. gr. xxv. To be dissolved in the same quantity of water as the preceding powder, the two then mixed, and drank in a state of effervescence. No. 2.—Calomel and Extr. of Jalap. R. Calomel, gr. xij. Extr- jalapae, gr. xvj. k t. pil. iv. One to be taken every four hours, until they operate. No. 3.—Calomel and Rhubarb. R. Calomel, gr. xv. Pulv. rhei, gr. xxv. Conserv. rosar. q. s. Ft. pil. viii. Two to be taken at bed-time, followed by a dose of magnesia next morning. 6 No. 4.—Aloes, Rhubarb, S,-c. R. Pulv. aloes, pulv. rhei aa gr. xij. Mass. ex. hydrarg. gr. xij. Saponis Hispan. q, s. 01. carui, gtt. ij. Ft. pil. viij. One every three hours until they operate. No. 5.—Rhubarb and Soap. R. Pulv. rhei, £j. Saponis purificat. gr. x. Ft. pil. xv. Two or three to be taken at bed-time. No. 6.—Senna and Manna. R. Fol. sennae, gvj. Mannae, Zi Sem. fceniculi, zjj, M. Infuse in a pint of hot water, and give when cold in divided doses.—If a powerful cathartic is desired, add |j. Epsom Salts. 876 [APPENDIX.] No. 1.—Croton Oil. R. 01. Croton. tiglii, gtt. iv. Sacch. alb. Gum arab. aa 3j. Aquae menthae, giv. M. Dose, a tablespoonful every hour or two hours until it operates. No. 8.— Colchicum and Magnesia. R. Magnes. ustae, 3jss. Gnm. arab. Sacch. alb. aa Qij. Vini colchici, gtt. xl vel Ix. Aquae menthae, ^iv. M. Dose, a tablespoonful every two or three hours, watching its effects. In gout and rheumatism. No. 9.—Magnesia and Rhubarb. R. Magnesias ustae, 3j. Pulv. rhei, gr. x. ----zinziber. gr. v. M. To be taken in syrup. No. 10.—Castor oil, or Oleaginous Mixture. R. Olei ricini, 3j. Pulv. gum. arab. 3iss. Sacch. alb. 3j. Aqua? destillatae, ^iij. 01. anisi, gtt. ij vel vj. To be rubbed up in a mortar. Dose, a tablespoonful every hour until it ope- rates. No. 11.—Calomel and Gamboge. R. Calomel, gr. xvj. Gum gambogiae, . gr. ij. Conserv. rosee, q. s. Ft. pil. viij. One to be given every two hours. EMETICS. No. 12.—Sulphate of Zinc and Ipecacuanha. R. Sulph. zinci, 3J. Aquae destillatae, giij. Ipecac, pulv. gss. M. A tablespoonful every fifteen minutes until it operates, giving, at the same time, draughts of warm water. No. 13.—Solution of Tartarized Antimony. R. Antimonii tart. gr. iv. Aquae destillatae, gij. M. A tablespoonful to be given every ten or fifteen minutes until emesis follows. No. 14.—Solutio Vitrolica of Dr. Mosely. R. Sulph. zinci, ^iss. Sulph. alum, et potassae, Jss. Aquae ferventis, oct. ss. Dissolve and filter. Dose, a tablespoonful for adults, and a teaspoonful for a child six months old, every morning on an empty stomach. [APPENDIX.] 877 DIAPHORETICS. No. 15. R. Antimonii tart. gr. j. Spts. nitri dulcis, gj. Aquae destillatae, jjiv. M. Dose, a tablespoonful every hour or two, unless it sickens the stomach. No. 16.—Neutral Mixture. R. Succi limonis, §iss. Sub-carb. potassae, q. s. ad saturandum. Sacch. albi ^iss. Tart, antimonii, gr. ss. vel gr. j. Aquae destillatae, §iv. M. Dose, a tablespoonful every two hours: in fevers. No. 17.—Nitrous Powders. R. Nitrat. potassae, gj. Tart, antimonii, gr. ss. vel gr. j. Calomel gr. ij. Ft. pulv. viij. One to be given every two hours. No. 18.—Dover's Powders. R. Pulv. opii, ----Ipecac. aa gr. iij. Sulph. potassae, gr. xxiv. Ft. pulv. iij. One to be given every three or four hours. EXPECTORANTS. No. 19.—Prussic Acid. R. Acid. Hydrocianici secund. Pharmac. Lond. gtt. xij. Syrup, tolutan, ^ss. Pulv. gum. arab. ^\\]. Aquae destillatae, gviiss. M. Dose, a tablespoonful every three hours. No. 20.—Brown Mixture. R. Extr. glycyrrh. Gum arab. aa gij. Aquae fervent. §iv. Dissolve and add— Spts. nitri dulcis, 3j. Vini antimonii, 3SS' Tinct. opii, gtt. xl. M. Dose, a tablespoonful every hour, or two hours. No. 21.— Tolu Mixture. R. Gum arab. 3j. Aquae fervent. oct. j. Syrup, tolutan. ^iss. Morphiae sulph. gr. ss. Antim. tart. gr. j. vel ij. M. Dose, a tablespoonful every hour or two hours. No. 22.—Seneka Root and Squills. R. Rad. senegae, gj. Scillae pulv. 9j. Aquae ferventis, oct. j. Make an infusion.—Dose, a teaspoonful frequently repeated. 878 [APPENDIX.] No. 23. — Copaiva Mixture. R. Balsami copaibae, gtt. xl. Sacch. albi, ^ij. Gum. arab. 3j. Aquae destillatae, 51V. M. Dose, a tablespoonful every two hours. No. 24.—Peruvian Balsam, $c. R. Balsami Peruv. ^ss. Mel. despumat. 3J. Rub them together in a mortar, and slowly add— Aquae destillatae, 3 viij. M. Dose, a tablespoonful every half hour or hour. In catarrh. No. 25.— Uva Ursi and Potash. R. Potassae subcarb. Pulv. uvae ursi aagj. Ft. pulv. viij. One to be given every three hours. No. 26.—Gum Ammoniac with squills. R. Gum ammoniac. gj. Aquae destillatae, §iv. Dissolve and add— Oxymel. scillae, ^ij. Tinct. opii camph. §ss. M. Dose, a tablespoonful every two hours. DIURETICS. No. 27.—Digitalis, Squills, fyc; R. Pulv. digitalis, gr. vj. Pulv. scillae, gr. xij. Calomel, gr. viij. vel xij. Ft. pil. xij. One to be given every four or six hours, followed by diuretic drinks. No. 28.—Squills and Nitre. R. Pulv. scillae, gr. vi. Nitrat. potassae, ^ss. Pulv. zinzib. 9ss. Ft. pulv. vj.—One to be given every three or four hours, unless they produce emesis. No. 29.—Oil of Juniper and Nitre. R. 01. juniperi, gtt. x. vel xij. Sacch. alb. Gurnmi arab. aa ^j. Aquae destillatae, giv. Spts. nitri dulc. 3j. M. A tablespoonful every two hours. No. 30.—Colchicum and Digitalis. R. Vini colchici, gtt. lx. Tinct. digitalis, gtt. xl. Aquae destillatae, ^iv. M. Dose, a teaspoonful every two or three hours, watching the effects. No. 31.— Turpentine Mixture, R. 01. terebinth. gtt. cxx. Gum arab. [APPENDIX.] 879 Sacch. alb. aa 3iss. Aquae destillatae, ^iv. 01. juniperi, gtt. iv. M. A tablespoonful every two hours. No. 32.—Copaiva and Cubebs. R. Balsami copaib. Pulv. cubebae, aa. giss. Gum arab. Sacch. albi, aa giss. Aquae menthae, giv. M. Dose, a tablespoonful three or four times a day. No. 33.—Bicarbonate of Soda and Digitalis. R. Bicarb, sodae, giss. Aquae destillatae, giv. Tinct. digitalis, gtt. xx. M. A tablespoonful to be given every two hours. No. 34.—Mixture of Dandelion and Potash. R. Extr. taraxaci, ^iss. Carb. potassae, gj. Aquas destillatae, giv. 01. menthae vel fceniculi, gtt. ij. M. Dose, a tablespoonful four times a day. ALTERATIVES. No. 35.—Iodine and Iodide of Potassium. R. Iodid. potassii, gr. vj. Iodini, gr. iij. Aquae destillatae, 3j. M. Dose, from six to twelve drops thrice a day, in a little cold water. No. 36.—Blue Pill, Antimony, fyc. R. Sulph. antimonii praecip. gr. v. Mass. ex hydrarg. Extr. hyoscyami, aa 9j. Ft. pil. x. One to be given three times a day. In gastrodynia, irritable sto- mach, $rc. No. 37.—Muriatic Acid Mixture. R. Acidi muriatic. 3j- Decocti hordei, Oj. Sacchar. purificati, 3j. M. Dose, a tablespoonful three or four times a day. In chronic hepatic affections. No. 38.—Nitric Acid Mixture. R. Acid, nitrici diluti, 3j. Aquae purae, Oj. Extr. taraxaci, 3ij. Syrup, zinzib. £ij. M. Dose a tablespoonful every two or three hours. In chronic hepatitis. No. 39.—Hydriodate of Iron. R. Iodid. ferri, tjj. Aquae destillatae, §j. M. Dose, six to twelve drops three times a day, in a little cold water. 880 [APPENDIX.] No. 40.—Blue Pill and Rhubarb. R. Mass. ex hydrarg. J)ss. Pulv. rhei, 9j. 01. ani si, gtt. v. Conserv. rosae, q. s. Ft. pil. x. A pill to be taken morning and evening. No. 41.—Blue Pill and Gentian. R. Mass. ex hydrarg. 9j. Extr. gentiana?, ^ss. Conserv. rosae, q. s. Ft. pil. x. One to be taken every night at bed-time. No. 42.—Blue Pill and Camphor. R. Camphorae gum. gr. xvj. Mass. ex hydrarg. gr. viij. Mucilag. acaciae, q. s. Ft. pil. viij. One to be taken morning, noon and night. When a decided ano- dyne effect is desired, add from half a grain to a grain of opium to each pill. No. 43.— Camphor with Laudanum, fyc. R. Aquae camphorae, ^iv. Tinct. opii, gtt. xl. vel lx. Tinct. lavend. compos. %). vel ^ij. M. Give a tablespoonful every two hours. In diarrhoea and dysentery. No. 44.—Camphor, Nitric Acid, and Laudanum. R. Aquae camphorae, 3iv. Acidi nitrici, gtt. iv. Tinct. opii, gtt. xl vel lx. M. Dose, a tablespoonful every hour or two hours. In diarrhoea and dysen- tery. No. 45.—Nitro-muriatic Acid Solution.* R. Acid, nitric. 3ss, -----muriatic. gtt. XX. Aquae destillatae, 3>». Spts. nitri dulcis. 3SS- M. Dose, from twenty to forty drops every three hours, in a wineglass of sweetened water. No. 46.—Calomel and Opium. R. Calomel, gr. ij. Gum. opii, gr. iij. Ft. pil. viij.—One to be given every three or four hours. No. 47.—Non-purgative Saline Mixture in Cholera. , R. Supercarb. sodae, ^ij. Muriat. sodae, ^iv. Chlorat. potassae, gss. M. Divide into four powders, one to be given every hour in half a tumbler of water. To be continued until reaction takes place, and then given in proportionably diminished doses'.—Dr. Wakefield. EMMENAGOGUES. No. 48.—Spurred Rye and Aloes. R. Secalis cornut. 3j. * The nitric acid bath is made by adding an ounce and a half of the acid to a gallon of water. [APPENDIX] 881 Pulv. aloes, gr. viij. vel xij. Zinzib. pulv. 9ss. Ft. pulv. viij—One to be taken morning, noon and night. No. 49.—Savine and Sulphate of Potash. R. Pulv. sabinae, Zinzib. pulv. aa 9ij. Potassae sulphat. giss. Ft. pil. vi.—One to be taken morning and evening. No. 50.—Muriate of Iron with Aloes and Castor. R. Tinct. ferri muriat. Tinct. aloes compos. Tinct. castorei, aa sjij. M. Give a teaspoonful three times a day, in a wineglassful of infusion of hops. No. 51.— Tincture of Hellebore and Myrrh. R. Tinct. hellebori nigri, 3ss. -----myrrhae, 3j. -----cantharid. 3j. M. Dose, thirty drops morning, noon and night, in a little sweetened water. No. 52— Tincture of Iodine. R. Iodini, 9ij. Spts. vini rect. Sjj. Spts. lavend. compos. sjij. M. Dose, from ten to twenty drops thrice a-day, in a little sweetened water. No. 53. — Guaiacum, Savine and Copaiba. R. Tinct. guaiaci, gj. ----sabinae, gij. Balsam, copaibae, gss. M. A teaspoonful three times a day. No. 54.—Aloes with Iron, fyc. R. Ferri sulphat. Potassae subcarb. aa Qj. Pulv. myrrhae, 3j. Aloes, gss. Ft. pil. xxx. Two to be taken every morning and evening. ANTHELMINTICS. FOR LUMBRICI. No 55.— Worm-seed Oil. R. 01. chenopodii, 3j. Sacch. albi, Gum arab. aa Jjij. Aquae destillatae, giij. M. To children of two years old and upwards, give a teaspoonful four times a day for three days, and then administer a brisk cathartic. No. 56.—Pink-root Infusion. R. Rad. spigeliae, *ss. Aquae bullient. Oss. Make an infusion. When cold it may be sweetened. To children three years old and upwards, give a tablespoonful three or four times a day. To adults a small teacupful, watching its effects. 74 882 [APPENDIX.] No. 51.—Electuary of Tin. R. Pulv. stanni, gj. Syrup, simp. ^iv. M. Give this mixture in four doses, on four successive days, and then follow it by a brisk cathartic. FOR TtENIA. No. 58.—Gamboge and Calomel. R. Gambogiae gum. gr. vj. Calomel, gr. xvj. Pulv. spigeliae, gr. x. Ft. pulv. ij. To be taken two successive mornings, and then followed by a cathartic of senna and salts. No. 59.— Oil of Turpentine. R. Olei terebinth. Jij. Gum arab. Sacch. alb. aazij. Aquae menthae, glv. M. A large tablespoonful to be taken four successive mornings. To be then followed by a cathartic. FOR ASCARIDES. No. 60.—Enema. R. Pulv. aloes, gss. Aquae fervent. Oss. M. To be used as an injection. No. 61.— Olive Oil and Camphor Enema. R. Aquae camph. 01. olivarum, aa giij. M. Use as an injection. NARCOTICS. No. 62.—Morphia. R. Sulph. morphiae, gr. ij. Aquae destillatae, ^ij. M. A teaspoonful is equal to sixteen drops of laudanum. No. 63.— Opium and Hyoscyamus R. Gum opii, gr. iv. Extr. hyoscyami, gr. xij. Ft. pil. vj. One for a dose. No. 64.— Camphor Water and Hoffman's Anodyne. R. Aquae camph. Jiv. Liquor, anod. HofFmani, gij. M. Dose, a tablespoonful every two hours; diluted if necessary. No. 65.—Black Drop and Digitalis. R. Tinct. opii acetat. gtt. xl. ----- digitalis, gtt. xxx. Aquae destillatae, gj. M. Dose, a teaspoonful every three or four hours. [APPENDIX] 883 No. 66.—Extract of Hyoscyamus and Cicuta. R. Extr. hyoscyami, ----Conii, aa 9j. Ft. pil. x. One for a dose, to be repeated according to necessity. No. 67.—Infusion of Camphor and Hops. R. Flor. lupulorum, 3j. Gum camph. 3ss. Aquae bullient. Oj. Dose, from a tablespoonful to a wineglassful, every two or three hours. No. 68.—Laudanum, Digitalis and Spts. of Nitre. R. Tinct. opii, gtt. lxxx. Spts. nitri dulcis, 3j. Aquae destillatae, §ij. Tinct. digitalis, gtt. xl. M. Dose, a teaspoonful every two or three hours. No. 69. — Calomel and Opium. R. Calomel, Qij. Gum opii, gr. viij. vel x. Ft. pil. viij. One to be given every hour or two hours. In colic. No. 70.—Ether and Camphor. R. Ether, sulphuric. §j. Gum camphorae, gss. Dissolve. Dose, from five to ten drops, at short intervals, in a little cold water. In sick stomach accompanying nervous excitement, and in cholera. No*. 71.—Nux Vomica. R. Extr. nucis vomicae, 9ss. Conserv. rosae, q. s. Ft. pil. xxx. One may be taken two or three times a day. In spasmodic diseases. No. 72.—Strychnine. R. Strychniae purificatae, gr* j* Conserv. rosar. gss. M. And divide into twelve pills. One to be taken morning, noon and night. No. 73.—Stramonium. R. Extr. stramonii, gss. Saponis purificat. 3S6. vel 3J. Mucilag. gum arab. q. s. Ft. pil. xxx. Dose, one, morning, noon and night. No. 74. — Pills of Belladonna. R. Extr. belladonnas, gr. vj. Conserv. rosae, q. s. Divide into twelve pills. One or two for a dose. ANTISPASMODICS. No. 75.—Musk and Camphor. R. Moschi opt. 3J. Sacch. albi, Gum arab. aa giss. Aquae destillatae, 884 [APPENDIX.] Aquae camphorae, aa^ij. M. Dose, a tablespoonful every half hour or hour. No. 76. — Castor and Ether. R. Tinct. castorei, !|ss. jEther. sulphuric. 3j. Aquae destillatae, §iv. Tinct. opii, gtt. xl. M. Dose, a tablespoonful every hour or two hours. No. 77.—Lac Assafoztida. R. Gum assafcet. 9ij. Gum arab. Sacch. albi, aa gij. Aquae cinnam. §iv. M. A tablespoonful every hour or two hours. No. 78.—Assafoztida and Musk. R. Gum assafcet. Moschi opt. aa Qj. Mucilag. gum arab. q. s. Ft. pil. x. One to be given every hour or two hours. No. 79.—Spts. of Hartshorn. R. Spts. ammoniae aromat. gss. Aquae destillatae, 3iv. M. Dose, a tablespoonful every fifteen or twenty minutes, diluted if necessary. No. 80.— Valerian and Camphor. R. Rad. valerian, contus. 3j. Gum camphor. Qij. Aquae bullient. Oct. j. M. Infuse until cold. Dose, a tablespoonful or more every hour or two hours. No. 81.—Ether and Laudanum. R. jEther. sulphuric. £ij. Tinct. opii, gtt. lx. Aquae menthae, §ij. M. Dose, a tablespoonful every ten or fifteen minutes in half a wineglass of cold water. STIMULANTS. No. 82.—Spirits of Turpentine. R. Olei terebinth. gtt. cxx. Gum arab. Sacch. albi, aa jjij. Aquae destillatae, giv. M. Dose, a tablespoonful every two hours. No. 83.—Carbonate of Ammonia. R. Carb. ammoniae, 9'ij. Sacch. alb. aa 3is3. Gum arab. Aquae destillatae, £iv. M. Dose, same as the former. No. 84.—Pills of Cayenne Pepper. R. Pulv. capsici, 3ss. Mucilag. gum arab. q. s. Ft. pil. x. One to be given every hour or two hours. [APPENDIX.] No. 85.—Infusion of Cloves and Ginger. R. Caryoph. contus. Zinzib. pulv. aa zjj. M n L, Aquae bullient- Oct. ss! M. L»ose, a tablespoonful taken hot and frequently repeated. No. 86.— Turpentine and Guaiacum. R. Pulv. guaiac. Qjj. p .. Terebinth. Venetae, n. s.' tt. pil. xij. One to be given every four hours. No. 87.—Camphor and Guaiacum. R. Tinct. opii camph. M ~ ----guaiac. ammoniat. aa Si. M. Dose, a teaspoonful every hour or two hours, in a little water. TONICS. No. 88.—Columbo, Iron and Ginger. R. Pulv. columbo, ----carb. ferri, _, ----zinzib. aa 3j 11. pulv. xij. One to be taken thrice a day. No. 89.—Gentian and Quassia. R. Extr. gentian, Vt •• ~ ,----quassiae, aa Qss. * t. pil. x. One to be taken three times a day. No. 90.—Sulphate of Quinine. R. Sulph. quiniae, gr. xvj. Aquae destillatae, Jij. M. Dose, a teaspoonful every hour, in the absence of fever. No. 91.—Wine Whey. R. Lactis recent. Oj. Vini Madeirae, jij. Boil the milk, and then add the wine. No. 92.—Subcarb. of Iron and Valerian. R. Subcarb. ferri, J}jj. Pulv. valerian, gjj. ---— zinziber. 3ss. Ft. pulv. viij. One to be taken three times a day.*" No. 93.—Infusion of Wild-cherry Bark. R. Cort. pruni virg. Jj, Sem. caryoph. gj. Aquae purae, Oct. j. M. Stand for a few hours. Dose, a wineglassful four times a day. No. 94.—Infusion of Peruvian Bark. R. Cort. cinchonce opt. ?j. Aquae bullient. Oj. M. And stand till cold. Dose a wineglassful three or four times a day. N. B. The infusions of quassia, gentian, columbo, serpentaria, &c. are made the same proportions. 74* 886 [APPENDIX.] No. 95.—Nitrate of Silver. R. Nitrat. argenti, gr. j. Conserv. rosae, q. s. Ft. pil. viij. vel xij. One to be taken morning, noon and night. No. 96.—Nitrate of Silver ivith Belladonna. R. Nitrat. argenti, gr. ij. Pulv. belladonnae, 9j. Extr. glycyrrh. 3j. Ft. pil. xxxvi. One to be given morning, noon and night. In epilepsy and pertussis. No. 97.—Aromatic Julep. R. Caryoph. Nucis moschat. Zinzib. aa oij. Infuse in half a pint of hot water. Dose, a teaspoontul frequently repeated. In diarrhoea and cholera morbus. ASTRINGENTS. No. 98. R. Subcarb. sodae, Bij- Cretae ppt. V}. Pulv. gum arab. Sacch. albi, aa 5SS- Aquae destillatae, 3U- 01. anisi, g». ij. M. Dose, a teaspoonful every two, three or foi it hours. children. Bowel complaints of No. 99. Acetate of Lead, Opium and Calomel. R. Acetat. plumbi, 9j. Pulv. opii, gr. x. Calomel, gr. v. Ft. pil. x. One to be given every two, three or four hours. In dysentery. No. 100.—Chalk Mixture. R. Cretae ppt. gij. Pulv. gum arab. Sacch. albi, aa giss. Tinct. opii, gtt. xl. 01. cinnam. gtt. ij. Aquae destillatae, 3iv. M. Dose, a tablespoonful every hour or two hours. In diarrhoea. No. 101.—Infusion of Logwood. R. Ligni haematoxyli, 3jj. Aquae bullientis, Oj. Infuse, and stand till cold. Dose, from a tablespoonful to a wineglassful, according to circumstances. No. 102. — Sulphate of Zinc and Myrrh. R. Sulph. zinci, gr. x. Pulv. myrrhae, 3iss. Confec. rosae, q. s. Ft. pil. xx. Two may be taken morning and evening. [APPENDIX] 887 No. 103.— Tincture of Muriate of Iron. R. Tinct. muriat. ferri, gj. Aquae destillatae, S,iij. M. Dose, a tablespoonful every three hours. No. 104.—Alum Whey. R. Lac. bullientis, Oj. Pulv. aluminis, gij. Boil them until the coagulum separates, and strain. Dose, a wineglassful occasionally. No. 105.— Yellow Wash. R. Corros. muriat. hydrarg. gr. vi. Aquae calcis, 3iv. M. Used as a wash in venereal ulcers. No. 106.—Black Wash. R. Calomel, gj. Aquae calcis, giv. M. Used as the preceding. INJECTIONS FOR THE URETHRA. No. 107.—Acetate of Zinc. R. Acetat. zinci, gr. vj. Aquae rosae, giv. M. Injection in gonorrhoea. No. 108.— Opiate Injection. R. Gum opii, gr. viij. Aquae rosae, 3iv. M. In gonorrhoea. No. 109. — Injection of Zinc and Bole. R. Sulph. zinci, 9j. Boli armenae, 3ij. Gum arab. giij. Aquae, 3viij. M. In gonorrhoea. No. 110.—Sulphate of Copper. R. Sulph. cupri, gr. viij. Aquae destillatae, .?V'U- Tinct. opii, giss. M. Injection for chronic gonorrhoea. No. 111.—Styptic Water. R. Ferri sulphat. Alum, sulph. aa SJss. Aquae, 3xij. Dissolve and cool, then add— Acid, sulphuric, (3j. This is the Aqua Stypiica of the Surgical Pharmacopoeia, and is used to check external haemorrhages. No. 112.—Styptic Water of Copper and Zinc. R. Zinci sulphat. Cupri suiphat. aa 3j. Aquae rosae, ^viij. Dissolve. Used as the preceding. 888 [APPENDIX ] OINTMENTS. No. 113.—Kreosote Ointment. R. 01. kreosot. gtt. v. Cerat. simp. 3j. Camphorae gum. 3ss. M. Applied to tetters and ulcerated surfaces. No. 114.—Red Precipitate Ointment. R. Hydrarg. oxyd. rub. 3j. Cerat. simp. 3j. Ft. Unguent. In scabies and indolent ulcers. No. 115.— Tartar Emetic Ointment. R. Tartrat. antimonii, 3j. Cerat. simp. 5j. Mix into an ointment. No. 116.—Iodine Ointment. R. Iodini, 9j. Cerat. simp. 5J. Ft. Unguentum. No. 117. — Ointment of Hydriodate of Potash. R. Hydriodat. potassae, 9j. Cerat. simp. 3J. Ft. Unguentum. INDEX. Abirritation, 37. Acne, 684. Acarus scabiei, 682. Albuminuria, 721. Amaurosis, 641. Amphoric respiration, 417. Albumen in dropsies, 462. Amenorrhoea, 785. Anasarca, 872. Anaemia, 42. 459. 513. Angina tonsillaris, 195. ------ pectoris, 467. Aneurism, 503. Arteries, ossification of, 502. Aortic aneurism, 504. Aphthae, 192. Asthenic diseases, 33. Ascaris, 227. -------in asthma, 446. Asiatic cholera, 281. Auscultation, 345. 358. Arachnitis, 539. Asthma, 439. Ascites, 873. Atrophy of the heart, 494. B Biliary calculi, 332. Bellows sound, 453. Blood, diseased conditions of the, 458. -----in plethora, 459. -----in anaemia, 459. -----in fevers, 460. -----in inflammation, 461. -----in haemorrhage, 462. -----in dropsies, 462. -----in organic diseases, 462. -----in the neuroses, 463. -----buffy, 24. Bloody sweat, 709. ------urine, 737. Bleeding in cold stage of fevers, 92. Blue-skin, 517. Bladder, inflammation of, 718. -------stone of the, 729. Bony concretions of uterus, 778. Bruit de soufflet, 453,454. ----de rape, 453. Brain, diseases of, 521. _____inflammation of, 121. 534. 546. Bruner's glands in fever, 138. 257. Bright's kidney, 721. Bronchitis, 353. --------chronic, 357. C Cancrum oris, 194. Catarrhal ophthalmia, 629. Calculus of the kidney, 725. Cancer of the uterus, 769. Carditis, 480. Catarrh, 352. Catalepsy, 581. Cavernous respiration, 417. Cessation of the menses, 804. Chemosis, 628. Chlorosis, 786. Chicken-pox, 176. Chronic dysentery, 281. Chordee, 714. Cold stage of fevers, 69. 85. 92. Congestion, 86. of the lungs, 393. Continued fever, 116. Cholera morbus, 282. Asiatic, 284. Congestive fever, 125. -- scarlet fever, 150. Chancre, 747. Chincough, 738. Critical davs, 67. 140. Chorea, 585. Constriction of the rectum, 225. Consumption, 414. Coma, 527. Cow-pox, 171. Colic, 214. Painters', 216. Convulsions, 527. Colica pictonum, 216. Cynanche tonsillaris, 195. Croup, 368. Crowing disease, 377. Crusta lactea, 676. Cynanche trachealis, 368. Cysts, tuberculous, 420. Cyanosis, 517. D Delirium, 528. tremens, 611. Dentition, 187. Diathesis, 41. Diphtheritis, 200. 369. Diabetes, 739. 890 INDEX. Diarrhoea, 264. Dilatation of the heart, 493. Dothinenteritis, 257. Dropsy, 852. Dysentery, 271. --------- chronic, 281. Dyspnoea, 350. Dysmenorrhoea, 792. E Ear, diseases of the, 644. Ecthyma, 682. Effusion, pleuritic, 402. Egophony, 401. Enteritis, 261 Endocarditis, 482. 500. Empyema, 404. Emphysema, 441. ■----------interlobular, 441. ----------vesicular, 441. Eruptive fever, 143. Emprosthotonos, 572. Epilepsy, 578. Error loci, 16. Eryispelas. 652. Exsanguinity, 573. Excitability, 37. Excitation, 37. Exanthemata, 143. Exudation, 254. ---------of blood, 708. Eye, diseases of the, 619. ---inflammation of the, 620. F False croup, 377. Fibrine in fever, 460. ------ in the phlegmasia?, 461 ------ in organic diseases, 461. ------ in the neuroses, 463. Fever, doctrines of, 30. ----- inflammatory, 122. ----- congestive, 125. ----- pathology of, 127. -----remittent, 116. -----from inflammation, 120. ----- infantile remittent, 112. ----- continued, 116. ----- causes of, 56. ----- typhus, 130. ----- synochus, 130. ----- physiological doctrines of, 36. ----- varieties of, 53. ----- intermittent, 68. -----yellow, 99. ----- from functional derangement, 117. ----- typhoid fever, 134. ----- hectic, 141. ----- eruptive, 143. ----- scarlet, 148. Flatulency, 205. Fluor albus, 781. G Gangrene of the mouth, 194. Galvanism, mode of using, 582. Gastrodynia, 206. Gastralgia, 206. Gastritis, 259. Gallstones, 332. Gargouillement, 417. Globus hystericus, 583. Gleet, 714. Gonorrhoea, 713. Gout, 817. 839. ----rheumatic, 843. H Haematuria, 737. Haematemesis, 208. Haemorrhage from the stomach, 208. ----------from the bowels, 210. Herpes praeputialis, 748. Hectic fever, 141. Haemorrhoids, 212. Headache, 526. Hot stage of fever, 70. 87. 94. Haemoptysis, 407. Hepatitis, acute, 325. -------- chronic, 326. Herpes, 693. Hepatization, 393. Hooping cough, 378. Heteromorphism, 418. Heart, dilatation of the, 490. ------hypertrophy of the, 485. ------ossification of, 493. ------tuburcles of, 493. ------valvular disease of, 497. ------atrophy of, 494. ------rupture of, 495. ------sounds of the, 451. Hyperaemia, 42. Hypertrophy of the heart, 484. Hydro-pneumothorax, 406. Hydropericardium, 477. Hydrocephalus, 559. ■------------chronic, 564. Hydrophobia, 575. Hysteria, 583. Hypochondriasis, 609. Hydatids of the uterus, 779. Hydrothorax, 873. I Indigestion, 201. Ileus, 220. Ileitis, 257. Impetigo, 675. Incontinence of urine, 735. Inflammation, 16. -----------causes of, 21. -----------terminations of, 25. -----------of the tonsils, 195. -----------of the throat, 198. -----------of the oesophagus, 198. -----------of the bowels, 235. 261. -----------■ of the mucous membranes, 253. -----------of the stomach, 259. INDEX. 891 Inflammation of the.spleen, 334. '-----------of the bronchial tubes, 353. -----------of the larynx, 366. -----------of the liver, 320. — of the lungs, 390. of the brain, 534. 546. -----------of the spinal marrow, 566. ■-----------of the eye, 620. -----------of the conjunctiva, 627. -----------of the eyeball, 637. -----------of the sclerotica, 637. -----------of the iris, 637. -----------of the urethra, 713. ■--------■---of the bladder, 718. -----------of the kidneys, 720. -----------of the testes, 761. —----------of the uterus, 763. Intussusception, 213. Intermittent fever, 68. ---------treatment of, 91. ---------pathology of, 85. Intestinal concretions, 225. --------worms, 226. Infiltration, tuberculous, 420. Irritation, 37, 38. Induration of the lungs, 394. Insanity, 601. Itch, 681. Iritis, 637. J Jaundice, 331. K Kidney, inflammation of, 720. Labiae, diseases of the, 757. Laryngitis, 366. Leucorrhoea, 781. Lepra, 687. Lienteria, 264. Lichen, 673. Liver, tubercles of the, 330. ----diseases of the, 320. ----acute inflammation of, 324. ----chronic inflammation of, 326. ----abscess of, 327. Lungs, diseases of, 345. Lockjaw, 571. Lumbago, 843. M Marsh miasmata, 90. Mania, 601. Mania-a-potu, 611. Menorrhagia, 799. Menses, cessation of the, 804, Metallic tinkling, 418. Melanosis, 433. Melanomia, 435. Medullary sarcoma, 435. Menstruation, 785. Measles, 158. ______inoculation for, 164. Meteorism, 136. Melaena, 210. Miliaria, 177. Miliary fever, 177. Monomania, 605. Mucous follicles, diseased, 137. Mumps, 191. N Nettle rash, 179. Nephritis, 720. albuminous, 721. Neuralgia, 586. of the heart, 467. 587. Nodes, 755. O Q3dema pulmonum, 446. Ossification of the heart, 497. of the arteries, 502. Opisthotonos, 572. Opium in cold stage of fevers, 92. Ophthalmia, 620. ---------catarrhal, 628. ---------Egyptian, 628. ---------gonorrhoeal, 629. ---------purulent, 630. ---------infantile, 630. pustular, 636. Otitis, 644. Otorrhoea, 646. Ovaria, diseased, 806. Pain, 25. Pathology of intermittents, 85. Papular diseases, 672. Parotitis, 191. Palpitation, 465. Paralysis, 528. 596. Paraplegia, 529. Pectoriloquy, 417. Peripneumonia notha, 354. Pemphigus, 625. Peritonitis, 235. chronic, 249. Pertussis, 378. Periodicity, 88. Peyer's glands in fever, 138. 257. Pericarditis, 474. Physiological doctrines, 36. Pharyngitis, 198. Phlebitis, 506. Phlegmasia dolens, 507. Phymosis, 748. Phthisis pulmonalis, 414. Pestis, 181. Pityriasis, 691. Piles, 212. Plethora, 459.512. Plague, 181. Pleurisy, 404. ------chronic, 400. — haemorrhagic, 403. Pneumonia, 390. ---------of children, 398. 892 INDEX. Podagra, 817. Pompholyx, 695. Porrigo, 676. ------larvalis, 676. Pneumothorax, 406. Pulmonary consumption, 414. ---------cedema, 446. Prolapsus ani, 225. --------uteri, 771. Prostate, stone of the, 730. Prurigo, 673. Psoriasis, 689. Pyrosis, 205. Purpura, 696. Puerperal fever, 237. Purulent ophthalmia, 628. 630. Pustular ophthalmia, 636. -------diseases, 675. Q. Quotidian fever, 69. Quartan fever, 69. Quinine, use of, 97, 98. R. Ramollissement, 25. 533. Red globules in anaemia, 459. ----------in haemorrhage, 462. ----------in plethora, 452. ----------in inflammation, 461. Respiratory organs, diseases of, 345. Retroversion of the uterus, 773. Remittent fever, 116. Remittent, infantile, 112. Retention of urine, 734. Rheumatism, 837. ----------chronic, 842. Rheumatic gout, 843. Roseola, 178. Rose-rash, 178. Ronchi, 418. Rubeola. 158. Rupia, 682. Rupture of the heart, 495. S. Scrofula, 844. Scabies, 681. Scarlet fever, 148. Scarlatina, 148. Sclerotica, inflammation of the, 637. Sciatica, 843. Skin, diseases of the, 649. Sounds of the heart, 451. Small-pox, 164. --------modified, 168. Spasmodic cholera, 284. Spleen, diseases of the, 334. ------inflammation of the, 334. ------enlargement of the, 385. Sthenic diseases, 33. Stomatitis, 192. Stethoscopic sounds in consumption, 415. ---------------in aneurism, 498. Spinal irritation, 568. Squamous diseases, 686. THE Strofulus, 672. Stone in the bladder, 729. ----in the urethra, 730. Sudamina, 136. Sweating stage of fevers, 88. 95. Sycosis, 685. Suppression of urine, 731. Syphilis, 747. Syphilitic sequellae, 755. T. Tape worm, 226. 230. Tabes mesenterica, 270. I Tetanus, 571. Tertian fever, 69. Tenia, 226. Testes, inflammation of the, 76K Tic douloureux, 587. Tracheitis, 368. Trismus, 572. --------nascentium, 575. Tourniquet in chill, 94. Tubercles of the intestines, 259. --------of the liver, 330. Typhus fever, Typhoid fever, 134. Tympanitis, 205. Tubercles of the lungs, 419. ---------of the heart, 495. ---------of the uterus, 777 I U. Urticaria, 179. Urethra, inflammation of, 713. -------stone in the, 730. Urine, suppression of, 731. ----- retention of, 734. ----- incontinence of, 735. Uterus, inflammation of the, 763. ------cancer of the, 767. 769. ------sarcoma of the, 767. ------prolapsus of the, 771. ------retroversion of the, 773. ------polypus of, 774. ------tubercles of, 775. Uvula, inflammation of, 147. V. Variola, 164. Varioloid, 168. Vaccination, 171. Varicella, 176. Valvular diseases, 497. Vascularity of inflammation, 255. Venereal, 747. I Vertigo, 526. Vesicular diseases, 693. Ulceration, 26. W. Water canker, 194. Water-brash, 205. Worms in the intestines, 227. .# VALUABLE BOOKS PUBLISHED LINDSAY & BLAKISTON, North West corner of Fourth and Chesnut Streets, Philadelphia. A Fourth Edition, brought up to the present time, Of MACKINTOSH'S PRINCIPLES OF PATHOLOGY AND PRACTICE OF MEDICINE. Fourth American from the last London Edition, WITH NOTES AND ADDITIONS, BY SAMUEL GEORGE MORTON, M. D. Late Physician to the Philadelphia Hospital, &c. &c. In one Volume, royal 8vo. The publishers, in offering to the patronage of the Medical Profession and Students of Me- dicine, the present edition of Mackintosh's Practice, deem it unnecessary to offer any remarks in commendation of a work so well known. The fact of its having passed through three edi- tions within a comparatively short period, and within that time having been highly recom- mended and used as a text book by the Professors in some of the first Medical Institutions in this country, with the constant demand which has existed for a new edition, give it at once strong claims upon the attention of the Profession as a work of great practical value. The present edition is fully brought up to the present state of the science, and is published in one volume, printed in a handsome style, and at a low price. It is therefore confidently recom- mended by the publishers as a text book to the various Medical Schools throughout theeountry. " Good white paper, clear large type, substantial bind- ing, and last, though not least, a full and accurate index-. are the mechanical merits of Morton's Mackintosh. In these days of cheap publishing, it is refreshing to lay hands upon a book like this. The style of ' getting up' the work does credit to the ability and liberality of Messrs. Lindsay & Blakiston, as publishers, i*nd we wish them, what we are 6ure they deserve, entire success. The work itself is well arranged, commencing with a general history of inflammation and fevers. Part second treats of diseases connected with the digestive organs. Part third, diseases of the respiratory system. Part fourth, diseases of the circulating system. And so on, in similar parts or divisions, all the various diseases are grouped and separately considered. The diseases are graphically described,so that they may be readily recognised by any person who is master of the contents of the volume. The treatment is lucidly detailed, and the whole leaves little, if any thing, to be desired by the student. But it is supererogatory to say any thing of the charac- ter or value of any work which, like this, has been printed for the eighth time. We know of no instance of a worth- less volume reaching even a second edition; and, accord- ing to our experience, whenever a third or fourth impres- sion of a work is called for by the public, it may be re- garded as a sure guarantee of high merit. The work of Dr. Mackintosh, on the Practice of Medi- cine, has ever been a favorite. We believe the present edition, enriched bv the discriminating labor of Dr. Samuel George Morton, than whom there are very few better qua- lified to write on this subject, both on account of his ex- perience and his ability to truly observe, will be still pre- ferred to most of the works on Practice, published in the last five years. Dr. Morton has brought not only his own experience and skill to perfect the work of Dr. Mackintosh but he has also added judiciously from the labors of both American and European authors, thus bringing the book un to this day""—V. S. Gazette. , , .. "That th?s volume should have passed to a fourth edi- tion in this country, is a strong proof of its popularity. It is a most valuable epitome of medical practice, founded upon the most approved pathology, the state of which at the present day, it very accurately represents. No better book can be purchased by the student than this, which ranks with the excellent works of Graves, Armstrong and Watson, to which in style and arrangement it is closely allied. The author was a man of great learning, indefa- tigable zeal, and extensive practice. As a pathologist, he was able, warm and enthusiastic. He writes agreeably, with clearness and vigor, and his book bears the marks at once of deep thought, close and correct observation, ample experience and accurate knowledge of past and ac- tual pathology. The American editor, well known as one of the savans of our sister city, in which professional cha- racter has attained to so prond an eminence, has added much valuable matter, and filled up ably and usefully many hiatuses left in the original. The "work is one of the most useful text books on the subject of which it treats, extant in our tongue, and should be in the hands of every student, and on the shelves of every medical library."— New York Journal of Medical Science. " The high estimate placed upon this work by those best qualified to judge of its merit, is found in the fact, that while the press has been teeming with books upon the same subject, and while the publishers of medical period- icals are sending out excellent treatises upon medicine, in monthly and quarterly emissions, this large volume has gone through eight editions, four in England, and four in this country. The present comes to us with the addition- al value of Dr. Morton's notes and additions, which, he modestly tells ug in his preface, would have been far more ably supplied by the hands of Dr. Mackintosh himself, hacl it not been for his ' untimely and lamented death,'— we are not sure of this, Dr. Morton is an able and indus- trious man, and has given abundant evidence to the me- dical profession of his capacity, to do justice to any sub- ject which he may undertake to write upon, and we have no doubt that the additions of which he speaks so humbly add much to the value of the work."—American Jourvul of Dental Science. THE MEDICAL STUDENT'S TADE MECTJM, OR MANUAL OF EXAMINATIONS UPON ANATOMY, CHEMISTRY, MATERIA MEDICA, SURGERY, PRACTICE OF MEDICINE, OBSTETRICS AND POISONS, ADAPTED TO THE USE OF MEDICAL STUDENTS GENERALLY, BY GEORGE MENDENHALL, M. I>. Honorary Member of the Philadelphia Medical Society, Physician to the Cincinnati Dispensary, &c. A small Pocket Volume. 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