LECTURES 
 
 ON THE MORE IMPORTANT 
 
 ERUPTIVE FEVERS 
 
 HEMORRHAGES AND DROPSIES, 
 
 GOUT AND RHEUMATISM. 
 
 DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. 
 
 BY 
 
 N. CHAPMAN, M.D. 
 
 PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE, 
 ETC. ETC. 
 
 PHILADELPHIA; 
 LEA AND BLANCHARD 
 1844. 
 
^ 
 
 c 
 
 
 
 EifTERED according to the Act of Congress, in the year 1844, by 
 LEA & BLANCHARD, 
 in the Clerk's office of the District Court of the United States in and for the 
 Eastern District of Pennsylvania. 
 
 T. K. & P, G. COLLINS, PRINTBK*. 
 
TO 
 
 SAMUEL JACKSON, M.D. 
 
 PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, ETC. ETC. 
 
 THIS VOLUME 
 
 IS INSCRIBED, 
 
 BY HIS FAITHFUL AND AFFECTIONATE FRIEND, 
 
 N. CHAPMAN. 
 
NOTICE TO THE READER. 
 
 The motives which have led the author to the publication 
 of a portion of his Lectures, have been already set forth in a 
 previous volume, " On The Principal Diseases of the Abdominal 
 and Thoracic Viscera." Prompted by the same considerations, 
 he has been induced to continue the work. That this, like the 
 preceding volume, comes forth with one disadvantage, he is 
 aware. As a fragment of a course of lectures, it is deprived 
 of numerous facts or discussions, theoretical or practical, illus- 
 trative or exegetical, distributed under other heads, which could 
 not have been displaced and concentrated in it, without a rude 
 violation of the integrity of the plan, and injustice to the entire 
 undertaking. Nevertheless, he trusts that the work does not 
 suffer materially in this respect— and, at all events, that, what- 
 ever the defect may be to others, it cannot be felt by his class, 
 by whom the whole course is heard. 
 
 Philadelphia, October, 1844. 
 
CONTENTS. 
 
 Page 
 
 EXANTHEMATOUS FEVERS, - .... 13 
 
 Variola, or Small-Pox, - - .- - - 13 
 Inoculated Small-Pox, - - - - - -44 
 
 Varicella, or Chicken-Pox, ----- 55 
 
 Variola, Vaccina or Vaccina, or Cow-Pox, - - 60 
 
 Varioloid Disease, ------ 85 
 
 Rubeola, Morbilli, or Measles, - - - - 113 
 
 Scarlatina vel Febris Rubra — Scarlet Fever, - - 126 
 
 HjEMORRHAGIA, OR HEMORRHAGE, - - - - 152 
 
 Haemoptysis, or Spitting of Blood, .... 171 
 
 HEMORRHAGIC NaRIUM OR HEMORRHAGE FROM THE NOSE, - - 197 
 
 hematemesis, or vomiting of blood, - - - - 206 
 
 Hematuria, or Voiding of Bloody Urine, ... 218 
 
 Hemorrhagia Uterina, or Uterine Hemorrhage, - - 225 
 
 Hemorrhois, or Hemorrhoids, ----- 238 
 
 Cutaneous Hemorrhage, - 255 
 
 Purpura Hemorrhagica, ... - - 255 
 
 HYDROPS OR DROPSY, ------ 262 
 
 Ascites, -------- 283 
 
 Hydrops Saccatus vel Hydrops Cysticus, or Encysted Dropsy, 305 
 
 Hydrops Ovarii, ...... 306 
 
 Hydrops Pectoris, vel Hydrops Thoracis, - - - 317 
 
 Hydrops Pericardii vel Hydropericardium, ... 330 
 
 Hydrocephalus Internus, ..-.-- 335 
 
 Subacute Hydrencephalus, ----- 355 
 
 Chronic Hydrencephalus, - - - - - 358 
 
 Anasarca, ------- 365 
 
 ON SOME OF THE DISEASES OF THE MUSCULAR OR FI- 
 BROUS SYSTEM, ----- 377 
 
 Arthritis or Gout, ------ 377 
 
 Chronic Gout, ------- 405 
 
 Retrocedent, Retrograde, or Displaced Gout, - - 406 
 
 Atonic, Irregular, or Misplaced Gout, - - - 408 
 
 Rheumatismus, or Rheumatism, - * - - 417 
 
 Chronic Rheumatism, ------ 437 
 
EXANTHEIATOUS FEVERS 
 
 My attention is now to be directed to a set of cutaneous affec- 
 tions, denominated exanthemata. This is a bad title, as some of 
 them are attended by a pustular eruption, and not an efflorescence 
 or rash, as the term imports. To many of the febrile diseases, 
 an eruption is a constant incident. But such as I have at present 
 in view, are strongly marked by several peculiarities. They 
 originate in a specific contagion, — the consequent fever runs a 
 definite course, productive of a similar virulent eruption, and 
 destroys, with few exceptions, the susceptibility of the system to a 
 repetition of attack. 
 
 VARIOLA, OR SMALL-POX. 
 
 This is a disease of modern times. No account of it is to 
 be met with in the writings of Greece or Rome, which have 
 descended to us. Endeavours have been made by Willan and 
 others, to trace it to antiquity. But elaborate and recondite as 
 were their researches, they have not produced any satisfactory 
 evidence of its existence, and the fact, as stated, is now suffi- 
 ciently conceded. Forcibly has it been urged by Sydenham, 
 Mead and Friend, that, since Hippocrates, and, especially, Celsus 
 and Galen, are silent in regard to it, the works of the two latter 
 being a sort of digest of the knowledge of their predecessors, we 
 are entitled to this conclusion, — and the more so, from the pre- 
 cision of their histories of diseases, — that no such had occurred, 
 or with which they were acquainted. 
 
 The earliest notice of it is by the Arabian writers. An old 
 
 manuscript, in the library at Leyden, dated 572, declares that, 
 
 " in this year, small-pox and measles made their appearance in 
 
 Arabia." It seems, however, that several years before, it broke 
 
 2 
 
14 EXANTHEMATOTTS FEVERS. 
 
 out at the memorable siege of Mecca, where it raged with great 
 violence in the Christian army, leading to its total discomfiture. 
 This event happened, according to Gibbon, the historian, two 
 months prior to the birth of Mahomet, which was in 569. Never- 
 theless, it is true, that Procopius, in his historical writings, of an 
 earlier date by twenty years, describes an epidemic, with so many 
 of the features of small-pox, it is difficult to resist the conviction 
 of its having been really that disease. Beginning at Pilasium, in 
 Egypt, in 544, it spread to Constantinople, everywhere proving 
 the severest scourge, and, what is very characteristic, there was 
 an exemption from any repetition of attacks. As given, how- 
 ever, by this writer, who had no medical knowledge, the account 
 is defective in technical precision, and I suspect has seldom been 
 regarded as adequate authority in the controversies on this sub- 
 ject. 
 
 To Rhazes, who lived at the commencement of the tenth cen- 
 tury, we are indebted for the first full and accurate description of 
 small-pox. He states that it passed out of Ethiopia into Arabia. 
 To the writings of his predecessors, long since lost, by whom it 
 had been previously noticed, he, however, refers, and especially 
 to those of Ahron, a physician of Alexandria, in Egypt. The 
 latter resided in that city, in 641, when attacked by the Arabians 
 under Omar, the successor of Mahomet, and it is not improbable, 
 the disease was conveyed to it by the invading army, and in this 
 way he became conversant with it. This was seventy -nine years 
 after the siege of Mecca, on which occasion, so far as ascertained, 
 small-pox, as I have said, sprung into being. 
 
 By some, however, it is supposed, that it originated in China, 
 or the remoter India, or that, at least, it was known in these 
 regions for centuries anterior to the period I have mentioned. 
 But medical writings not existing, or to which access can be had, 
 among these people, this opinion, not resting on authentic records, 
 is a mere deduction from their mythology, religious institutions, 
 some allusions in their civil history, their traditions, and other 
 sources equally vague and distrustful. 
 
 Considering, however, the intimate connection of the Arabians 
 with the East, they might have derived it from that quarter of 
 the world. Be this as it may, we have the most satisfactory 
 proof of its introduction and diffusion through Spain, Sicily and 
 the Levant, by the Saracens, when they, in the eighth century, 
 
EXANTHEMATOUS FEVERS. 15 
 
 overran these countries. But though it had thus gained a partial 
 admission into Europe, it did not generally, till the close of the 
 eleventh or the beginning of the twelfth century, when the cru- 
 saders were engaged in the Holy Wars. 
 
 Contracting the contagion in Palestine, these bold and enthu- 
 siastic adventurers introduced it, on their return, into their native 
 places. The intercourse of the nations of Europe with each 
 other, becoming greatly extended by commerce, about this time, 
 it spread rapidly throughout Christendom, and, for several hun- 
 dred years, its ravages were terrible. Nor were these, subse- 
 quently, in our own hemisphere less extensive, in proportion to 
 the number of subjects. Conveyed to it by the successors of 
 Columbus, the tale of the misery and desolation it inflicted is 
 painful to peruse. Twenty -five years after the discovery of this 
 continent it occurred, and we are told, that it destroyed more 
 than a moiety of the population of the provinces into which it 
 penetrated. Three millions and a half are computed to have 
 fallen victims to it, in a very short time, in the kingdom of Mexico 
 alone.* 
 
 Brought, afterwards, by emigrants from Europe to our imme- 
 diate land, it swept off, also, several tribes of the aborigines, 
 leaving scarcely a sufficiency of them to preserve their names. 
 Gradually it reached other and obscurer regions, owing to the 
 enterprises of discovery and exploration, or to the slower en- 
 croachments of civilization, till very few portions of the globe, 
 perhaps, can now claim an exemption from it. There is, indeed, 
 only a single exception to the universality of its pervasion, of 
 which I am aware. " No case of small-pox, measles, or whoop- 
 ing cough, has been met with in New South Wales,"t which is 
 the more remarkable, from the freedom of communication with 
 that colony. 
 
 Not having existed in the classic ages, there could be no term 
 for it in the Greek or Latin languages. But, as some designation 
 was required for the disease, variola was coined out of the Latin 
 word varius, signifying spotted or speckled, or varus, a pimple, 
 or as some conjecture, from virus or virulentus, poisonous or ma- 
 lignant. The latter derivation has some support, from the Spanish 
 
 * Robertson's History of America. 
 
 •j- Evidence before the Committee of Emigration of the British House of 
 Commons. 
 
16 EXANTHEMATOUS FEVERS. 
 
 appellation of the disease viruelas, and the more so, as the whole 
 of the titles of the exanthematous fevers were originally conferred 
 by the school of Cordova, where the teaching of medicine was 
 first instituted in modern Europe. The vernacular term is said 
 to come from the Saxon pocca, a pock or pouch, and the epithet 
 small, variola minuta, was afterwards adopted to distinguish it 
 from syphilis, when it appeared, then vulgarly called great pox. 
 The first case on record of variola, by this name, is that of 
 Elfrida, daughter of Alfred, of England, and wife of Baldwin 
 the Bold, Earl of Flanders — and the next, that of her grandson, 
 Baldwin. The one occurred in 907, and the other in 961. These 
 cases are interesting, as showing that the disease had crept into 
 the west of Europe at an earlier date than is generally stated. 
 Nor, probably, were they the only instances of it. Destitute of 
 medical writers at the time, there was no regular history of the 
 disease, and it is presumable that these two cases were singled 
 out by the monkish annalist, who relates them, as notable events, 
 from the superior rank of the personages in whom they happened. 
 
 The variolous disease is usually divided into two species or 
 varieties, according to the appearance of the eruption — the dis- 
 tinct or discrete, and confluent, or, when the pustules are sepa- 
 rate, or with intervening spaces between them, and when they 
 run into each other and coalesce, so as to form nearly an undis- 
 tinguishable mass. But this is an arbitrary division, it often 
 happening that, while the eruption is distinct in one, it may be 
 confluent in other portions of the body. Frequently does this 
 occur in relation to the lower extremities and face particularly. I 
 have seen cases with scarcely a pustule on the former, and on the 
 latter one unbroken series. Wrong is it, also, to characterize a 
 disease by a single incident, however prominent it may be, and 
 the more so when it is fluctuating, and liable to diverse modifi- 
 cations. Besides which, the distinction is founded on an external 
 appearance, having, comparatively, little connection with the real 
 pathology of the disease. As variola is attended by fever, or 
 a general condition actively inflammatory or passively congestive, 
 it seems to me it were better to treat of it, at least as concerns 
 practical advantages, in conformity with these views— and hence 
 I shall adopt such an arrangement. 
 
 Nothing very peculiar is discernible in the introductory symp- 
 toms of the first or inflammatory small-pox. Like pyrexia, 
 
EXANTHEMATOUS FEVERS. 17 
 
 generally, it commences with languor, weariness, aches in the 
 head, back and lower extremities, chilliness, alternated by flushes 
 of heat, thirst, nausea or vomiting, precordial or epigastric 
 uneasiness, and some rigidity, or soreness of throat. Fever 
 being developed, the pulse becomes full and vigorous, the skin 
 warm, the face turgid, the eyes slightly injected, the respiration 
 hurried, the tongue white, or sometimes red at the point or edges, 
 the stomach still irritated, and betraying tenderness on pressure, 
 the bowels costive, and the urine scanty and high coloured. The 
 irritation extending to the lungs or appendages, these betray the 
 implication, by acute or dull pain in some part of the chest, and 
 by more or less embarrassment of breathing, according as the 
 pulmonary substance or tissues, or the trachea, or its termina- 
 tions, may be concerned. 
 
 Continuing pretty much in this way, till towards the third day, 
 some exacerbation of the febrile state is manifested, and now 
 confusion of mind or even delirium may occur, or there is heavy 
 somnolency only. The epigastrium is exceedingly tender, the 
 vomiting more violent, the tongue very florid, the hands and 
 feet cold, while the surface, generally, is hotter, emitting a pecu- 
 liar and offensive odour. Nor is the pulmonary disturbance less 
 heightened, by an increase of the catarrhal, laryngitic, bronchitic, 
 pleuritic, or pneumonic affections. During this period, haemor- 
 rhage from the nose is apt to occur in adults, and convulsions in 
 children, in whom this further peculiarity may be remarked, that 
 they perspire less, and have not, in an equal degree, the smell to 
 which I have alluded. An exasperation of symptoms is usually 
 the immediate precursor of the eruption. 
 
 Breaking out, as minute red elevated specks, about the end of 
 the third day,< first on the face, particularly on the forehead, nose, 
 chin and around the mouth, then on the neck and wrists, the 
 eruption extends over other parts of the body, the chest, abdomen, 
 and back, — lastly, on the lower extremities, and is completed in 
 forty-eight hours. Much more numerous are the pustules on the 
 face than elsewhere : perhaps, one-third or fourth part of the 
 whole crop is crowded within this small space. They are largest 
 on the hands and feet. It is said that the pustules sometimes 
 "undergo a grouped or crescentic arrangement," which I have 
 not observed. From the commencement of the eruption, the fever 
 
18 EXANTHEMAT0US FEVERS. 
 
 abates, and with its completion, where the attack is moderate, 
 entirely subsides. 
 
 These red specks, at the close of the second day, become a 
 little more elevated, — having a slight central depression, and an 
 inflamed base. Towards the fourth day, they receive a further 
 change. Now may be perceived in them, a small portion of 
 limpid fluid, — thence they enlarge and become conspicuously 
 umbilicated. An inflamed circular margin or areola, of a rose 
 or damask colour, surrounds each, which, the eruption being con- 
 siderable, spreads and approaches each other, occasioning some 
 increase of tumefaction, especially of the face and eyelids. By 
 the seventh or eighth day, the vesicles having further augmented 
 in size, they assume a more spheroidal shape, and begin to fill 
 with purulent matter. This filling proceeds from the circumfer- 
 ence to the centre. It is supposed, though not satisfactorily, that 
 the vesicle is thus gradually converted into a pustule by the 
 absorption of the pellucid fluid, and the secretion of pus in place 
 of it, or by the former being changed into the latter. This sup- 
 purative process continues for three or four days, the pustules 
 growing still larger, fuller, more yellow and opaque, till they 
 attain maturity, which is generally on the eleventh day, and from 
 distension, lose their central depression, or at least the largest of 
 them undergo this change. Negroes, it is remarked, have never 
 the eruption so prominently developed. The pustules are smaller, 
 flatter, and contain less fluid, which may be referred to the thick- 
 ness and density of their cuticle, binding more firmly down the 
 cutis vera. 
 
 Now, at this maturative stage, the secondary fever, as it is 
 called, — the antecedent being termed the primary fever, — arises, 
 owing to the irritation of the skin, which subsides with the cause 
 of it. Concomitantly with this, is an aggravation of the soreness 
 of throat, and difficulty of swallowing the saliva and fluids of 
 the fauces, which become very viscid, creating a constant scriatus, 
 or hawking, or a copious salivation ensues, in grown persons, or 
 diarrhoea in children, and in both the voice is hoarse, with other 
 evidence of laryngeal irritation. 
 
 Little alteration immediately takes place in the eruption, and, 
 sometimes, it remains stationary for several days. Commonly, 
 however, a dark spot is soon discernible in the centre of the 
 pustules, when, in vulgar parlance, the eruption is said to begin 
 
EXANTHEMATOUS FEVERS. 19 
 
 to turn, and, with this appearance, they progressively shrink and 
 dry away, till scabs are formed, which, falling off, leave a red or 
 purplish surface, that slowly disappears, or pits, or scars, or 
 seams, which permanently endure. In the decline of this state 
 of things, the same order is observed as in the rise and progress 
 of the eruption, first decaying on the face, and so, successively, 
 as it appeared. 
 
 Conformably to the preceding account, the career of this dis- 
 ease is distinguished by four different stages. The invasive, 
 lasting three days, — the eruptive, two days, — the maturative, six 
 days, — and the declinative or scabbing, four or five days, with, 
 however, various deviations, in each respect, the whole process 
 being seldom over in less than a fortnight, and may continue 
 much longer. 
 
 When distinct and benignant, such is the usual character of 
 inflammatory small-pox. But it is subject to great varieties in 
 many other of its features, and which are made the basis of 
 numerous species. My limits are too narrowed to notice, in 
 detail, these diversities. The form and contents of the pustules 
 are sometimes widely different, and hence the distinctions of vesi- 
 cular, vesiculo-pustular, crystalline, watery, siliquose, varicose, 
 horny pocks, &c. &c. By no means certain, is it, however, that 
 such are varieties of real small-pox. They may, I think, with 
 greater propriety, be referred to the class of varioloids. 
 
 To these may be added other peculiarities — the first, where 
 one or more pocks are included in another larger pock, or vesicle, 
 — the second in which fresh pocks are formed on the tops of those 
 — previously existing, — and a third, when there is only an efflo- 
 rescence. These several varieties, sometimes prevail pretty 
 generally, though oftener individually, here and there, a case 
 presenting itself as a mere anomaly. 
 
 The disease being of an extremely typhoid, congestive or 
 adynamic nature, it may be ushered in with the manifestations of 
 collapse, cold skin, pale and sunken countenance, great anxiety 
 and oppression, and a very feeble circulation. Death here, in 
 some instances, abruptly takes place, with very slight or scarcely 
 any reaction, the system sinking, as it were, under the pressure 
 of a morbid influence, from which it cannot be extricated either 
 by the resources of nature or of art. 
 
 More frequently, however, the invasion is indicated by languor 
 
20 -EXANTHEMATOUS FEVERS. 
 
 and iistlessness, dejection of spirits, heavy sighing, muscular sore- 
 ness and severe pain in the back and lower extremities, alter- 
 nations of chilliness and flushes, great precordial distress, and 
 disorder of stomach. This state, usually protracted, is slowly 
 succeeded by the development of fever, with a small, weak, 
 quick pulse, unequal distribution of temperature, the head and 
 trunk being extremely hot, amounting to even the calor mor- 
 dax, while the extremities are cool, the perspiration scanty, or 
 the reverse, copious, and of a cadaverous odour. As the disease 
 proceeds, it is marked by a disclosure of cerebral and nervous 
 disturbance, giddiness, disposition to syncope, heaviness or abso- 
 lute coma, subsultus tendinum, sometimes convulsions, free dis- 
 charges of pellucid urine, or total suppression of the secretion of 
 it, and watery diarrhoea, particularly if there be not vomiting. 
 
 The state of the epigastrium is not uniform, sometimes ex- 
 quisitely tender on pressure, and is often otherwise, owing to the 
 extinguishment of organic sensibility. Nor is that of the tongue, 
 which is florid, and apparently raw, or becomes heavily encrusted 
 with dark sordes. 
 
 The eruption may show itself earlier, by a day or two, than 
 the ordinary period, — while, in other instances, it is more delayed, 
 even to the fifth or sixth day, sometimes partially appears, and 
 recedes, producing the most deadly sickness, syncope, or stupor 
 and convulsions. Taking place, however, the face is covered 
 with small papular specks, which run into each other, forming a 
 red, tumefied rugous surface. 
 
 But, on some occasions, the primary appearance is that of an 
 erysipelatous rash, or efflorescence. Trivial or no remission of 
 fever is discernible on the occurrence of the eruption in any of 
 its shapes, and very often it is exasperated. 
 
 Great irregularity prevails in the further progress of the case. 
 The eruption tardily advances, or reversely, very rapidly, so that 
 the entire superficies is almost simultaneously covered. It may 
 happen, that the natural powers stop at this point, — no further 
 effort is made towards pustulation, and the eruption becomes 
 livid, or the whole recedes. But where it is otherwise, the 
 pimples slowly enlarge, and fill with a thin, gleety, or darkish 
 fluid, and rarely with yellow, consistent, purulent matter. These 
 imperfect vesicles, instead of assuming a definite figure, with a 
 flattened surface and central indentation, are of every shape, 
 
EXANTHEMATOUS FEVERS. 21 
 
 sometimes conoid, or the reverse, sunken, with ragged edges, 
 coalescent, or, if there be intervening spaces, they are very pallid, 
 or, as may be, dark from livid petechia?, vibices, or ecchymosis. 
 Nearly every portion of surface is, at this time, more or less 
 swollen, — the face, the eyelids, the latter particularly, — so as to 
 be closed,— and the hands and feet, successively, in scarcely a 
 less degree. Tenderness or soreness of the skin is complained of, 
 and the itching is most harassing. No remonstrance can induce 
 a forbearance from rubbing or scratching, and the eruption is 
 terribly lacerated in some instances. The pustules having reached 
 maturity, become blended, forming one mass, or, in some parts, 
 no separation can be discerned between them, constituting the 
 confluent disease, which, though it may occur in the inflam- 
 matory, is much more incident to this form of it. Excessive 
 exhaustion not existing, an increase with the secondary fever of 
 all the affections takes place. 
 
 To an aggravation of sore throat and difficulty of swallowing, 
 are added obstruction of the larynx or bronchi, and much pul- 
 monary and cerebral disorder, from heavy venous congestions of, 
 or effusions into these organs. Cases of extraordinary malignity 
 are, moreover, marked, as previously mentioned, by petechia?, 
 vibices, colliquative haemorrhages, especially bloody urine, with 
 copious diarrhoea, and the pustules, finally bursting, the matter 
 escaping, hardens into brown crusts, which very slowly fall off 
 should life be preserved. 
 
 Of the malignant, there are as many varieties as of the more 
 benignant disease, among which, may be enumerated, the erysipe- 
 latous, the morbillous, the miliary, sanguineous, and gangrenous 
 or putrid, so called from the exhibition of such appearances, 
 instead of those of the ordinary eruption. 
 
 By some it is affirmed that, during the epidemic prevalence of 
 small-pox .especially, there is often the coincidence of a fever, 
 having all the characteristics of that disease, save the cutaneous 
 affection. This is the variolous fever of Sydenham and the 
 variolx sine variolis of De Haen, and more modern writers. 
 Exactly such an occurrence, I have not witnessed. But the 
 dominant influence of these epidemics over other diseases has 
 been remarked by me, and confessedly where individuals, how- 
 ever protected, are exposed to the concentrated contagion, as in 
 nursing the sick, it is not uncommon for them to incur fever of a 
 
22 EXANTHEMATOUS FEVERS. 
 
 variolous aspect. That the disease too, often aborts, ending 
 fatally in the inchoative stage, is sufficiently known. But some- 
 thing very different from either of these cases, is meant in the 
 form of disease we are now contemplating, by those who have 
 described it. They evidently deem it to be a species of vario- 
 lous affection, which, owing to some modifying circumstances, 
 not ascertained, passes away without involving the skin in the 
 usual manner. The hypothesis has some support in analogy. 
 We see the same thing in relation to scarlatina, it existing inde- 
 pendently of any exantheme, and have the stronger illustration 
 of variolation, where the small-pox virus becomes so changed in 
 its operation, by the mode of application, as sometimes to produce 
 little or no eruption. 
 
 Not inconceivable is it, that there may be some unknown 
 causes having the same effect, in a still higher degree. 
 
 The preceding description of small-pox, is merely a sketch, 
 sufficient only to a general comprehension of the disease in its 
 average presentations. To delineate it in its infinite modifica- 
 tions, with all their details, or such, at least, as have been repre- 
 sented, would require a most elaborate work. 
 
 From the historical evidence I have presented, it results that 
 the disease, probably, was developed at the siege of Mecca, for 
 the first time, though under what peculiar circumstances gene- 
 rated, we have no real information. Conformably to the super- 
 stitious spirit of that dark age, there is a miraculous account of 
 its origin, almost too ridiculous to be repeated. The infidels tell 
 us, that, at the moment of their greatest distress, a flock of birds 
 came to their succour, with faces like lions, holding in each claw 
 a small stone of the size of a pea, which, being let fall on the 
 Christian army, occasioned an eruption, by which the whole of 
 it was destroyed, — while the latter, not to be outdone, ascribed 
 the calamitous event to an impious stratagem of the Devil himself. 
 
 An old tradition refers its derivation to the camel, and I shall, 
 hereafter, mention some facts calculated to show that it may 
 have pre-existed in horned cattle. Its epizootic origin is, on the 
 whole, I think, deemed the most probable conjecture on the sub- 
 ject, though strong objections may be urged against it. 
 
 That variola now arises from a specific contagion, whatever 
 may have been the cause of its primary development, cannot be 
 doubted. As certain is it that the virus may exist in the form of 
 
EXANTHEMATOUS FEVERS. 23 
 
 palpable matter, or as a subtile emanation, the one operating by- 
 contact, the other through the medium of the atmosphere. Not 
 so well determined is the distance to which this effluvium may 
 be conveyed. That it might be wafted by the winds, and infect 
 within a great, though indefinite space, was once believed. Of 
 late a different impression is entertained, and the sphere of its 
 influence in the open air is circumscribed to ten or twelve feet. 
 The experiments of Haygarth, confirmed by those of Ryan, 
 Professor at Lyons, render the point tolerably clear. Not im- 
 probable, however, does it seem, that the contagious principle is 
 connected with the peculiar odour in the disease, and as far as 
 this may be smelt, is the danger of infection. Common people 
 believe it to be so, and, perhaps, on adequate grounds. 
 
 Whether the contagion can be conveyed by fomites, has been 
 lately questioned, at which I am surprised, having thought the 
 affirmative evidence very satisfactory. Medical men, engaged in 
 the practice of inoculation, and attending patients in all stages of 
 small-pox, not conveying the disease, though adopting no pre- 
 cautions against it by a change of clothes or otherwise, is the fact 
 mainly relied on, which, surely, is inconclusive. More time than 
 such transient visits afford, may be required for the impregnation. 
 The true test would be an exposure to the apparel or bedding of 
 the patient. Facts prove that it may be imparted from the dead 
 body, among which Mr. Caesar Hawkins, of London, states that 
 a subject was brought into his dissecting room covered with 
 small-pox, which gave the disease to four of his class, and much 
 evidence might be adduced of the enduring tenacity of the con- 
 tagion, even to the walls of a room in which the patient had laid 
 weeks or months before. Every precaution, I think, should be 
 adopted, under such circumstances, to prevent infection, by the 
 destruction or purification of all articles likely to serve as fomites, 
 and by the freest and persistent ventilation. 
 
 Curious is it, that the contagiousness of the disease should so 
 long have escaped detection. No allusion to such a property in 
 it can be traced, till after the time of Sydenham. That close 
 observer, himself unsuspicious of contagion, refers the production 
 of the disease to a peculiar constitution of the season. Boerhaave, 
 however, soon afterwards announced the fact, which has never 
 since been disputed. 
 
 We know not exactly at what period of the disease this 
 
24 EXANTHEMATOUS FEVERS. 
 
 property is acquired — some of the authorities, and particularly 
 Heberden and Haygarth, among the very highest of them, main- 
 taining that it is not, for days after the appearance of the exan- 
 theme, or indeed till its maturation. By others, it is alleged that 
 it occurs as early as the preliminary fever, and that the poisonous 
 effluvia escape both from the lungs and the skin. These latter 
 views, however, are without confirmation. As we know that 
 the contagious principle is secreted by the eruption, and have no 
 evidence of its being derived from any other source, it follows 
 that it cannot exist prior to the formation, and, perhaps, the 
 maturity of the cutaneous affection, though, as in the vaccine, it 
 may possibly be eliminated by the vesicle as well as the pustule. 
 Nor is it less evident, that, since the lungs are destitute of the 
 eruption, they do not concur in the generation or emission of the 
 contagious halitus. 
 
 The latent or incubative period of the virus is fourteen days, 
 which, according to my experience, is observed with much regu- 
 larity. Fordyce, who paid great attention to it, agrees with me 
 on this point, and such, I think, was the common opinion of our 
 practitioners when the disease prevailed widely among us. The 
 late Professor Rutherford, of Edinburgh, was in the habit of 
 saying that, on one occasion, he knew a number of soldiers, 
 accidentally exposed to the contagion, in whom the disease 
 showed itself, on an average, at this period. Facts of the same 
 purport are very familiar, some of which have come under my 
 own notice. For the most part, it is pretty certain in its effects, 
 and all ages are liable to the disease. Even the foetus in utero, 
 sometimes, though rarely, becomes infected, and there are several 
 cases recorded by Jenner and others, of its happening where 
 the mother entirely escaped from previous protection. 
 
 An instance is, indeed, given by Sir William Watson, of a 
 child having been born with the marks of the disease, showing 
 that it had suffered and recovered from it in the fcetal state. 
 
 Nevertheless, some individuals, however exposed, have no 
 susceptibility to it, continuing unimpaired through a long life. 
 Entire families sometimes enjoy this exemption. Fodere men- 
 tions the very remarkable instances of those of both of his grand- 
 fathers having escaped, and that he himself, though in advanced 
 age, and often subjected to its contagion, had never had the dis- 
 ease. It has, indeed, been calculated, that one in fifty has such 
 
EXANTHEMATOUS FEVERS. 25 
 
 a constitutional immunity. But this estimate seems too large, 
 and in no instance, is an exemption from it to be too confidently- 
 relied on. Examples are numerous, of persons who, after escaping 
 for a term of years, where affectability being awakened by some 
 mysterious change of condition, the disease attacked, and for the 
 most part, fatally. 
 
 But while contagion must be admitted as an inherent and 
 uniform quality of small-pox, it is not less true, that it is mate- 
 rially dependent, for its nurture and dissemination, as well as for 
 its infinite modifications, on an epidemic influence. That it ever 
 arises, de novo, from the same combination of circumstances 
 which first called it into existence, the state of our knowledge is 
 not sufficiently precise to determine positively. But such was 
 the opinion of the early historians of the disease, and which is 
 not wanting in support from the manner of its occasional subse- 
 quent recurrences. From time to time it has burst forth, with- 
 out our being able to trace its revival to any concealed contagion, 
 spreading most rapidly, widely, and always in its worst shapes, 
 from country to country, — exercising an unequivocal sway over 
 all other diseases ; — then suddenly disappearing, to return again 
 at some future period, — in all which features, conforming to the 
 phenomena and laws of epidemics. The late prevalence of it 
 supplies a striking illustration of this fact. Breaking out at 
 Edinburgh, in a few years it pervaded nearly the whole world, 
 exhibiting everywhere all those traits I have mentioned. Thus 
 existing, the cause also proves far more operative, so that it 
 subverts, in many instances, the protection afforded by previous 
 attacks, whether naturally or artificially acquired, and secondary 
 small-pox becomes a less unfrequent event. 
 
 The histories of the disease confirm these statements. Nor are 
 we without more immediate evidence of it. In 1823, when 
 small-pox appeared in this city, after a long interval, it could not 
 be traced to any imported or derivative source of contagion. 
 Cases sprang up, as it were, spontaneously, at a distance from 
 each other, independent of any probable intercourse, wearing 
 universally a most formidable character, and the failures of 
 variolation, and especially of vaccination, were numerous, with 
 some few examples of the disease, previously had in the natural 
 way, affording no security. As further proof of the dominant 
 epidemic influence at the time, it may be said, that in the 
 3 
 
26 EXANTHEMATOUS FEVERS. 
 
 whole compass of our experience, never was exhibited such a 
 tendency to cutaneous affections — every disease, whatever might 
 be its nature, displaying in its course, some eruptive appearance, 
 and often of the most anomalous character and aspect. 
 
 Conversely, there are times and places at which the contagion 
 of variola becomes so inactive, owing, as is supposed, to peculiar 
 states of the atmosphere, that it will not operate, some of the 
 most striking proofs of which, it may be well to cite. Examples 
 are related by Van Swieten and Odier, where the disease could 
 not be communicated in certain situations, whatever might be 
 the degree of exposure to the contagion, and Sir John Pringle, 
 physician-general to the British army in Flanders, in the war 
 of 1756, states, that on one occasion, the disease was brought into 
 camp by a body of troops, without it at all extending, though 
 no preventive was adopted. The former Professor Von Doeveren, 
 of Leydon, supplies us with an analogous fact. "Twelve children, 
 labouring under small-pox, entered the city of Groningen with a 
 company of foot. These children were dispersed in the houses 
 of the poorer sort of inhabitants, in the midst of numbers who 
 had not had the distemper. Nevertheless, after the most sedulous 
 inquiry, not an individual could be found to whom the infection 
 had been communicated." His colleague, Professor Sanderson, 
 also mentions an account of similar import, " that in the Orphan 
 House at the Hague, one of the children was seized with small- 
 pox, and though the intercourse between the patient and the 
 rest of the orphans was not interrupted, none of them caught the 
 disease." 
 
 From Sir James McGregor, who held a high appointment in 
 the medical staff, in India, we further learn, that while the disease 
 was raging in the vicinity of the barracks at Bombay, not a 
 soldier took it, subjected, as they were, to the contagion by the 
 freest intercourse with the infected, — and we are assured by 
 Buckhardt, a very respectable authority, that small-pox has 
 never been known in a narrow district of Egypt, prevailing, as 
 it frequently had done, in the surrounding country. As before 
 noticed, it is, indeed, affirmed, that neither it nor any other of 
 the diseases arising from specific contagions, has hitherto been 
 developed in New South Wales. Controlled as they all are, by 
 seasons, and each by temporary conditions of weather, of the 
 latter of which we have a remarkable instance in relation to 
 
EXANTHEMATOUS FEVERS. 27 
 
 small-pox particularly, in the suppression it receives from the 
 prevalence of the Harmattan winds, we are not to be surprised 
 at the influence, in the same way, of more permanent states of the 
 atmosphere, local or general. I have to add that, in a great 
 degree, the same difficulty has been sometimes experienced in 
 the propagation of these diseases, under similar circumstances, 
 by inoculation. 
 
 Notwithstanding the plausibility of the conjecture alluded to, 
 that the contagion of small-pox is occasionally generated anew, 
 I am not disposed to adopt it. To me it seems more probable, 
 that the semina of contagion, like those of plants, or ova of 
 animals, and especially of insects, may remain dormant for an 
 indefinite period. As the latter are hatched into existence, by a 
 proper degree of temperature, and other propitious circumstances, 
 so is it required, to bring the former into activity, a peculiar con- 
 stitution of atmosphere. We are not wanting in proof, that the 
 seminal principle, in each of the instances cited, will endure for a 
 long term of years in a latent state, waiting, as it were, for the 
 vivifying impulse to be supplied, — and may it not be equally 
 true in regard to contagion ? The musquito, the locust, not to 
 enumerate more examples, disappear for a protracted season, 
 having deposited their eggs, to be awakened into life at some 
 favourable conjuncture. Every agriculturist is aware of the 
 reversions of certain plants, at remote and irregular periods, the 
 seeds of which must have remained in the soil. As clearly does 
 it seem, that the material of this and all other contagious dis- 
 eases, is governed by a similar law. Much reliance, I am aware, 
 has been placed on the doctrine of equivocal generation, in the 
 explanation of some of the preceding phenomena. But can it be 
 reasonably credited, that any fortuitous combination of elements, 
 which this doctrine supposes, is productive of such definite 
 results ? 
 
 Lastly, may it be demanded, if the action of the variolous cause 
 can be suspended for months, by change of season only, why 
 may it not be by other influences for years? We have seen, 
 among ourselves, the disease raging during winter, and ceasing 
 on the approach of spring, to appear again on the return of cold 
 weather, and pursuing this order for a lengthened period. It 
 might, perhaps, be shown, — though I am not prepared to extend 
 the doctrine so far, that every disease has one definite cause, 
 
28 EXANTHEMATOUS FEVERS. 
 
 which is active or inert, according to the presence or absence of 
 those contingencies by which its operation is controlled. Can we, 
 at least on any other supposition, so easily explain their occasional 
 prevalence, or the reverse, and, particularly, epidemic visitations 
 and their suspensions ? Nearly every disease may assume this 
 popular character — and its being sporadic or more general, mild 
 or otherwise, I think must be referred to the extent and force of 
 the agency by which the cause of the disease is developed and 
 strengthened. 
 
 Well evolved, the variolous eruption is so strongly and une- 
 quivocally designated, that it can seldom be mistaken. Chicken- 
 pox is one of the cases with which it may most readily be 
 confounded. Even here, however, the discriminating circum- 
 stances are, for the most part, prominent and clearly defined. 
 The latter is preceded by little febrile or other uneasiness, and 
 about the second day of attack vesicles appear, which, by the 
 fourth or fifth day, dry away, — at a time when the eruption of 
 small-pox has not gone through its earliest stage. The eruption 
 too, in varicella, is apt to come out in successive crops — is, as inti- 
 mated, vesicular and not pustular, and the vesicle pointed, and 
 filled with lymph. That of small-pox, on the contrary, is flat 
 and indented in the middle, and does not lose these peculiarities 
 till it reaches complete maturity, when, distended with pus, it 
 becomes ovate or globular. Devoid of the cellulated structure 
 of the variolous pustule, the varicellous vesicle is, moreover, 
 merely cuticle, easily ruptured, when, or by puncture, the whole 
 of the fluid at once runs out. 
 
 Nevertheless, it cannot be denied that, in some instances, 
 chicken-pox assumes so much the aspect of small-pox, as to 
 embarrass practitioners the most conversant with the two dis- 
 eases. Eminent writers on the eruptive affections, confess this 
 — and I have known sometimes the same degree of perplexity 
 to occur in this city. 
 
 Examples of umbilicated varicella are not rare, of an imper- 
 fect formation, as well in regard to the pustules as other circum- 
 stances. But it occasionally happens, that in a family where the 
 disease is prevailing at the time, as I have witnessed myself, a 
 case will arise to all intents and purposes, variola in its external 
 physiognomy — and we shall presently see that varicellous epi- 
 demics of this character have existed. 
 
EXANTHEMATOUS FEVERS. 29 
 
 There is also the varioloid disease, in which the difficulty of 
 diagnosis is, perhaps, still greater. Commonly, however, it may 
 be recognized by the mildness of the prelusive fever, by the 
 earlier appearance of the eruption, which is scanty, and rather 
 vesicular than pustular, — by the absence of the variolous odour, 
 and by the more speedy commencement of desiccation, — as well 
 as by leaving behind, in place of pits or indentations, a smooth 
 red surface, or small excrescent elevations. As, however, in 
 varicella, cases of it are not unfrequent, so intimately allied to 
 variola in every feature, as to defy the best powers of discrimina- 
 tion. But more of this hereafter. 
 
 Little is usually to be apprehended in the discreet or distinct 
 small-pox. The confluent, on the contrary, is always alarming, 
 — though less so, where the fever is inflammatory, and the vital 
 forces unimpaired. By the aid of common skill, the constitution 
 will work out its preservation. 
 
 Never exempt from danger is the typhoid or congestive con- 
 dition, and, when malignant, scarcely a hope can be indulged. 
 Much may be deduced from some other circumstances. Nearly 
 always fatal is the disease in infancy, still more so in advanced 
 life, and is most favourable between the second and tenth years 
 of age. The season of puberty, in females, is said to be unpro- 
 pitious, by a high authority, which I have not remarked. But 
 with pregnancy it is awfully fatal. 
 
 An eruption, covering the surface, though not confluent, is 
 dangerous from the injury done to the skin, and is particularly 
 so where the face is thickly invested. The character of the pus- 
 tules, too, materially influences the result. It is best when they 
 are elevated, round or oval, environed by a definite red areola, 
 and filled with thick yellow pus,— coming out seasonably, and 
 passing normally through the several stages to maturity. Devia- 
 tions in any respect from this, are calculated to excite solicitude, 
 and especially where the eruption either lingers in its appearance, 
 or manifests itself prematurely, — or the pustules are flat and 
 nearly empty, or indurated or filled with a lymphy, or serous, or 
 darkish fluid, and, above all, with blood. 
 
 Cessation of fever, with pallor, and other evidences of collapse, 
 during the eruptive stage, is alarming, and the more so, if followed 
 by suppression of urine, or recession of the eruption. The sud- 
 den subsidence of the swelling of the hands, or of the salivation, 
 
 3* 
 
30 EXANTHEMATOUS FEVERS. 
 
 is a bad indication. Complicated with any of the affections 
 formerly noticed, the danger is considerably enhanced,— though 
 less when inflammatory than heavily congestive. Laryngitis, 
 however, is an exception, which nearly always proves fatal, on 
 attaining to any height, and the same may be said of bronchitis, 
 the inordinate secretions occasioning suffocation. Derangement 
 in the cerebral and nervous system, evinced by tremors, subsultus 
 tendinum, stupor or delirium, slow and muttering, or wild, par- 
 ticularly the delirium ferox of the old writers, is, moreover, of 
 evil import. Not less so, perhaps, are passive haemorrhages from 
 the bowels, kidneys, or other parts, or petechias, vibices, slough- 
 ing of the fauces, and the other signs of what was once considered 
 a putrid diathesis. 
 
 The eleventh and thirteenth days are thought, usually, the 
 most dangerous, — though the eruptive stage throughout is critical, 
 and much is to be apprehended from any extraordinary violence 
 of the secondary fever. But, under all circumstances, natural 
 small-pox proves frightfully fatal, — one out of four dying, what- 
 ever may be the advantage of situation, or the degree of medical 
 skill, — and this mortality takes place when there is no extraor- 
 dinary violence in the disease. The reports of the London Small- 
 pox Hospital, show that, for the last fifty years, the deaths have 
 averaged about thirty, though, on some occasions, amounting 
 to forty per cent. With the malignity incident to some of the 
 occurrences of it, two out of three perish, or even a greater propor- 
 tion. We lost, in the beginning, more than one-half in hospital 
 practice, in the last epidemic prevalence of it in this city. The 
 same mortality has happened elsewhere, and especially, in the 
 hospital at Ceylon, in the year 1819. 
 
 Diversified as this disease is by gradations of severity, as well 
 as adventitious complications, the phenomena, on dissection, must 
 of course, be materially different. The mucous membrane of 
 the stomach and small intestines is florid and highly injected, in 
 patches or more diffused, and that of the lungs often in a similar 
 condition, though usually not so intense, with the brain, particu- 
 larly its arachnoid tissue, scarcely less affected. But in very 
 violent attacks, the ravages of the disease are manifested through- 
 out the parts enumerated, to the destruction of organization, in 
 which condition is also sometimes found most of the contents of 
 the abdomen. 
 
EXANTHEMATOUS FEVERS. 31 
 
 The case being of a typhoid congestive character, the pheno- 
 mena are correspondently modified. Connected with pervading 
 lesions of the mucous membranes, such as livid or enchymosed 
 blotches, and sometimes softenings, erosions or ulcerations, there 
 are venous engorgements of the solid organs, in substance and 
 investing tissues, with effusions, more or less, in the great cavities. 
 The old writers represent the state of things as that of one mass 
 of putrefaction. 
 
 Both in France and England, much attention has lately been 
 paid to post-mortem examinations in this disease. We learn, 
 that, in the " Maison des Enfans," at Paris, the appearances 
 were, inflammation and ulceration of the internal coat of the 
 intestines, with pustular eruptions there, and frequently more or 
 less of peritonitis. False membranes, as in croup, were also dis- 
 covered in these cases, lining the whole alimentary canal, from 
 the ossophagus to the rectum. 
 
 Mr. Hastings and Mr. Alcock, of England, tell us that, united 
 with such phenomena, the air passages were even more affected, 
 — everywhere, throughout their whole extent, meeting with 
 inflammation, and its immediate or secondary consequences — 
 extravasations, adventitious membranes, ulcerations, &c. Greater 
 lesions of this structure is a common observation of the British 
 writers, which, if they really exist, must be ascribed to the influ- 
 ence of their severe, damp climate, so prone to originate pul- 
 monary disease, as well as to modify others, by implications of 
 the lungs. 
 
 Cross, who has a deserved reputation, found additionally what 
 he considered imperfect pustules, in the primae viae. « The 
 rectum, the colon and ileum/' says he, "were marked with 
 circular patches, distinct and white," which he considered as 
 such. By Rostan, and several others of the late cultivators of 
 morbid anatomy, the same observation has been reported. 
 
 Examinations have been abundantly made in this city, many 
 of which I had opportunities of witnessing. The phenomena, in 
 general, corresponded very much to the preceding description, — 
 consisting of a mixture of inflammation and congestion, the one 
 or the other state preponderating, according to the character of 
 the case. The alimentary canal was decidedly most affected. 
 But though every part of it was occasionally phlogosed, I saw 
 nothing like regular pustules, nor did I hear of any such having 
 
22 EXANTHEMATOUS FEVERS. 
 
 been detected. The mucous tissue, however, of the bowels, in 
 some instances, was found studded with prominent points, which 
 were referred only to follicular inflammation, and, I believe, 
 justly. Difficult, indeed, is it to conceive how a pustule could 
 be formed in this membrane, without its chorion were previously 
 thickened by exposure to the air, such being its natural delicacy 
 of texture, that it would probably burst long before maturation ; 
 and in this opinion I am confirmed by Contunius, Cazenave, 
 and Schedel, who, in their numerous dissections, never observed 
 pustules in this situation. They are, I have no doubt, confined 
 to the skin, or lining of open passages — the mouth— the fauces, 
 &c, or the upper portion of the larynx, perhaps exclusively, ex- 
 cepting in those rare instances of prolapsus of the uterus or rec- 
 tum, where, by long exposure to the atmosphere, the mucus is 
 partially or completely converted in the tegumentary tissue. 
 
 Equal research has been directed to determine the anatomical 
 characters of the exterior surface. Those who are interested in 
 such minute and unimportant investigations, I must refer to other 
 sources of intelligence, and shall now give only the most promi- 
 nent appearances. The cutis vera is the seat of the eruption. 
 Commencing here at what are called the stigmata or red-points, 
 an irradiation of the phlogosis takes place, forming around these 
 an areola or halo of the several shades of red, and of different 
 dimensions, according to circumstances. Not caused, as once 
 supposed, by enlarged papillae, the eruption proceeds merely 
 from vessels shooting out of the stigmata effusing lymph and next 
 secreting pus, by which vesicles and pustules are successively 
 raised. Deposited on the true skin, there is to be found a thick 
 pulpy-like matter, probably lymph, and subsequently may be 
 seen the sloughs of ulceration. Though the inflammation rarely 
 extends to the subcellular membrane, save in confluent or malig- 
 nant attacks, an erysipelatous blush is often diffused in various 
 degrees over the external surface. By some of the highest of 
 the present authorities, it is maintained that the ulceration of the 
 cutis, to which I have just referred, is the most unerring criterion 
 of genuine small-pox, — serving to discriminate it from ail of its 
 affiliated affections. But it cannot be uniformly trusted. Cases 
 of varicella, of the varioloid, and, indeed, of any eruption 
 becoming pustular, I have known productive of precisely the 
 
EXANTHEMATOUS FEVERS. 33 
 
 same effect. By this ulceration it is, the pits or scars, or seams, 
 are occasioned, which, when deep, indelibly remain. 
 
 The pock has, in the early stage, a cellulated or multilocular 
 structure, losing in part at maturity this conformation by a con- 
 version into a sac, charged with pus, and is now acuminated, 
 or globular, having lost its antecedent flat and umbilicated as- 
 pect, so characteristic of small-pox. 
 
 These are the principal phenomena appertaining to the skin 
 in the ordinary and regular forms of the disease. The appear- 
 ances in the anomalous deviations of it are very different, which, 
 however, as not being well ascertained, or of any practical utility, 
 I may be spared the endeavour to describe. 
 
 Nothing in this view of the morbid anatomy of variola, strikes 
 us more than the total want of light shed by dissection on the 
 peculiarity of the nature of the disease. Not a single circum- 
 stance does it conduce to this end. The phenomena of the 
 interior structures are the same as in rubeola, scarlatina, and 
 indeed of most of the continued fevers. It is an instance, addi- 
 tional to an immense mass of proof, which might be adduced of 
 the utter fruitlessness of autopsic inspections, with the design for 
 which they are at present so ardently pursued. 
 
 Easy will it be, after the foregoing exposition of the disease, to 
 deduce its pathology. Like the exanthematous fevers generally, 
 it is radicated in the mucous membrane, chiefly of the up'per por- 
 tion of the alimentary tube, to be thrown off finally on the tegu- 
 mentary tissue as the natural process of cure. The whole of 
 these affections thus arise, and the great aim of nature to relieve 
 the system of them, is by a transference of the irritation from the 
 interior to the exterior surface, as better able to endure it. The 
 metastasis being complete, the effort succeeds, and all does well. 
 But where the irritation still lingers behind, or comes out. par- 
 tially, or after reappearing, recedes, or instead of a translation, 
 an extension of it takes place, without interruption of con- 
 tinuity, so as to embrace both tissues, the inward and outward, 
 then a deplorable state of things inevitably prevails. 
 
 Of such an origin of small-pox, the evidence is stronger than 
 of any of these affections. Not to insist on the proofs of this 
 position which, in common with its congenera it supplies, — the 
 early symptoms, the relief afforded by the appearance of the 
 
34 EXANTHEMATOUS FEVERS. 
 
 eruption, and the phenomena on dissection, it may be demon- 
 strated in another way. 
 
 By repeated, and well conducted experiments, it has been 
 shown that the virus of small-pox cannot act through the skin, 
 without an abraded or punctured cuticle, in which event it gives 
 rise to local irritation, and, as an ultimate result, the inoculated 
 disease. 
 
 It must then operate on an interior surface. Elsewhere I 
 have shown, and I think conclusively, that affluvia, contagious 
 or otherwise, are not received by the lungs into the circula- 
 tion. The stomach, therefore, being the remaining surface, to 
 which the poison can have access, must constitute, of necessity, 
 the seat of the initiatory impression. It is on such an hypothesis, 
 only, that the difference between the natural and inoculated 
 varieties of the disease is explicable. 
 
 Were the virus actually conveyed into the blood, and did it 
 produce its effects, through the medium of that fluid, it would be 
 of no moment at what point of the system the intromission took 
 place. From the thorough commingling which the blood under- 
 goes, in the route of the circulation, any portion of it being 
 vitiated, the whole must be equally so, and the disease ensuing, 
 in every case, be essentially the same. 
 
 Granting, however, as is the fact, that the virus instead of en- 
 tering the blood, deranges the system by sympathy, and the 
 difficulty of explanation at once vanishes. 
 
 Disease is violent, or the reverse, according to the importance 
 of the organ injured,— the nature of the lesion, and the power 
 and extent of its connections. No organ is more important than 
 the stomach; the injury it suffers in this case, is usually severe, 
 and its sympathies, in strength and extent, seem paramount to 
 those of any other. Consequently, on its reception of the virus, 
 it being deranged, casual small-pox, marked with severer symp- 
 toms, is the ordinary result. 
 
 But under inoculation, the poison operating on a small portion 
 of the skin, only, which is more capable of sustaining the injury, 
 — and the sympathies of that portion being comparatively weak 
 and limited, it follows that the affection excited must be com- 
 paratively moderate. This difference is strikingly illustrated in 
 the endermic application of active remedies, where, to attain the 
 effect of a dose by the stomach, three or four times the amount 
 
EXANTHEMATOUS FEVERS. 35 
 
 is required ! What, in fine, is the lesion, that would not prove 
 more serious, inflicted on the stomach, than the skin ? 
 
 Nor, without the adoption of this hypothesis, can an explana- 
 tion be had of some other phenomena of the disease. Casual 
 small-pox, we have seen, shows itself on the fourteenth day, 
 while that from inoculation, in half the time, — and if, in each 
 instance, the virus acts by entering the circulation, and com- 
 mingling with the blood, how could this wide difference happen? 
 
 Nor is it of any moment, in the process of inoculation, whether 
 a larger or smaller quantity of the virus be inserted, the subsequent 
 effect being not at all controlled by this circumstance. An ounce 
 of the virus would, probably, not make a stronger constitutional 
 impression than a single particle. Conceding this, which, to a 
 certain extent, has been demonstrated, and it is scarcely possible 
 to have more conclusive proof that the disease is propagated by 
 irritation, and not by any contamination of the blood. Not a 
 tittle of evidence, indeed, is there, that the blood is thus vitiated. 
 Can we infect from it, which we ought surely to do, did it contain 
 the virus? As in all other instances of disease, there is here a 
 point primarily irritated, with which the system, being brought 
 into concent, a general disorder ensues. 
 
 That such is true as regards the inoculated disease, or, in other 
 words, that the subsequent effects are dependent on the original 
 irritation, is as manifest as that a stream of water with its vari- 
 ous ramifications, proceeds from a fountain by which it is fed. 
 If this be not so, why are we vigilant to preserve the integrity 
 of the parent pustule against those molestations by which it 
 might be affected ? Do we not know that, when this is disturbed 
 in its progress so as to subvert its specific action, no specific 
 impression is made on the system, and the act of inoculation 
 becomes impaired, or is completely defeated .? Duly estimating 
 this fact, I think no more ought to be exacted, to establish the 
 position for which 1 am contending. 
 
 Contradictory of these views, however, the occasional occur- 
 rence of the disease in the foetus is adduced, as of a very decisive 
 nature. But the reverse does it import. No one point in phy- 
 siology is better established, or more freely allowed, than that 
 there is no direct vascular connection between the parent and 
 the offspring. Destitute, then, of any intercommunication by 
 blood-vessels, how can the virus in the maternal blood reach the 
 
36 EXANTHEMATOTJS FEVERS. 
 
 fetus ? The basis of the hypothesis thus proved to be unsound, 
 it of course falls. Two modes explanatory of the infection of the 
 foetus, under these circumstances, may be conjectured. The 
 contagion might, possibly, as has been suggested, though I do 
 not believe it, penetrate through the vagina of the mother, and 
 thus be brought to act on the uterine contents. No necessity 
 is there, however, to resort to such a supposition. To a certain 
 extent, the foetus is an integral portion of the maternal system, 
 evolved, sustained and perfected by its resources, and susceptible 
 of derivative impressions from it. Of the precise means, or 
 manner of the connection between them, we are not informed. 
 Nerves are said to have been demonstrated in the placenta and 
 umbilical cord. But I insist on no such medium of connection, 
 it not being essential to the support of my proposition. Though 
 to be traced generally to an inosculation of nerves, numerous are 
 the sympathies seemingly independent of it. Not to cite exam- 
 ples superfluously to this purport, what, I demand, is the nervous 
 communication between the parotid gland and the testes, or 
 the mammae ? What that between the uterus and mammae ? 
 Let, however, the explanation be as it may, the fact is undeni- 
 able. It is by the adoption of sympathy, that a solution of this 
 problem can only be had, and by which we are supplied with 
 a clue, like that of Ariadne, to conduct us through the mysteries 
 of the animal economy, otherwise more dark and intricate than 
 the Daedalion labyrinth itself. 
 
 An additional remark or two only have I to make, in regard 
 to the pathology of small-pox. From what has been said, it 
 sufficiently appears that irritation commences in the mucous 
 membrane of the stomach particularly, which, in the natural 
 course of things, is translated to the skin, as a part more capable 
 of bearing it. The metastasis being complete and firmly esta- 
 blished there, the issue is generally favourable. But when the 
 eruption is very extensive, and, especially, confluent, the func- 
 tions of that integument, so important in the operations of the 
 animal economy, are interrupted, its vitality impaired, or, per- 
 haps, destroyed, and death ensues, from this condition chiefly or 
 entirely. 
 
 Not the least curious circumstance connected with the history 
 of this and its kindred affections, is the usual destruction of sus- 
 ceptibility of the system to any repetition of attacks. What is 
 
EXANTHEMATOUS FEVERS. 37 
 
 the mode of action of that infinitely small portion of virus, and 
 the nature of the change it produces in the organism, which, 
 with no appreciable disturbance of its identity, accomplishes this 
 wonderful end ? Considerable ingenuity has been exercised in 
 the solution of the enigma, without, however, shedding a single 
 ray of light on it. Like generation, growth, and many other 
 vital operations, it is hid in impenetrable obscurity. To recite 
 the vain conjectures of others, or to obtrude one of my own on 
 the subject, were idle, and both I shall hence decline. An in- 
 quisitive personage once said to a venerable medical friend of 
 mine, Why cannot an individual have the small-pox twice? 
 Tell me, he quickly replied, the reason foe has it at all, and I 
 will then endeavour to solve your difficulty ! This smart retort, 
 I suspect, conveys about as good an answer, though no explana- 
 tion, as will be found in any of the graver speculations regarding 
 this mystery. 
 
 We now come to the treatment of small-pox, which must be 
 deemed an incurable disease, so far, at least, as that in common 
 with most, or, perhaps, all fevers dependent on a specific con- 
 tagion, it will run a definite course in spite of our efforts. Nature 
 here works to the deliverance of the system by a series of unin- 
 telligible processes, which eventuate in the recreation of the same 
 sort of virus as that which had originally excited the affection. 
 
 Disease is one of the curses entailed on our fallen condition, 
 and to perpetuate this particular class, it would seem to be or- 
 dained that we should be debarred the power of counteracting 
 the agency by which the seminal principle is regenerated. In 
 this respect, the same pains are taken as in the preservation of 
 some of the productions of the animal and vegetable kingdoms. 
 As the seeds for future regeneration are there elaborated, so is 
 the principle of contagion by these contagious fevers. 
 
 Could these cases be cured, a chasm would be made in the 
 order of a particular design, which is not permitted. Yet, in 
 conformity with the general benevolence of Providence, what 
 cannot be entirely relieved we are enabled to palliate, and such 
 is the amount of our best endeavours in small-pox. 
 
 It may be collected, from the preceding views, that, where the 
 disease is mild, and pursuing its career undisturbed by anoma- 
 lous or exasperated affections, it were better to forbear the use 
 of remedies, and to leave it pretty much to the efforts of nature, 
 4 
 
38 EXANTHEMATOTJS FEVERS. 
 
 regulating mainly the diet and temperature. But, our aid being 
 demanded, we adopt essentially the same plan in the variolous as 
 ordinary fevers, accommodated to the condition, inflammatory, 
 congestive, or mixed. 
 
 To the first of these states I am now to address myself. For 
 the most part, it will be right to commence the treatment with 
 an emetic, and especially where we have reason to suspect irri- 
 tating ingesta, or an otherwise vitiated stomach. But it should 
 be restricted to the earliest stage, and resorted to with all those 
 cautions, regarding the existence of gastric inflammation, on the 
 importance of which I have elsewhere insisted. This remedy, 
 thus timely exhibited, has signally useful effects in the whole of 
 the eruptive fevers, operating, probably, as well by rectification 
 of the stomach itself, as by occasioning a determination to the cuta- 
 neous surface, thus preparing it for the reception of the eruption. 
 
 Next, a recurrence is to be had to the saline laxatives, so as to 
 keep the bowels in a soluble state. Calomel was here greatly 
 preferred by the older practitioners, under an impression that it 
 exercised some specific influence. But such a notion, I think, is 
 unfounded — and, though not pernicious in moderation, mercurial 
 purging is unnecessary. 
 
 Excessive intestinal evacuation, particularly by drastic articles, 
 should, however, be carefully avoided, as concentrating and 
 fixing the disease in its original position, or tending greatly to 
 the prevention of the translation of it to the skin, and, in other 
 respects, interfering with the natural process of cure. 
 
 Mild diaphoretics, the acetate of ammonia, or dulcified spirits 
 of nitre, or a weak solution of emetic tartar, or the neutral mix- 
 ture, or both combined, are used. 
 
 It has been remarked that a moderate perspirable condition, 
 not a sweat, is among the most salutary occurrences in the 
 disease, and hence the importance of the means by which it is 
 excited or maintained. 
 
 The preceding remedies may answer. But, when the fever is 
 high, with a heated skin, and much local affection of any of the 
 great organs, venesection cannot be dispensed with, and ought 
 to be repeated, as the necessity of the case imposes. There is, 
 however, some difference of opinion among practitioners as to 
 venesection, though the weight of authority is decidedly in favour 
 of it. Commencing with Rhazes, we may trace the strongest 
 
EXANTHEMATOTJS FEVERS. 39 
 
 recommendation of it through Sydenham, Mead, Friend, Hux- 
 ham, down to Armstrong, and still more recent writers, including, 
 also, the best practitioners of our own country at all times. Ne- 
 vertheless, it has no decided curative effect, and the same may 
 be alleged of all other means. But, though it does not arrest or 
 change, it abates the intensity of action, and it is on this principle 
 we resort to it, in common with the rest of the measures usually 
 prescribed in the eruptive fevers, among which, topical bleeding 
 is of the utmost importance. Most of the vital organs are now 
 deeply implicated, and, to preserve the integrity of their structure, 
 should be our principal aim. To relieve tenderness of the epi- 
 gastrium, and the attendant gastric distress, or phlogosis of the 
 brain or lungs, or overfulness of these organs, leeches or cups 
 are incomparably effectual, and ought never to be neglected. 
 
 When the surface is very hot, applications of cold water have 
 been recommended, even by aspersion. But sanctioned as it is 
 by some high authority, the propriety of the practice is question- 
 able. Better were it merely to sponge the surface, the utility of 
 which cannot be too strongly urged. 
 
 Convulsions in children, which I have said are apt to occur, 
 may, when slight, be relieved by cold applications to the head, 
 with a stimulating pediluvium at the same time. But should 
 they be violent, the loss of blood, sinapisms to the extremities, 
 and an opiate become necessary. 
 
 The extent of the eruption, and other affections, being pretty 
 nearly proportioned to the degree of reaction, the leading object 
 is to restrain, and keep this down, with which intention the anti- 
 phlogistic plan must be pursued in every respect. But above 
 all, is it required to have the patient in a cool and well ventilated 
 apartment, more so than in any other disease, and to let him 
 sleep on a mattrass, with little covering. It has, indeed, been 
 found beneficial in hot weather, to expose him, even to the cool 
 external air, where an unusual degree of heat and fever prevails. 
 
 This cooling or antiphlogistic practice was adopted early in 
 the history of the disease. By Rhazes, such is, at least, recom- 
 mended, which, in the revolutions of our science, and especially 
 when the chemists and humoralists got possession of the schools, 
 was entirely changed by their preposterous pathological and 
 therapeutic views. 
 
 Considering the virus to be in the blood, and that it was to be 
 
40 EXANTHEMATOUS FEVERS. 
 
 expelled through the skin, by the force of fever, they adopted the 
 most heating and alexipharmic measures to accomplish this end. 
 The patient was wrapt up warmly in bed, the room kept heated, 
 the doors and windows carefully closed, to the exclusion of every 
 breath of fresh air, and stimulating sudorifics, with wine and 
 cordials, administered copiously. Gaddiston, who lived in the 
 fourteenth century, the first court physician, and I believe the 
 very earliest of English medical writers,* went further, and 
 recommended that the patient should also be surrounded with 
 " red curtains, red walls, red furniture of all kinds, so that every 
 thing he saw should be red, under the idea that there was some- 
 thing glowing or otherwise beneficial in that colour." 
 
 Giving an account of the practice of the time, Sennertus, who 
 wrote at the beginning of the seventeenth century, says : " That, 
 while using these means, every attention is to be paid, especially 
 in winter, to the exclusion of cold air. The patient, therefore, 
 is to be tended in a warm chamber, and carefully covered up, 
 lest, by closing the pores of the skin, the efforts of nature should 
 be impeded, the humours driven on internal organs, and matter 
 which ought to be expelled, retained within the body, to the 
 imminent danger of the patient, and the certainty of increasing 
 restlessness, fever and other symptoms."! 
 
 Diemerbrock, who lived about the same time, holds even 
 stronger language on the subject. « Keep," says he, "the patient 
 in a chamber close shut. If it be winter, let the air be corrected 
 by large fires. Take care that no cold gets into the patient's 
 bed. Cover him over with red blankets. Not that the colour is 
 material, but because all the best, thickest, and warmest blankets 
 are dyed red. Never shift the patient's linen till after the four- 
 teenth day, for fear of striking in the pock to the irrecoverable 
 ruin of the patient. Far better is it to let the patient bear with 
 the stench, than to let him change his linen, and thus be the 
 cause of his own death. Nevertheless, if a change be absolutely 
 necessary, be sure that he puts on the foul linen that he put off 
 before he fell sick, and above all things, take care that this supply 
 of semi-clean linen be well warmed. Sudorific expulsives are, 
 in the mean time, to be given plentifully, such as treacle, pearls 
 and saffron." 
 
 * The book is entitled Rosa Angllca. 
 ■j- De Variolis et Morbillis ; torn. vi. 
 
EXANTHEMATOUS FEVERS. 41 
 
 As might be supposed, the mortality from such a plan, was 
 immense. The keen sagacity of Sydenham discovered the error, 
 and dictated the appropriate reformation, in the revival of the 
 ancient practice, which has since been established by lengthened 
 and concurrent experience. 
 
 In regard to the typhoid form of the disease, the treatment is 
 different. This is a case of weak, inflammatory action, mixed 
 up with a preponderance of congestion, and is to be managed on 
 the principles, and by the remedies applicable to this condition 
 under ordinary circumstances. 
 
 Evacuations of the alimentary canal are commenced with, 
 though not to be carried to any great extent. An emetic, how- 
 ever, and purging in the beginning, should be practised where 
 there is heavy visceral turgescence, and the latter by calomel. 
 The loss of blood is sometimes of equal importance, and has 
 been too much overlooked. Even when venesection is not 
 allowable, topical bleeding may be safely and efficaciously em- 
 ployed. Early, however, we are sometimes compelled to resort 
 to the means calculated to sustain the vis vitse. To promote the 
 filling and maturation of the pustules, a process languidly per- 
 formed by the natural powers, or to restore the eruption, when 
 it recedes, a combination of the sulphate of quinine and opium, 
 or the carbonate of ammonia or camphor, and wine whey, with 
 the warm-bath, constitute the best of our resources. Emetics 
 have been proposed for the latter purpose, and might be service- 
 able. More certain, however, with either intention, are sinapisms 
 and blisters, which are commonly put on the extremities, and, 
 though indubitably serviceable there, are less so than over the epi- 
 gastrium. Be it remembered, that, in all those affections seated 
 in the stomach, much is attained in their feeble states, by arousing 
 the energies of that viscus, and such applications are eminently 
 appropriate to the occasion. 
 
 The case advancing with increased prostration of strength, an 
 appeal is to be made to the freest use of the cordial and diffusible 
 stimuli, at the head of which, in point of efficacy, is wine. 
 
 That the spirit of turpentine, as an internal remedy, might be 
 useful at this period, is probable from analogy. Especially does 
 it seem suited to those cases attended by petechiae, vibices and 
 passive haemorrhage. But I have no adequate experience with 
 
 4* 
 
42 EXANTHEMATOUS FEVERS. 
 
 it. Much is said by Sydenham, under these circumstances, of 
 the peculiar efficacy of the sulphuric acid. 
 
 As previously stated, it is a usual event, in both forms of this 
 disease, at the full maturity of the eruption, the latter being large, 
 for a fever to arise, or, if it have continued, to increase consider- 
 ably. Except puncturing the pustules, so as to remove the irri- 
 tation of distension, I am not aware of any peculiarity in the 
 established treatment. This is to be shaped to the nature of the 
 case, and, inflammatory or typhoid, to be managed on similar 
 principles and by the same measures, as if such were the state 
 originally. Extreme nervous irritation and inquietude supervene 
 in some instances. Combinations of opium and camphor are 
 here very apposite, and so is Hoffman's anodyne liquor. 
 
 I have suggested that the state of the skin itself, in the confluent 
 disease, most materially influences the result. The condition is 
 very similar to that of an extensive scald or burn, productive of 
 nearly the same train of symptoms, occasioning death probably 
 in the same mode. 
 
 How far certain lotions, or other external applications, might 
 in this case be beneficial, remains to be proved. We shall pre- 
 sently see that camphor holds out some favourable promises. 
 What should further encourage us to the employment of topical 
 applications, is their unequivocal efficacy in erysipelas. Many 
 are the instances of this disease kept up by irritation of the skin, 
 that would terminate fatally were it not thus allayed. 
 
 An application to the surface of the mucilage of flaxseed, in 
 the active inflammatory stage, I am sure would be proper — and, 
 perhaps, in the subsequent or asthenic condition, the camphorated 
 or Kentish ointment might be equally so — such being the most 
 successful remedies in the analogous affections to which I have 
 alluded. 
 
 These are views, I believe, entirely original with myself, which 
 I have not had opportunities of subjecting to an adequate prac- 
 tical test. The experiment, however, I cannot help thinking is 
 worthy of trial. 
 
 Of the minor parts of the treatment in small-pox, one, which 
 demands particular attention, is the prevention of those marks 
 which are so detrimental to female beauty. As an exposure to 
 the air is thought necessary to the production of the eruption, so 
 our contrivances are directed to its exclusion. 
 
EXANTHEMATOUS FEVERS. 43 
 
 Covering the face with fine cambric, spread with the mildest 
 cerate, sometimes succeeds; — and, formerly, our practitioners 
 relied greatly on a coating of the blue mercurial ointment in this 
 disease and in erysipelas. But it so frequently induced very terri- 
 ble salivations, that it came to be discontinued. Calomel ointment, 
 and a weak solution of corrosive sublimate, were also popular 
 applications at the same period, which have fallen into abeyance. 
 Camphor is reputed to have the same effect. Rosentein, a re- 
 spectable writer on the diseases of children, affirms that, if the 
 skin be smeared over with camphorated ointment, the eruption 
 will not take place on that part. Baron Larry informs us that, 
 while in Egypt, he learnt that it was the practice there to pro- 
 tect the face with gold leaf, such as is used by gilders — and Le- 
 grand, a Parisian physician, has declared that he found it on 
 trial completely successful, even in the worst cases. The leaf 
 should be previously smeared with the mucilage of gum arabic, 
 to secure its adhesion to the skin. By some other of the French 
 writers, Velpeau and Mayreux, we are told that puncturing the 
 pustules with a lancet, and then touching them delicately with 
 lunar caustic, they will be so destroyed as to leave no marks. 
 But this must be done on the first or second day of the eruption, 
 it being nugatory afterwards. Neither of the expedients men- 
 tioned have I tried, though they are certainly deserving of atten- 
 tion. My own practice has been to subdue inflammation as far 
 as possible by cooling lotions, to open the pustules as soon as 
 they fill, and wash them with milk and water, taking care, also, 
 as far as possible, to keep the face covered. It appears, however, 
 that the most effectual means is the exclusion of light. Experi- 
 ments, made some years ago, at New Orleans, if they can be 
 relied on, and I know of no reason why they should be distrusted, 
 are very satisfactory on this point. To try the effect of this ex- 
 pedient, a certain number of patients, during the eruptive and 
 maturative stages of the disease, were confined in a dark ward 
 of an hospital, and not a pit or scar, or other deformity of the 
 skin, was left, though some of them had the disease most vio- 
 lently, even in the confluent form. These experiments were 
 originally performed by Dr. Picton, a graduate of the University 
 of Pennsylvania, and were contained in his inaugural thesis, 
 which I had published on account of its merits. Notices of their 
 
44 EXANTHEMATOUS FEVERS. 
 
 confirmation I have lately seen in the medical journals of several 
 of the European countries. 
 
 Not the least serious of the local affections, is ophthalmia, 
 causing very often blindness, by disorganizing the eyes. There 
 is, however, as usually managed, nothing peculiar in the reme- 
 dies. To prevent the inflammation, Rosentein advises, as very 
 effectual, a bag of camphor to be kept before them. As to the 
 ulcerated throat, an occasional incident also, the same detergent 
 gargles, as in angina maligna, are to be directed. The best 
 preventive, according to the writer just cited, is the free use of a 
 camphorated gargle. 
 
 With this, I dismiss the subject of casual small-pox. 
 
 INOCULATED SMALL-POX. 
 
 Long has it been known, that, by inoculation, this disease is 
 disarmed of much of its violence, and of nearly all its danger. To 
 such success had its management been reduced, under propitious 
 circumstances, that it was computed only a very few deaths took 
 place. 
 
 Woodville asserts this as the result of his practice in the small- 
 pox hospital of London. Baron Dimsdale, the great inoculator 
 of his time, computes that not one in fifteen hundred died, and 
 the Suttons aver, that they did not lose a single patient in twenty 
 years. The late Professor Kuhn told me, that he had never lost 
 one whom he inoculated — the same statement was made to me 
 by Professor Physick, of his success, and who added that, he learnt 
 from Professor Rush, that he had lost only three, owing, in part, 
 to extraneous causes. Of the many whom I formerly had under 
 my care, I do not recollect a solitary instance of death. The 
 reports of the London Small-pox Hospital, for 1797, 1798, and 
 1799, show that among five thousand nine hundred and sixty- 
 four cases, nine deaths occurred, or one in six hundred and 
 sixty-two, which is probably near the average, where proper 
 advantages are commanded. Nevertheless, as we shall presently 
 see, the average of mortality is considerable, — though there is 
 still little to be dreaded from the practice when skilfully con- 
 ducted. 
 
 An explanation has already been given of the mitigation of 
 
EXANTHEMATOUS FEVERS. 45 
 
 the disease by this process. But it is alleged that it undergoes a 
 further change from it. My allusion is to the deprivation it 
 sustains of its infectious nature, or that, in this state of ameliora- 
 tion, it ceases to communicate itself through the medium of the 
 atmosphere. Looking over the writers on the subject, I find 
 that, while its capability, under these circumstances, is generally 
 not doubted, there are many of the highest authority, particularly 
 of the continent of Europe, by whom it is utterly denied, and 
 others that concede it in a slight degree only. These reports are 
 entitled to the more weight, as proceeding from individuals 
 whose attention was directed specially to the inquiry. 
 
 I can spare time to select only a few, from an immense mass 
 of facts which might be adduced. These are all to be met with 
 from the middle to the close of the last century, — henceforward 
 vaccination engrossed the medical mind, to the total exclusion of 
 further investigations of small-pox. Medicus, a very distin- 
 guished man, in his correspondence with, perhaps, the still more 
 eminent Petit, states that, though he had inoculated very largely, 
 not more than ten instances had occurred to him in which there 
 was any reason to suspect infection. Meige, who was a re- 
 nowned inoculator, of most extensive practice, declares that he 
 had only seen a single case, and that induced by contact " per 
 osculum, idioque proximum, per contactum accidit." By Pro- 
 fessor Schroider, of Gottingen, we are told that, " he had never 
 met with an instance in which the inoculated small-pox had by 
 infection given the disease." The same assurance we have 
 received from the well known Odier, of Geneva, — and Schevanke, 
 Watkinson, and several other respectable writers afford most 
 striking proofs of inoculation having been pursued in communi- 
 ties, and sometimes in hospitals or other confined places, where 
 infection, if existing at all, must have been concentrated, with- 
 out any manifestation of effect on unprotected individuals freely 
 exposed to it. To this question, says Watkinson, " I have paid 
 particular attention, since the establishment of a dispensary for 
 general inoculation, and can with truth affirm, that not a single 
 instance has occurred in that charity, in which the contagion was 
 spread by an inoculated patient. Where the chance of spread- 
 ing it has been apparently great, T have been very strict in my 
 inquiries." He adds, that " some inhabited narrow streets, or 
 little courts, and ground floors, the doors of which were kept 
 
46 EXANTHEMATOTTS FEVERS. 
 
 open, and though surrounded by persons obnoxious to the dis- 
 ease, and especially by a set of children, who continually played 
 before the houses, a few yards only from the sick, all escaped 
 infection." Exceedingly strong is the testimony of Mr. Holwell, 
 at least in regard to India. Living in that region for thirty years, 
 and during the period inoculating multitudes, he affirms posi- 
 tively that " it never spreads the infection, as is commonly ima- 
 gined in Europe." 
 
 On this point, I cannot come to any satisfactory conclusion, from 
 the want of adequate experience. No opportunities, indeed, 
 have we in this city, for prosecuting the investigation. By 
 legislative enactment, so heavy a penalty was imposed on inocu- 
 lation, that the practice has long been entirely suppressed. Ex- 
 cept clandestinely, I doubt whether we have had an instance of 
 it for thirty or more years. That inoculated variola may be 
 uninfectious, is, however, not improbable in itself, and is cor- 
 roborated by some analogies. Examples are abundant of dis- 
 eases indisputably contagious, and not at all infectious, that is, sup- 
 plying a virus operative by contact or inoculation, without the 
 generation or escape of any effluvia efficient to a similar end, 
 among which syphilis is conspicuous. But a more pertinent illus- 
 tration we have in the vaccine affection, which, while contagious, 
 is totally void of infection, and, as it is probably modified small- 
 pox, it may be rationally conceived that, by inoculation, such a 
 change is wrought in the latter disease, as to bring it into the same 
 category. Granting the plausibility of all this, I still think that 
 better evidence than any hitherto adduced, is required to deter- 
 mine the question, and, from the deep interest it involves in seve- 
 ral relations, I trust it will command the most careful observations 
 and experiments, by which alone certainty can be obtained. 
 
 By whom the great discovery of inoculation was made, or 
 among what people it originated, are questions of some obscurity. 
 The Chinese, who reluctantly acknowledge a priority of claim to 
 any thing, aver, that the practice of propagating small-pox, by 
 the introduction of scales of the eruption into the nostrils, imme- 
 morially prevailed among them. Even if it did, it must be con- 
 sidered as giving the affection in the natural way, and not by 
 inoculation. They denominated it sowing or disseminating the 
 disease. 
 
 Tradition reports also, that the practice of artificially impart- 
 
EXANTHEMATOUS FEVERS. 47 
 
 ing small-pox, existed at a very remote period in Hindostan, and 
 the execution of the office was committed to a particular tribe of 
 Bramins, exclusively professing a knowledge of the art, who 
 were delegated for the purpose, from certain religious colleges, 
 to travel through the provinces. With a vast deal of ceremony 
 and superstitious observance, the operation was performed by 
 applying cotton soaked in the virus, on a small incision, and 
 which was really inoculation. 
 
 The credit of introducing this discovery into Europe is gene- 
 rally accorded to the well-known Lady Mary Wortley Montague, 
 while at Constantinople as the wife of the British ambassador. 
 Writing home on the subject, she says: "The small-pox, so 
 general and fatal among us, is here entirely harmless, by the 
 invention of engrafting, which is the term they give it. There 
 is a set of old women who make it their business to perform the 
 operation every autumn, in the month of September. Every 
 year thousands undergo this operation, and the French ambas- 
 sador says, pleasantly, that they take the small-pox here by way 
 of diversion, as they take the waters in other countries. There 
 is no example of any one who has died in it— and you may 
 believe I am well satisfied of the safety of this, since I intend to 
 try it on my dear little son. I am patriot enough to take pains 
 to bring this useful invention into fashion in England." The 
 communication of this event by her was in 1717. Soon after- 
 wards she had her son inoculated, and, five years later, returning 
 home, her daughter was subjected to the same operation, the 
 very first done in Europe. 
 
 An attempt has been made, though unavailingly, to despoil 
 her of this distinguished honour, by alleging that the usage ex- 
 isted antecedently in Wales, and the Highlands of Scotland, as 
 well as in several of the countries of the continent of Europe. It 
 is said that, in Wales, it was called buying the disease, from a 
 notion that inoculation could not produce the proper effect, 
 unless the person from whom the variolous matter was taken, re- 
 ceived a piece of money, or some other article, in exchange for it, 
 from those it was intended to infect.* Be it as it may, these 
 averments against her claim, in my opinion, want the support 
 of authentic evidence. Yet it is true that the practice of inocula- 
 
 * Woodvill's Hist, of Inoculation, vol. i. p. 42. 
 
48 EXANTHEMATOUS FEVERS. 
 
 tion or engrafting the disease, as it was then entitled, had been 
 published in England, in 1714, by Timoni, a physician of Con- 
 stantinople, and by Pylanini, of Venice, and the next year by 
 Kennedy, an English surgeon, who had visited Turkey. These 
 publications, however, attracted little or no attention, and cannot 
 derogate from her pretensions. 
 
 As means of preserving the exquisite beauty of their women, 
 the practice prevailed with the Circassians, from whom the Turks 
 borrowed it, and seeing its efficacy constantly illustrated, the 
 celebrated female, to whom I have alluded, ventured on the trial 
 just mentioned, and extended the benefits of the practice to her 
 own country. 
 
 Like all innovations or new discoveries, this encountered in 
 the commencement a violent opposition, as well from popular 
 ignorance as medical prejudices. It was arraigned as an impious 
 attempt to counteract the visitations of Providence, not recollect- 
 ing, according to such a notion, that every effort to arrest or 
 mitigate the evils to which humanity is exposed, even the whole 
 art of medicine itself, becomes involved in the same criminality. 
 The pulpit thundered forth its anathemas against the sinfulness 
 of the act, representing it, when voluntarily submitted to by an 
 adult, in the enormity of suicide, and in children, as an atrocious 
 murder of the "little innocents," for which the most awful re- 
 sponsibilities were hereafter incurred. Not wanting, indeed, 
 were some, who, in the frenzy of fanaticism, went so far as to 
 pronounce it the invention of Satan himself, and its supporters as 
 sorcerers and atheists, arrayed against the will of God. By one 
 of these infuriated preachers it was gravely declared that inocu- 
 lation is a very ancient art, first practised by the Devil on Job, 
 and to which all the afflictions of that memorable sufferer were 
 referred. This odd conceit, however, did not escape animadver- 
 sion, and was very appropriately answered by a wag, at the time, 
 in the following doggerel rhymes : 
 
 "We are told by one of the black robe, 
 The Devil inoculated Job ; 
 Suppose 'tis true, what he doth tell, 
 Pray, neighbours, did not Job do well?" 
 
 Disreputable, also, was the conduct of a part of our own pro- 
 fession, raising objections to it as futile as they were ridiculous 
 and absurd. But, happily, in this instance, there were enough 
 
EXANTHEMATOUS FEVERS. 49 
 
 of those master spirits, who are prompt to arise, on such occasions, 
 to put down ill-directed hostility, and to secure the ultimate tri- 
 umph of a good cause. 
 
 Much praise is due to our own country for the establishment 
 of the practice. In 1721, when it had only been adopted in 
 England in a few instances, and these chiefly on malefactors, 
 whose punishment by death was commuted, and a load of pre- 
 judice still existed against it, Boylston, of Boston, a name de- 
 servedly high in the annals of American medicine, against the 
 unanimous opinion of the other physicians of that city, and in 
 direct contravention of an edict of the municipal authorities, car- 
 rying with it heavy penal consequences, had the intrepidity to 
 inoculate two hundred and eighty-six persons, of whom six 
 only died. The disease was prevailing extensively at the time, 
 and, out of five thousand seven hundred and fifty-nine persons, 
 who took it in the natural way, eight hundred and eighty-four 
 perished. 
 
 To escape from the conviction of the inestimable advantage of 
 the process, after so successful an experiment, was impossible, 
 and, when the result transpired in England, doubt and hesitation 
 were rapidly removed,* and the practice, in no long time, came to 
 be generally adopted. Enlightened on the subject, perhaps by 
 this very intelligence, the reigning family at the period stepped 
 forward and submitted to inoculation, to enforce it by the weight 
 of their example, which, no doubt, to a great extent, had an 
 effect. 
 
 Treating of the events of 1723, Smollet, the historian, says: 
 " That the practice of inoculation for the small-pox was by this 
 time introduced into England from Turkey. The Prince Frede- 
 rick, the two Princesses Amelia and Caroline, the Duke of Bed- 
 ford and his sister, with many other persons of distinction, un- 
 derwent the operation with success.' 7 Comparing dates, it will 
 be seen that this was two years after the report of Boylston. 
 Yet, owing to the death of the grandson of the renowned Marl- 
 borough, and, perhaps, of some other distinguished personages, ' 
 such was the panic excited, the practice relapsed into discredit in 
 England, and to such a degree that, so lately as the middle of the 
 last century, it had fallen almost into neglect or disuse. Neither 
 
 * Ramsay's History, vol. i. p. 272. 
 
50 EXAXTHEMATOUS FEVERS. 
 
 in Turkey nor in England, we have reason to suppose, had the 
 practice been so successful as represented. The low and illiterate 
 character of the individuals, into whose hands it had devolved in 
 the former country, avouches the want of skill among them, and, 
 in regard to that of the latter, we are now aware of its mortality, 
 averaging one in fifty subjects. 
 
 Meade relates, that about this time, the most favourable ac- 
 counts of the success of inoculation arrived from America and 
 the West Indies, which, affording encouragement to its revival, 
 the College of Physicians declared in its favour — a well-regulated 
 hospital appropriated to this object was opened in London, and 
 henceforward it became firmly established, till the introduction 
 of vaccination, by which it has been nearly superseded. Largely, 
 however, was this ultimate triumph owing to the improvements 
 made in the treatment of the disease by the celebrated Suttons.* 
 
 The progress of this discovery was, throughout the continent 
 of Europe, still more retarded. Except in Hanover, into which 
 it had very partially crept, nowhere was it to be recognized. 
 Narcotized Germany laid, at the time, prostrate under the stu- 
 pefaction of despotism, unable to •• shake the poppies from her 
 head," — insensible to improvements, and, perhaps, without the 
 consciousness of possessing those fine intellectual energies she 
 has since displayed. The very attempts to introduce this new 
 practice were met by mounds of popular prejudice, encouraged 
 and fortified by her most eminent medical men, De Haen, Van 
 Swieten, &c. 
 
 Even in France, with the illumination of her literature, science 
 and philosophy, it had to encounter, for a season, an irresistible 
 opposition. Condemned, ex cathedra, by the faculty of medicine 
 at Paris, it remained slighted for many years. Neither appeals 
 
 * These were two brothers, who, after having been trained to surgery, settled 
 in different portions of England, devoting themselves principally, I believe, to 
 the study and practice of inoculation, and acquired immense reputation for 
 superiority of skill. The merits of their practice consisted in abridging the 
 •preparatory course from a month to a week, using the antimonials and mercurial 
 purging, in selecting with care the matter to be employed, and infecting by a 
 single puncture, in the restriction to a spare diet and cooling drinks, — the avoid- 
 ance of inordinate exercise or other heating exertions, and in the freest exposure 
 of the patient, during the fever, to cold air. They, in fact, did little more than 
 imitate the plan of Sydenham in regard to the management of the natural 
 disease. 
 
EXANTHEMATOUS FEVERS. 51 
 
 to reason nor common sense, nor the weight of cumulative facts, 
 had any effect. Finally, however, Voltaire, returning from Eng- 
 land, whither he had been, took the subject in hand, and, by his 
 representations of the immense advantage of the new practice, 
 which he had there witnessed, and above all, as the only pre- 
 servative of female beauty against the most hideous deformities, 
 enlisted the ladies of the court in its behalf, and henceforward 
 inoculation became quite the vogue in the higher circles, whence 
 it spread, as other fashions, among the people. To the influence 
 of this extraordinary man, operating on the vanity of women, 
 does it appear that we are mainly to assign the just appreciation 
 of one of the greatest boons ever conferred on humanity — such 
 being the mysterious modes often adopted by Providence for the 
 revelation or dispensation of infinite goodness ! Means, how- 
 ever, were still wanting to execute the plan which had been 
 devised of extending this blessing to the poor, and these were 
 supplied on the coming into power of Turgot, the wise, the 
 liberal, the beneficent minister of the French treasury. Enough, 
 perhaps, has been said to show that this, in common with every 
 other improvement, wheresoever it may emanate, was eagerly 
 received, and skilfully pursued by our own, in the proper sense 
 of the term, truly enlightened country, whose mind has never 
 been perverted by vulgar prejudice, or weakened by fearful 
 superstition, or its determinations thwarted by aristocratic influ- 
 ence, or the power of antiquated corporations, or that of govern- 
 ment itself, so perniciously felt in the old world. 
 
 As inoculation is a voluntary proceeding, it may be so regu- 
 lated generally, as to time and other circumstances, as to ensure 
 the most favourable results. 
 
 The mild weather of spring or autumn affords the best sea- 
 son, and not an age earlier than six months should be preferred. 
 Children of debilitated or vitiated constitutions are to be excluded, 
 except where a strong necessity exists, and the same restriction 
 applies, indeed, to individuals of every period of life. Milder is 
 the disease in early than adult or more advanced age. 
 
 The preparation of the system, so called, was once deemed of 
 the utmost importance, and the same notion, even at present, is 
 by many entertained. The practice consisted in a great reduc- 
 tion in diet, the avoidance of all heating or stimulating causes, — 
 in bleeding and purgation, and, lastly, in a mercurial or antimo- 
 
52 EXANTHEMATOUS FEVERS. 
 
 nial course of ten or fifteen days, or for double this period. There 
 was, too, to use the somewhat exaggerated language of Jenner, 
 "bleeding till the blood was thin, purging till the body was 
 wasted to a skeleton, and starving on vegetable diet to keep it 
 so." Excepting the omission of mercury, and commencing the 
 other preparatory measures, subsequently to the act of inocula- 
 tion, the same restricted and medicated plan continued, for the 
 most part, to be pursued. 
 
 By some very able practitioners, however, the utility, and 
 even propriety of this sort of preparation, are utterly denied. 
 Being in a sound state, the system, it is maintained, will more 
 eifectually bear with, or resist a morbid attack, than when the 
 order of health is partially subverted, which it must be by the 
 disturbance it receives from the action of medicine, or any sud- 
 den change in the habits of life. 
 
 The correctness of this doctrine in its general application, as 
 well as in relation particularly to the case before us, I think is 
 amply confirmed. Cullen says: — "I doubt, on the whole, if 
 inoculation derives any advantage from those pretended prepar- 
 atory courses of medicine." Baron Dimsdale, Sir George Baker, 
 Fordyce, &c, hold the same language, and, in this view of the 
 subject, most of our practitioners acted when inoculation was 
 common among us. 
 
 Let it not, however, be understood, that the doctrine goes so 
 far as to deny the necessity of an alteration in a course of living, 
 of undue indulgence, or of any other bad habits. The constitu- 
 tion, under such circumstances, is already vitiated, and before it is 
 infected by the disease, ought to be rectified. 
 
 Consequence was also attached to the procuring of matter from 
 a mild case. But it having been ascertained that this has not 
 the slightest influence, it came to be disregarded. The most 
 lenient and distinct small-pox will produce the confluent and 
 malignant, and conversely, — the result being dependent on pecu- 
 liarities of constitution, or the mode of treatment, or some other 
 adventitious cause. 
 
 That a contrary opinion has been maintained, must not be 
 concealed, and I shall cite the strongest fact I have met with 
 to sustain it. By Adams, then physician to the London small- 
 pox hospital, it is related, that, adopting the notion of the power 
 to mitigate the disease, by successively inoculating from the 
 
EXANTHEMATOUS FEVERS. 53 
 
 mildest cases, he accordingly made the experiment, and, as he 
 says, ultimately attained complete success. His plan was to 
 select the virus from a peculiarly benignant variety of it, which 
 he occasionally met with, having an eruption of a pearly -like 
 appearance, attended by very slight constitutional disturbance, 
 and thought that, after a long train of breeding, he had firmly 
 and immutably fixed it as a milder stock from which to propa- 
 gate. This statement, could it be received, would be entitled to 
 great weight. But without impeaching its truth, it seems to 
 involve a consideration, which goes far to its invalidation, or 
 at least, to cast over it a very dark shade of doubt. It will be 
 perceived, that the experiment was made with a form of the 
 disease, whose identity with genuine small-pox does not appear 
 to have been adequately made out or verified, and, at all events, 
 as we hear of no confirmation of it, we may presume that it 
 proved fallacious. 
 
 In the act of inoculation, the virus is inserted under the cuticle, 
 or rubbed into a small incision by a lancet. The other modes 
 once practised, such as the application of a small piece of thread, 
 previously drawn through a pustule, or soaked in the matter, to 
 a scratch, and confined by strips of adhesive plaster, were finally 
 abandoned. Greater security being thought to be given by a 
 multiplication of infected points, this course was pursued to the 
 extent of two or three inoculations on each arm. Camper, how- 
 ever, having demonstrated, by a series of cautious experiments, 
 that a single puncture was as effective, producing as large a crop 
 of pustules, and affording equal protection, as any number up to 
 seven, which was the highest he deemed necessary to try, we 
 became content with a solitary inoculation. But, though the 
 quantity of virus used be of no consequence as to the specific 
 effect, care should be taken, not unnecessarily to enlarge or 
 irritate the wound, as common inflammation may be set up, by 
 which the design of the operation is defeated, and a troublesome 
 sore ensue in its place. 
 
 On the third, fourth, or fifth day, the inoculated point begins 
 to inflame, and at this time is merely a small red speck, which 
 progressively increases, till the close of the seventh day, when 
 the constitutional symptoms manifest themselves. Be it again 
 remarked, as deserving of attention, that there is a material 
 difference in this respect, in the two forms of the disease. The 
 
 5* 
 
54 EXANTHEMATOUS FEVERS. 
 
 system becomes affected, as we have seen in the inoculated, on 
 the seventh and on the fourteenth day, in natural small-pox. 
 It teaches us that, where an individual is exposed to the infec- 
 tion, its operation may be superseded by inoculation, and a 
 milder disease substituted in place of that which might other- 
 wise take place. 
 
 The inoculated disease makes its incursion by the ordinary 
 concomitants of pyrexia, with the addition of soreness and incipi- 
 ent tumefaction in the axilla of the affected arm. Great difference, 
 however, exists in the degree of constitutional disorder. It is 
 sometimes so slight as hardly to be perceived, while, on other 
 occasions, it is considerable, and does, though rarely, present the 
 utmost gradation of violence. The case, in its progressive evolu- 
 tion, being very similar to that of the natural disease, the history 
 of it need not be recapitulated. 
 
 Of the treatment, it may suffice to state that, when mild, little 
 is required to be done, and in the more vehement or malignant 
 forms, which I have said seldom occur, the course to be adopted 
 is such, as has already been suggested, under like circumstances 
 of the casual disease. 
 
 But here a question arises, involving the no less momentous 
 consideration than what are the signs, or criteria, by which we 
 are to determine in the case of inoculation, whether the system 
 has been so affected by the process, as to have its susceptibility 
 destroyed to future attacks. Exceedingly difficult is it, on this 
 point, to arrive at any satisfactory conclusion, or definite and 
 secure course of proceeding. In the later periods of inoculation, 
 a common conviction prevailed among practitioners, that a dis- 
 tinct pustule, with swelling in the axilla, and some febrile move- 
 ment, afforded sufficient evidence of the constitutional affection, 
 and they acted accordingly in practice. The late Professor Rush, 
 especially, inculcated this doctrine. Not a few have gone so far 
 as to maintain, that an unusually violent attack, instead of doing 
 away susceptibility, is rather to be construed as an indication of 
 the endurance of such a portion of it as to endanger a future 
 recurrence of the disease. We are, indeed, told by Sir Gilbert 
 Blane, " that all the well-authenticated cases of secondary small- 
 pox on record, have been of persons who, in the first instance, 
 had it severely. Where such facts are to be found in any num- 
 ber, I do not know. The only instance of the kind I can now 
 
EXANTHEMATOUS FEVERS. 55 
 
 recall, is that of Louis XV., of France, who, in advanced life 
 died of a secondary attack, having had the disease in childhood 
 so severely as to have left his face disfigured by pits and other 
 marks. The observation, I suspect, is without confirmation. 
 Neither of these views is true. Many cases, at least, there are, 
 even when the disease is naturally acquired, where an infinitely 
 stronger impression is necessary to afford an adequate protection, 
 and especially during an epidemic prevalence of the disease. The 
 early writers, their immediate successors, and down to compara- 
 tively modern times, hold this language, and are filled with ad- 
 monitions against a reliance on too slight an affection. By them 
 it is reiterated, that even a considerable eruption running regu- 
 larly through its stages, and still more so in the anomalous forms 
 of the disease, whether natural, or artificial, does not, in all 
 instances, furnish the requisite security. That a contrary opinion 
 was held by some cannot be denied, and more especially by 
 those who, in the enthusiasm of the moment, were desirous to 
 enhance the value of inoculation. 
 
 Devoted to the cause, and blinded by the spirit of controversy, 
 they overlooked all difficulties and objections, and presented the 
 case in the most favourable aspect, contending that the slightest 
 affection was adequate to the end, so completely removing all 
 susceptibility, as to preclude for ever the danger of any repetition 
 of attacks. 
 
 We now know this to be the illusive language of mere votaries, 
 and that a careful practitioner will not fail, in suspicious cases, 
 to renew the operation, at some short interval, as a test and a 
 safeguard. 
 
 VARICELLA, OR CHICKEN-POX. 
 
 The first of these titles is the diminutive of variola, expressive of 
 a slighter degree of that disease, and the second was probably 
 conferred from the resemblance of the varicellous affection, to a 
 similar one in chickens. The poultry of England, according to 
 Jenner, have such an eruption — and he further states, that "in 
 Bengal, they are subject to a disease very like small-pox, which 
 prevails epidemically, and is very fatal. Chickens there are 
 inoculated to preserve their lives."* 
 
 * Baron's Life of Jenner, p. 237. 
 
56 EXANTHEMATOUS FEVERS. 
 
 Early was it remarked, in the history of small-pox, even by 
 Rhazes, that certain exanthematous affections, analogous to it, 
 occasionally appeared, which afforded no protection against that 
 disease. These were subsequently described, about three hundred 
 and eighty years ago, by Vedius, under the title of chrystalli or 
 chrystalline pock, by reason of the vesicular, rather than the pus- 
 tular nature of the eruption — and, from that time, a pretty regular 
 account of varicella has been transmitted. By Sydenham, it is 
 especially noticed, as a spurious variety of variola, and such 
 seems to have been the view commonly entertained of it. But 
 it is probable, that the popular notion in relation to the affection 
 was otherwise, since various vulgar epithets, implying a distinc- 
 tion, were invented in the different countries of Europe, and 
 among these, the English terms, chicken-pock, swine-pock, and 
 hives. Fuller, indeed, acknowledges, in his work, printed in 
 1730, describing the eruption by this title, that he borrowed it 
 " from the nurses." Contemporaneous writers adopted the same 
 designation, and, henceforward, it is everywhere to be met with. 
 
 The first scientific examination of the subject, however, was 
 by Heberden, who, in a paper published in 1767,* contended, with 
 great force of argument, that varicella depends on a contagion, 
 specifically different from that of variola, and clearly pointed out 
 the difference in the two diseases, which came to be the univer- 
 sally received doctrine till, recently, its validity was questioned. 
 
 An attack of varicella is marked by few peculiarities. Com- 
 mencing, as most fevers do, and continuing in various degrees of 
 severity, till the expiration of the second or third day, the erup- 
 tion begins to be disclosed. Yet, for the most part, the fever is 
 moderate, and attracts little or no attention. The eruption is, 
 usually, vesicular, appearing on the face, next on the breast and 
 back, and ultimately on the extremities, — occasionally preceded 
 by a rash, which is attended by some itching or tingling. It 
 comes out in successive crops, so that some of the vesicles are 
 matured, — some shriveled away, and some just emerging, thus 
 presenting every stage of progression, and this consecutive train 
 may be maintained for several days. " They are, according to 
 Willan, about the size of a split pea, perfectly transparent, 
 covered simply by the cuticle, — and, when the eruption is 
 
 • Med. Trans. Coll. Phys. London, vol. i. 
 
EXANTHEMATOUS FEVERS. 57 
 
 copious, the body has the appearance of having been exposed 
 to a shower of boiling water, each drop of which had occasioned 
 a minute blister." There are, however, varieties in the configu- 
 ration of the vesicles, which were early recognized, and discrimi- 
 nated by the popular names of chicken-pox, swine-pox, and 
 hives,— and since, more classically entitled, lenticular, conoidal, 
 and globate varicella. 
 
 To Bateman and other writers of easy access, by whom all the 
 peculiarities of these modifications of the disease have been mi- 
 nutely indicated, I must refer for such information. It may be 
 succinctly stated that the eruption, thus, undoubtedly, diversified 
 as to shape, is sometimes, also, characterized by an earlier or 
 later appearance, by its being oftener purely vesicular through- 
 out its existence, though, in other instances, more pustular, as 
 well in figure as the contained fluid — that, without any secondary 
 fever, it begins to dry and scab, in the order of its successive 
 occurrence, the whole falling off by desquamation in four, six, 
 or eight days, seldom leaving any pits or other vestiges. Con- 
 trary to the tenour of authority, which represents the most com- 
 mon appearance of the eruption to be vesicular and globular, I 
 am sure that I have seen it much more frequently with sero- 
 purulent than thin, serous, or lymphy contents, and of an acu- 
 minated shape, the point soon breaking off, resembling in the 
 whole a truncated cone. 
 
 But, though such are the ordinary aspects and course of vari- 
 cella, it occasionally exhibits itself very differently. The fever is 
 infinitely more vehement, the local affections of the stomach, 
 lungs, and brain, correspondency heightened, and the case, as 
 well in the character and extent of the eruption as other features, 
 approaching very closely to small-pox. Epidemic varicella, of 
 this exasperated nature, has more than once occurred abroad, 
 and sporadic cases of a similar kind are familiar to us in this city. 
 I have repeatedly seen such, where the eruption was all over the 
 body, as thickly as well could be, and very many of the pustules 
 umbilicated. 
 
 That varicella belongs to the class of diseases proceeding from 
 a specific infection, is not disputed. But whether this be distinct, 
 or the same as that of variola, is a point still under discussion ; — 
 and the progress of opinion, in relation to it, has been already 
 adequately traced. By Professor Thompson it is, that the views. 
 
58 EXANTHEMATOTJS FEVERS. 
 
 as settled for a time by Heberden, have been endeavoured to be 
 reversed or overthrown, to revive again the ancient notion that 
 varicella is really modified small-pox. To this conclusion he 
 was led by a very attentive observation of the phenomena of the 
 epidemic variolous disease, at Edinburgh, in 1818, and confirmed 
 by an elaborate research into the subject. Expressed in a few 
 words, these are his arguments : — 
 
 • 1. That varicella and variola may each communicate the other 
 by a subjection to their respective contagions, by inoculation, or 
 through the atmosphere. 
 
 2. That neither disease ever prevails epidemically, without the 
 other being at the same time observable. 
 
 3. That varicella never shows itself, except in persons who 
 previously have had variola or vaccinia, and hence, that it is the 
 product of the variolous virus operating on a system thus modified. 
 
 Confessedly these positions are sustained by an immense mass 
 of facts, and a chain of very cogent and plausible reasoning. 
 Yet few converts have been made to them, and the weight of 
 authority still decidedly preponderates in favour of what was 
 antecedently considered as the established doctrine. 
 
 Let us next see how this side of the question is supported, and, 
 to attain greater perspicuity, I shall take up the adverse positions 
 just mentioned, in the order in which they are presented. 
 
 1. It is replied that it is exceedingly difficult, while the two 
 diseases are simultaneously prevailing, to assign the origin of a 
 case of the one to the infection from the other, as the contagion 
 of both is diffused at the same moment through the atmosphere. 
 Nor is it true that the two diseases can be mutually produced by 
 inoculation. The virus of variola causes small-pox only — and it 
 is altogether doubtful whether varicella be capable of propagation 
 in this mode. Experiments, which go to prove it, are contra- 
 dicted by a host of an opposite description, and it is not unrea- 
 sonable to presume that, in the few successful trials alleged, the 
 matter procured was variolous. On this point the language of 
 my friend, the late Mr. Bryce, of Edinburgh, a most respectable 
 authority, is very decisive. It is stated by him, "that he has 
 taken lymph from the vesicles of true varicella, with the greatest 
 care, at all periods of the disease, and all seasons of the year — 
 that he himself has inoculated, and seen others inoculate with it, 
 children who had never undergone either small or cow-pox, to 
 
EXANTHEMATOUS FEVERS. 59 
 
 the number of thirteen, yet in none of these was this disease, or 
 any thing like small-pox, ever produced." 
 
 2. That the allegation of the uniform simultaneous prevalence 
 of varicella and variola, is not borne out by the history of the 
 diseases. The fact is that, though they do occasionally co-exist, the 
 reverse oftener happens. Much proof might be adduced of their 
 separate and independent prevalence. Enough, however, may 
 it be to state, that we are assured, that from 1809 to 1823, vari- 
 cella was annually observed at Copenhagen, without variola, 
 and that it is well known, for quite as long a period, the same 
 happened in this city. 
 
 3. That it is erroneous to suppose that varicella cannot exist 
 in a system which has not undergone the variolous or vaccine 
 infection. Common experience denies it. Examples of the kind 
 were very familiar prior to the introduction of vaccination, when 
 the unprotected system was more frequently to be met with, and 
 are still sometimes witnessed. 
 
 To the preceding objections to the hypothesis I am combating, 
 it may be added, as calculated further to its invalidation, that 
 vaccination, when practised subsequently to varicella, pursues its 
 ordinary course, which it does not after small-pox, — that varicella 
 undergoes no change in a system modified by the influence of 
 vaccinia or variola, — that the varicellous and varioloid affections 
 are not the same, which they ought to be according to this doc- 
 trine, — and finally, that varicella, with few exceptions, is distinct 
 from small-pox, in the character of the eruption, the prelusive 
 and attendant symptoms, and in every other material respect. 
 
 The disease occurs so exclusively in infancy and childhood, 
 that some have denied its existence at all, in adult or more 
 advanced life. But this, perhaps, is going too far, as Willan, 
 Gregory, and others of our best authorities, have observed the 
 contrary, though the instances on record, well authenticated, are 
 extremely few. The question, at least, may be considered as not 
 satisfactorily determined. Existing sometimes sporadically or 
 sparsely, it much more commonly prevails epidemically, under 
 which circumstances, it makes a wide sweep, among children, 
 running through whole families, or the larger collection of them 
 in schools. 
 
 Enough, perhaps, has already been said of the discriminative 
 signs of this and the variolous affection, in their customary pre- 
 
60 EXANTHEMATOUS FEVERS. 
 
 sentations. Both, however, as previously stated, are liable to 
 anomalous deviations from their normal characters, in which 
 they sometimes become so assimilated as seriously to obscure 
 the diagnosis. Greater difficulty still is experienced in this 
 respect as to the varioloid disease. These two eruptions are 
 very frequently, indeed, in all their features, apparently identical, 
 and receive from the attending physician the one or the other 
 designation, as may suit his views at the moment. 
 
 As little have I to remark relative to the prognosis in varicella, 
 and still less of its anatomical phenomena and pathology. These 
 are points which may be safely left to be inferred, from facts 
 incidentally noticed in the progress of the inquiry. That vari- 
 cella is one of those eruptions in which the system loses its sus- 
 ceptibility to a second attack, or, if such occasionally happen, it 
 must be deemed an anomalous departure from the tenour of its 
 character, seems indisputable. All which I deem of importance 
 in the history of varicella has been given. As to the treatment 
 of it, scarcely any thing is usually required to be done, and when 
 it assumes a graver aspect, a course similar to that in mild small- 
 pox may be adopted. 
 
 VARIOLiE VACCINAE, OR VACCINIA, OR COW-POCK. 
 
 It is a very curious fact, showing how nicely balanced, in some 
 instances, are the dispensations of Providence, that hydrophobia 
 and vaccinia, the only diseases authentically derived from the 
 brute creation, should exercise so different an influence over 
 mankind. They are the antagonizing powers of evil and good 
 — the one the cause of terror, and too frequently of inevitable 
 death, and the other a •source of comfort, and the means of the 
 preservation of life. For though the latter is 
 
 " Like the toad ugly and venomous, 
 Wears yet a precious jewel in its head." 
 
 Confiding in accounts merely traditionary, or resting on 
 authority quite as questionable, it might be concluded, that, as a 
 preventive of small-pox, the process of vaccination had been 
 immemorially known in some of the oriental countries. 
 
 On its introduction into China, from Europe, in 1810, such 
 
EXANTHEMATOUS FEVERS. 61 
 
 a claim to priority was at once preferred by one of their writers, 
 who declares, that he finds the practice in a very ancient 
 Chinese work. Cow-pox, he says, originated in a fly, which, 
 fastening on the cow, sucks the blood, till it falls off — the blood 
 of this fly, being then used to impart the disease, by inocula- 
 tion, to the human species. More plausibly is it asserted, that 
 the practice had been adopted for upwards of a century in certain 
 parts of England, Wales, and Ireland, antecedently to the formal 
 promulgation of the fact. Entitled to still greater attention than 
 these fabulous or vague reports, — though also without confirm- 
 ation, is the averment that, in anticipation of this event by a 
 few years, a case of successful vaccination had been communi- 
 cated to Sir George Baker, then a distinguished practitioner of 
 London. Conceding, however, to it, and to all other pretensions, 
 the credit which can reasonably be claimed, it is still manifest, 
 from such seminal hints, no material advantage was gained. 
 
 To Edward Jenner, of England, is due the honour of having 
 introduced and established this momentous discovery, so interest- 
 ing to medical science, and replete with benefits to mankind. 
 
 He had, in the commencement, to encounter difficulties, and 
 to resist various attempts, open and disguised, to despoil him of 
 his well-earned laurels. Convinced, ultimately, however, of the 
 validity of his titles^ these were sanctioned by the British Parlia- 
 ment, after the most deliberate investigation — and, as a reward, 
 he had voted to him the sum of thirty thousand pounds sterling. 
 
 In 1768, while Jenner was a student of medicine, residing in 
 Gloucestershire, he heard of the prevalence of an affection on the 
 udder of cows, of a pustular nature, which occasionally infecting 
 the hands of those who milked them, produced a correspondent 
 affection, proving a preventive of small-pox, as well in the 
 natural way as by inoculation.* 
 
 Deeply impressed with the value of the intelligence he had 
 collected, Jenner repaired to London, to prosecute his studies 
 
 * Not uninteresting can it be here to mention, that I have been told by Dr. 
 Neil, of this city, that much about the same period, and certainly without any 
 information from abroad, his father, who practised physic on the Eastern Shore 
 of Maryland, was in possession of essentially similar facts. It has also been 
 rendered probable, by M. Husson, that a certain M. Robant, Protestant minister 
 at Montpellier, in France, had so early as 1781, made some verbal communica- 
 tions to several persons, indicating considerable knowledge of the subject. 
 6 
 
62 EXANTHEMATOUS FEVERS. 
 
 under the auspices of John Hunter. During the period of their 
 connection, frequent conversations were held between them, 
 regarding the cow-pock, and its reputed properties. Engrossed, 
 however, with other occupations, the preceptor was without 
 leisure, or did not deem the matter worthy of his immediate 
 attention. Having returned home, after a considerable interval, 
 Jenner resumed his favourite investigation, which he steadily 
 pursued, till the consummation of his mighty and marvellous 
 discovery. This took place on the 14th of May, 1796, which is 
 held to be the birth-day of vaccination. It was on that day, 
 says his biographer Barron, " that matter was taken from the 
 hand of Sarah Neimes, who had been infected by her mothers 
 cows, and inserted by two superficial incisions into the arms of 
 James Phipps, a healthy boy of about eight years old. He went 
 through the disease apparently in a regular and satisfactory 
 manner. But the most agitating part of the inquiry remained 
 to be performed. It was needful to ascertain whether he was 
 secure from the contagion of small-pox. This point, so full of 
 anxiety to Jenner, was fairly put to issue on the 1st of the follow- 
 ing July, when inoculation with variolous matter, immediately 
 taken from a pustule, was practised without any infection." But 
 though, having thus experimentally determined the fundamental 
 principle of his discovery, he still sedulously proceeded to perfect 
 it by the investigation of details, or of collateral matters, calcu- 
 lated to illustrate and confirm it. 
 
 The points which he thought he had ultimately demonstrated 
 were, that the cow-pock was readily imparted to the human 
 species by inoculation, to be passed from individual to individual, 
 without deterioration or change, giving an immunity against 
 small-pox, — it being itself a very mild affection, entailing no 
 pernicious consequences, and utterly destitute of the quality of 
 infection through the medium of the atmosphere, or of commu- 
 nication in any other mode than the one stated. 
 
 Entirely satisfied of the accuracy of his conclusions, he resolved 
 to lay them before the public through the transactions of the 
 Royal Society of London. That learned body, however, placed 
 such slender confidence in his representations, so extraordinary 
 did they appear — that his paper was returned, with a friendly 
 admonition to withhold it from the press, lest it should injure his 
 reputation. Happily, the advice was not followed— and in 1798, 
 
EXANTHEMATOUS FEVERS. 63 
 
 twenty years after the commencement of his inquiries, he pub- 
 lished, in a small pamphlet, in a style the most modest, his great 
 discovery. From this period, vaccination came progressively to 
 be diffused throughout the civilized world, meeting, in different 
 countries, various degrees of resistance, according to the extent 
 of prejudice against it, or the inefficiency of exertion in its 
 behalf. 
 
 More at home, however, than elsewhere, was it assailed by 
 vulgar or illiberal abuse, pretty much in the mode previously 
 pursued in regard to inoculation. Conspicuous among the anti- 
 vaccinists was Mosely, advantageously known by his writings 
 on tropical diseases, whose hostility amounted to fanaticism. 
 Determined in his opposition from the first, to the practice, he 
 ultimately issued a small tract on the subject, in which, amidst 
 other extravagant absurdities, he ventured the prediction that, 
 i( by the influence of bestial humours, imparted in the process, 
 the ' human form divine' would become degenerate, and another 
 brood of Minotaurs produced." 
 
 " Semibovemque virum, semivirumque bovem." 
 
 Mosely had occupied a considerable position in the profes- 
 sional and social relations of London, and his perpetration of 
 such folly created much surprise. But, as I have heard, he was 
 actually insane at the time. From the patronage of the Duke of 
 York, he had lavished on him the practice of the court, and 
 higher circles, with the lucrative sinecure of physician to the 
 Chelsea Hospital. Thus, as he was basking in the sunshine of 
 prosperity, an incident occurred to blight his fortunes. The Duke 
 having a cold, sent for Mosely, to consult him on the safety of 
 his going out to review a body of troops lately returned from the 
 Egyptian expedition, who protested against his leaving the house. 
 
 " The dawn was overcast, the morning lower'd, and 
 Heavily in clouds brought on the day." 
 
 Nothing, however, could restrain the ardour of the hero, and 
 while on the deluged field, he broke out with measles, and 
 became very ill. The physician was charged with criminal 
 ignorance, for not having promptly discerned the nature of the 
 inchoative disease that jeoparded the life of his royal highness, 
 and was instantly punished by deprivation of all his privileges, 
 honours, and appointments. Calamities so heavy, and unex- 
 
64 EXANTHEMATOTTS FEVERS. 
 
 pected, were insupportable. His mind gradually gave way 
 under the pressure of grief and mortification, and, while in a state 
 of hallucination, this unhappy production escaped from it. Not 
 long afterwards, he died in poverty, obscurity, and confirmed 
 madness : 
 
 " 0, how wretched 
 
 Is that poor man that hangs on princes' favours ! 
 There is, betwixt that smile we would aspire to, 
 That sweet aspect of princes, and their ruin, 
 More pangs and fears than wars or women have, 
 And when he falls, he falls like Lucifer, 
 Never to hope again."* 
 
 But, though subjected to this and some other annoyances pro- 
 ceeding from individuals of greater responsibility, actuated by 
 ignorance, envy, or malice, Jenner was encouraged and sustained 
 by the applauses of the better part of his profession, the counte- 
 nance of his sovereign, the liberal rewards of Parliament, and the 
 gratitude of mankind. Many of the most eminent personages of 
 the period courted his personal acquaintance, and nearly every 
 learned association enrolled him among its members, or bestowed 
 on him its honours. Not to swell the catalogue of his titles, he 
 was elected into the Royal Society of London, the National 
 Institute of France, and the American Philosophical Society, — 
 and received the degree of Doctor of Laws from Oxford and one 
 or more of our own universities. Both hemispheres united in 
 rendering him its grateful homage. 
 
 Napoleon himself, at the height of his glory, bowed to the 
 supremacy of his merits, in an offering of a tribute to them de- 
 serving of preservation, from its moral beauty. It happened that, 
 among the Englishmen detained at that moment in France, in 
 retaliation of an act of hostility of the British government, which 
 had engendered the most envenomed feelings, there was a noble- 
 man of great distinction, for whose release very strenuous efforts 
 had unavailingly been made. As a member of the National 
 
 * The above anecdote I give on the authority of a person entitled to confi- 
 dence. Part of the statement I know to be true. In the fall of 1801, 1 was on 
 Wimbleton Common, near London, on the occasion of the review, saw the duke 
 exposed to a heavy rain for several hours, read the daily bulletins of his illness 
 and it was generally said about town that Mosely had been dismissed and 
 degraded, for the very reasons mentioned. The anecdote is communicated to 
 vindicate, not to insult, the memory of a man of no common merit. 
 
EXANTHEMATOUS FEVERS. 65 
 
 Institute, it was thought that Jenner, from his powerful influence, 
 might, through that body, effect the object, and, accordingly, by 
 request, he made the application. The Institute, however, was 
 impotent without the emperor's approbation, and, therefore, ad- 
 dressed him on the subject, whose memorable reply was: "That, 
 which I would not grant to the prayer of embodied Europe be- 
 sides, I will concede to the wishes of the most illustrious bene- 
 factor of humanity. It shall be done." 
 
 " The hero's brows unfading laurels twine, 
 The civic crown, O Jenner! shall be thine." 
 
 Early adopted in the United States, and with little or no divi- 
 sion of sentiment as to its utility, vaccination was speedily spread 
 over the whole expanse of our territories. To the late Dr. B. 
 Waterhouse, of Boston, and Dr. J. R. Coxe, of this city, the first 
 two to engage in the enterprise, and the most zealous in its pro- 
 motion, the principal credit of this achievement is due.* 
 
 Of the origin and nature of the vaccine virus, we are not pre- 
 cisely informed. It has been seen that Jenner first detected it in 
 the udder of the cow. But he advanced the conjecture that a 
 remoter source of it might be found in a sort of icherous humour of 
 the horse's heel, vulgarly called the grease, which the cow received 
 by milkers previously handling the feet of the horse. This ex- 
 planation seemed to him the more probable, as it is customary, in 
 many parts of England, for men to perform the double office of 
 grooms and milkers. The account given of this fluid is too 
 curious to be omitted. He says, " the skin of the horse is subject 
 to an eruption of a vesicular character, which vesicle contains a 
 limpid fluid, showing itself most commonly in the heels. The 
 legs at first become cedematous, and then fissures are observable. 
 The skin contiguous to these fissures, when accurately examined, 
 is seen studded with small vesicles, surrounded by a small areola. 
 These vesicles contain the specific fluid. It is the ill management 
 
 * From a letter of Waterhouse to Jenner, lately published, I find that he 
 endeavours to arrogate to himself the whole merit of the introduction and esta- 
 blishment of vaccination in the United States. Especially does he aver that 
 nothing was done for the cause in Philadelphia. This is not true, and he knew 
 it was not true when he declared it. Coxe, especially, had eminently distin- 
 guished himself by the earliest, most persistent, and successful efforts in the 
 cultivation and promotion of the subject. Waterhouse, I am afraid, to borrow 
 one of his own words, was not a very reliable man. 
 
 6* 
 
66 EXANTHEMATOTJS FEVERS. 
 
 of horses in the stable that occasions the malady to appear more 
 frequently in the heel than other parts. I have detected it con- 
 nected with a sore in the neck of a horse, and on the thigh of a 
 colt." 
 
 Experiments soon made by Coleman, the well-known veteri- 
 nary surgeon, led to an inference opposite to the one of Jenner, 
 and which was supported by some very respectable authority. 
 But Jenner, in reply, affirmed that he had used the equine matter 
 with complete success — and several others to whom he had 
 transmitted it, as well as some deriving it themselves directly 
 from the horse, declared that they had propagated from it the 
 vaccine pustule in the human subject, capable of protection 
 against small-pox. Granting these facts, his deduction from them 
 is not warrantable. They only prove the identity of the virus in 
 the horse and cow, and not at all the priority of the origin in 
 either animal. Equally, almost, might a claim be set up for the 
 goat, sheep, and poultry, in each of which the pustule is said to 
 have been observed. Nor is proof wanting of the susceptibility 
 of the ass and the dog to the disease — a pustule having been 
 excited in each, supplying a virus causing the same affection in 
 the human species. 
 
 As regards the disease in the cow, it was the opinion of Jenner 
 that it is merely a local affection confined to the udder, show- 
 ing itself chiefly on the nipples in the form of irregular pustules. 
 These, at first, are of a palish blue colour, or, sometimes, ap- 
 proaching to lividness, surrounded by a sort of erysipelatous 
 inflammation, occasionally degenerating into phagedenic ulcers. 
 The disease is of rare occurrence, and never appears except when 
 cattle are collected in large herds, and then breaks out at very 
 uncertain periods among them, without any obvious or well- 
 ascertained cause. The infrequency and transient nature of its 
 prevalence are such, that Jenner was constantly interrupted in 
 his inquiries from the difficulty of procuring fresh supplies of 
 matter. During the year 1828 the National Vaccine Institution of 
 London, though they diligently sought it, could not hear of it in 
 the cattle of England. But, in 1830, it was reported to have 
 been found in the cows of Italy, and again, two years afterwards, 
 among those of India. It reappeared in France and Germany 
 in 1835, and the succeeding year in Britain. There is reason to 
 suppose that, at present, it is once more extinct in Europe. 
 
EXANTHEMATOUS FEVERS. 67 
 
 Whether it is now to be met with in the United States, or has 
 been for the last forty years, is doubtful. Formerly it seems to 
 have existed in our cattle. No evidence is there, within my 
 knowledge, of its ever having been detected in our horses or 
 other animals, with the exception stated. 
 
 By Jenner and his immediate disciples, it was supposed that 
 the variolous and vaccine diseases were once the same, having 
 received their present peculiarities by a transmission through the 
 constitution of the human and bovine races. The very title, 
 variolse vaccinae, which he conferred, sufficiently expresses this 
 hypothesis. 
 
 That horned cattle, at one period, were liable to an eruptive 
 fever, bearing a resemblance to variola, is rendered probable by 
 some very curious facts, which were unknown to Jenner, or, at 
 least, they are not mentioned by him. This disease, 1 believe, was 
 first described by Fracastorius, early in the sixteenth century,* 
 as prevailing among cattle throughout the Papal dominions, 
 and to which he gave the title of lues bovilla. By Ramazzini it 
 is noticed as recurring in 1690, and again in 1711 — and, also, by 
 Lancisi, each of whom has recorded it as existing in Lom- 
 bardy. They endeavour to prove, by quotations from the ancient 
 historians, Herodotus, Livy, &c, and the poets, Lucretius, Virgil, 
 Ovid, &c, that it was recognized even in such remote times. 
 
 My limits forbid me to borrow more from these authorities, 
 and which I the less regret, since their statements are corrobo- 
 rated by a more recent writer, who, perhaps, will claim greater 
 credit. From a communication by Dr. Ledyard, to the Royal 
 Society of London,t it appears that a similar disease, on different 
 occasions, had broken out in England, and, in 1745 and in 1780, 
 it very extensively pervaded that country. " The disease/' he 
 says, " in horned cattle, is an eruptive fever of the variolous kind 
 — it bears all the characteristic symptoms, crisis and event, of the 
 small-pox — and, whether received by contagion, infection, or by 
 inoculation, has the same appearances, stages and determination, 
 except more favourable by inoculation, and, with this distinctive 
 and decisive property, that a beast once having the sickness, 
 naturally or artificially, never has it a second time." Contempo- 
 raneously, or nearly so, it prevailed, likewise, in certain parts of 
 France and Holland. 
 
 * 1514. f Transactions, 17S0, part i. 
 
68 EXANTHEMATOUS FEVERS. 
 
 As recently as 1832, an analogous disease is described as 
 having broken out, in a district of India, among cattle. " The 
 animals appeared, for a day or two, dull and stupid. They were 
 seized with a distressing cough, accumulation of phlegm in the 
 mouth and fauces, and loss of appetite. On the fifth or sixth 
 day pustules made their appearance all over the body, especially 
 on the abdomen, accompanied with fever and much general 
 distress. These went on to ulceration — the hair falling off where- 
 ever a pustule ran its course. The mouth and fauces appeared 
 to be the principal seat of the disease — being, in bad cases, one 
 mass of ulceration, which impeded mastication, and proved fatal, 
 apparently, from inanition. The mortality, in this severe epi- 
 zootic, was calculated at from fifteen to twenty per cent."* 
 
 That no experiments were made to determine more precisely 
 the nature of the disease is to be regretted. 
 
 From these facts it has been conjectured with some plausibility, 
 that as vaccinia had not existed, or been recognized long before 
 Jenner's attention was attracted to the subject, it might have been 
 the remains, in a mitigated state, of the former more general 
 epizootic affection described by Ledyard. This inference is 
 countenanced by the consideration that epidemics become milder 
 by lengthened continuance, and it is not inconceivable, in this 
 very case, that what was originally a violent eruptive fever, may 
 have finally been softened down into simple vaccinia. 
 
 Even stronger proof have we of the identity of the two 
 diseases. Gesner informs us, that by inserting variolous matter 
 into the udder of cows, a pustular affection was induced precisely 
 like that of cow-pock, and we learn from Sunderland, of Bremen, 
 that, on covering cows for several days with the sheets of patients 
 under small-pox, the disease broke out in these animals. It has, 
 too, been stated by Ozaman, of Lyons, that if the variolous 
 matter be mixed with fresh cow's milk, so as adequately to 
 dilute its virulence, it induces, by inoculation, an eruption similar 
 to that of the vaccine pustule, and, as conclusive of their identity, 
 the virus taken from one of these pustules, causes the genuine 
 vaccine affection, furnishing complete security against small-pox. 
 
 To the accuracy of these reports, M. Robert, of Marseilles, 
 has attested, and who adds, that a mixture of the variolous and 
 
 * Cyclopedia of Prac. Med., vol. iv., p. 405. 
 
EXANTHEMATOUS FEVERS. 69 
 
 vaccine matter with milk, will at once excite, on inoculation, 
 the local vaccine pustule without, as in the other instance, occa- 
 sioning at first, a more general eruption. Not having seen these 
 publications, and indeed, only an incidental notice of them, and 
 being wholly unacquainted with the authors, I am incapable of 
 appreciating the evidence on which the statements rest, or the 
 degree of personal authority to which the writers are entitled. 
 They are, however, curious, and ought to be subjected to further 
 and decisive trials. Experiments of the kind were, indeed, more 
 recently repeated by Mr. Ceely, of England, who states posi- 
 tively, that by passing through the system of the cow, the vario- 
 lous is converted into the vaccine disease, and in demonstration 
 of which, appeals to the fact that the virus, thus generated, has 
 all the properties of that procured from a vesicle in the human 
 subject, as well in appearance as reality, it equally protecting 
 against small-pox. 
 
 Not very susceptible, however, does the cow appear to the 
 infection. Twice only did he succeed, after many fruitless efforts. 
 Five vesicles were only produced, from which source, several 
 hundred persons were vaccinated, who exhibited all the pheno- 
 mena of that process, in the most perfect form and degree. No 
 eruption, or any other circumstance, led him to suspect that he 
 had not propagated genuine variola? vaccinae. The lymph was 
 transmitted to several other individuals who, on trial of it, expe- 
 rienced similar results. He, moreover, succeeded in imparting, 
 after many disappointments, by what is termed retroinocula- 
 tion, the vaccine disease from man to the cow. The virus loses 
 some portion of its activity, the vesicles rising slower, and are 
 smaller, recovering, however, ultimately its power, by succes- 
 sively repassing through the human system. 
 
 This is all very specious, and may be true. But why has it 
 not been absolutely verified ? Five or six years have elapsed 
 since the discovery was proclaimed, and we hear no more about 
 it, — though, nearly the whole time, there has been the greatest 
 demand for new matter, and the most eager curiosity excited by 
 every thing relative to vaccination ! 
 
 Those, on the contrary, who deny the primitive identity of the 
 variolous and vaccine affections urge that, independently of the 
 striking difference in them, as they now exist, in general character 
 
70 EXANTHEMATOTJS FEVERS. 
 
 and physiognomy, there are some facts which give a downright 
 refutation to the hypothesis. 
 
 1st. It is said that variola is peculiar to the human species, all 
 perfectly authenticated efforts to infect brute animals with it 
 having failed. The celebrated Hunter, and some others more 
 recently, it is understood, did not succeed in their repeated 
 attempts to do it. Woodville, an unquestionable authority, says, 
 " that in the various attempts I have made to communicate the 
 small-pox to animals, as dogs, rabbits, poultry, &c., both by the 
 ordinary way of inoculation, and by injecting variolous matter 
 into the veins, no disease was produced."* But we are assured 
 by M. Vibourg, Professor in the Veterinary College, at Copen- 
 hagen, that he communicated small-pox with virus taken from 
 the human subject, to dogs, apes and swine, and that the same 
 had been effected at Berlin as to cows. These reports, it will be 
 perceived, are inconsistent with those from similar experiments 
 already cited, where the product was the vaccine and not the 
 variolous disease — and on a subsequent trial of covering cattle 
 with the sheets of variolous patients, fully impregnated with the 
 contagious matter, it turned out an utter fallacy. 
 
 To decide, where statements are so contradictory, and we are 
 without an adequate opportunity to ascertain all those circum- 
 stances so indispensable to the constitution of genuine testimony, 
 is difficult. It has been pronounced, by a distinguished judge of 
 our own country, that no man's evidence, in a complicated 
 transaction, is deserving of implicit credit without a cross exami- 
 nation — and I am persuaded there are few more just aphorisms. 
 Common experience teaches the fallibility in this respect, and 
 we are aware that circumstantial proof, where the chain is long, 
 and each link confirmatory, is held in courts of criminal judica- 
 ture to be entitled to greater weight than any single declaration, 
 however positively made. There is in philosophy a rule of 
 evidence more pertinent to this case, which alleges, that in all 
 instances of prodigies, or wide deviations from the order of 
 nature, or of events opposed to the tenour of general observation 
 and experience, it is safer to conclude that the relator intention- 
 ally falsifies, or is deceived, than that such occurrences had 
 actually taken place. Tried by this principle, we should be led 
 
 * Woodville's History of Inoculation, note, p. 3. 
 
EXANTHEMATOUS FEVERS, 71 
 
 determine against the averments of the susceptibility of ani- 
 mals to the contagion of small-pox. Those domesticated or 
 reclaimed are nearly as much exposed to it as man himself, and 
 who among us has ever known of any of them having been so 
 infected? As in law, a man is presumed innocent till he is 
 proved guilty, so in medicine, it were well that no fact or doc- 
 trine should be received without the clearest demonstration of 
 its verity, and by cumulative testimony, — that furnished from 
 different sources. 
 
 2d. That the two diseases are not capable of intermixture, 
 each preserving its peculiarities. Thus, it is found, that if inocu- 
 lation be performed with the two fluids blended, sometimes the 
 vaccine, and at other times the variolous disease will be excited, 
 without the slightest change of character from the process. 
 
 3d. That, when these fluids are inserted separately, though so 
 contiguously that a common pustule is produced, either the one 
 or the other disease will be raised by inoculation, according to 
 the side of the pustule from which the virus may be taken. 
 
 4th. That the two fluids being introduced at the same time, 
 each proves effective to the evolution of the respective diseases. 
 Yet, to a certain extent, their actions are reciprocally restrained 
 — the pustules of each, the vaccine and variolous, being smaller, 
 and proceeding slower to maturity. 
 
 These are the arguments by which the opposite views on this 
 point are vindicated. The question may be considered still as 
 subjudice, left open for decision on further and better evidence. 
 
 In the practice of vaccination, certain rules should be carefully 
 observed, the first of which regards the period of life. Except 
 under very urgent circumstances, the operation is not to be per- 
 formed sooner than a month after birth, and it were well if 
 further postponed. " The uncertainty of organization being com- 
 plete, and the extreme delicacy and irritability of the new-born 
 babe, are the grounds usually assigned for this advice." It can 
 scarcely be doubted that, at a very early age, the disease is less 
 readily imparted, or that, from the great constitutional changes 
 which belong to this period of existence, the vaccine impression, 
 when received, may be more likely to be weakened or entirely 
 destroyed, and hence, perhaps, one reason of the necessity for 
 repeating the operation after a certain period. 
 
12 EXANTHEMATOUS FEVERS. 
 
 Cutaneous affections of any kind, existing to some extent, the 
 operation is inadmissible. Not easy is it, in this state of the skin, 
 to get the virus to act, and, when it does, it is apt, as I shall pre- 
 sently show, to generate a mixed disease, devoid of the protective 
 power. Even the sulphurous impregnation of the skin, which 
 takes place in the cure of itch, we are told, by Jenner, prevents 
 the vaccine infection. To this purport, he relates the fact of his 
 inability to communicate the disease to a body of soldiers in this 
 condition, whose surface being cleansed by the warm bath, they 
 very readily received it. 
 
 Concerning the selection of the virus, much has been said. 
 Foreign writers, including Jenner, seem to prefer the pellucid 
 fluid, and urge the taking of it on or before the ninth day, or 
 previously to its becoming opaque and purulent, or the areola 
 being formed. That it is less active, after this time, is well esta- 
 blished. It is, also, alleged to be more certain in its effects, and 
 altogether better when derived from a child than a person at any 
 more advanced age. I cannot determine the truth of this by any 
 observation of my own. Common experience goes to show that 
 it is incomparably more efficient in the fluid state, or before 
 drying, which, indeed, is so much the case, that, after numerous 
 failures of the operation with such matter, however recent, we 
 almost invariably succeed with that immediately from the vesicle. 
 The use, however, of the fluid has been, for many years, nearly 
 abandoned in this city, and the scab substituted, to which we 
 were led by the following motives: — 
 
 1st. It allows the disease to run its course, free from the dan- 
 ger of changing its specific character by any artificial interference 
 or molestation. 
 
 2d. The virus embodied in the scab, by proper precautions, 
 may be much longer preserved in some instances— even for a 
 year or more, without vitiation or diminution of power. 
 
 3d. It supplies a larger amount of matter for an extensive 
 propagation of the disease. 
 
 Notwithstanding these recommendatory considerations, I am 
 not satisfied that we have done right in adopting the scab. Eu- 
 ropean practitioners, of the largest experience, have entered their 
 protest against it. By all it is admitted that the opaque or puru- 
 lent fluid is far less to be depended upon than the pellucid lymph, 
 and it is not to be conceived that the former, when dried into a 
 
EXANTHEMATOUS FEVERS. 73 
 
 scab, should acquire any new, or regain additional efficacy. It 
 will, too, be hereafter seen that, on the prevalence of epidemic 
 small-pox among us, the failures of vaccination were infinitely 
 more numerous than elsewhere, which may, with probability, be 
 referred to this cause. 
 
 No one denies that there is a choice in the scabs. Those hard 
 and compact, of a dark mahogany colour, and with a regular, 
 well-defined margin, should be selected. The pale grayish scab, 
 scaly or lamellated in its structure, with ragged edges, is always 
 suspicious, very liable to fail, or if it infects, produces an illegi- 
 timate disease, impotent to any security against small-pox. 
 
 Employing the scab, the loose, fuzzy parts which lie on the 
 inner surface, and attach to the circumference, are to be scraped 
 off, and a small portion of the real solid scab is to be pow- 
 dered and moistened, to the state of a thick or ropy fluid. As 
 in the case of the pellucid lymph, this may be inserted into a 
 small puncture or scratch, or what succeeds better, to lay it on 
 the skin, and work it in with the point of a lancet, taking care 
 not to penetrate so deep as to occasion bleeding, which is apt to 
 defeat the operation, by diluting the virus to inertness, or more 
 likely by washing it away. 
 
 Nearly always the incision heals, so as scarcely to leave a 
 vestige — any appearance to the contrary, denoting common 
 inflammation, instead of the specific action of the virus. The 
 infection succeeding, there may be usually seen on the close of 
 the third, or the beginning of the fourth day, a small red speck, 
 somewhat elevated, which, on pressure, imparts to the finger the 
 sensation of its enclosing a grain of some hard substance. This 
 minute pimple gradually enlarges — and about the sixth day, a 
 small vesicle is formed out of it, having a round or oval margin, 
 flat surface, with a slight indentation in the centre — is of a pink 
 colour, which changes to a deeper red, with a mixture of blue, 
 and is darkest in the middle. There is at the same time, thrown 
 close around its base, a narrow efflorescence like a ring. On the 
 eighth, ninth, or tenth day, for the period is not very precise, the 
 vesicle is changed into a pustule, and the areola becomes more 
 florid, and of half an inch more or less in diameter. The pus- 
 tule soon after attains its height, and the efflorescence, through- 
 out its whole extent, is tumefied, in which state it continues for 
 several days, then subsides and fades away. In the declination 
 7 
 
74 EXANTHEMATOTTS FEVERS. 
 
 of the pustule, the centre darkens first, and the whole, by degrees, 
 is converted into a hard smooth crust, of a mahogany com- 
 plexion. The crust drops off spontaneously, in the course of the 
 third week, leaving a cicatrix. 
 
 This is the development of the local affection. On the expira- 
 tion of the seventh day, in children somewhat advanced, or 
 adults, or those still older, in whom there is usually most disease, 
 the ordinary symptoms of fever are manifested, and sometimes 
 even to a considerable height. 
 
 Yet these are generally slight and evanescent in early life, the 
 only serious complaint being soreness and tumefaction under the 
 axilla, which even in infants exist, and hence care should be 
 taken that they be not raised up by the arms. 
 
 Connected with the history of vaccination, there are one or 
 two other circumstances deserving of notice. The local affection 
 is sometimes very prompt in its development, and rapid in its 
 career, appearing on the second day, and reaching maturity in 
 four or five days, — though oftener the reverse, and especially as 
 regards the slowness of its disclosure. I have known it to be 
 postponed, in one instance, to the fourteenth, in another to the 
 twenty-first day — and there is a third recorded, in which the 
 period was extended to six weeks. Yet more extraordinary, in 
 this last case, a second vaccination took effect, and subsequently 
 the first one became completely evolved. An instance, too, is 
 mentioned where the operation failing in a child, it was repeated 
 in ten days successfully, — the disease going regularly through its 
 several stages — and six months afterwards, the former one began 
 to inflame, and finally presented a genuine pustule, leaving 
 behind it a regular cicatrix.* 
 
 With few exceptions, there is a solitary pustule produced by 
 the act of vaccination, and that at the point of the insertion of 
 the matter. But occasionally we meet with a few vesicles of an 
 imperfect character around the areola of the original or parent 
 pustule. Cases also, — though very rarely, have been noticed, of 
 a sparse and scattered eruption on the body. Thus we learn 
 from the report of the Central Vaccine Committee of France, that 
 in 1818 — 19, there was a considerable number of instances, in 
 which many pustules occurred so completely formed, that matter 
 
 * Med. and Phys. Journal of London. 
 
EXANTHEMATOUS FEVERS. 75 
 
 taken from them produced the genuine disease. An explanation 
 of this phenomenon will be presently given in noticing the con- 
 troversy between Woodville and Jenner, in the early history of 
 vaccination, with regard to a similar event. Not improbably, at 
 least, the two occurrences belong to the same category. 
 
 This, then, is a brief account of the legitimate form of the 
 vaccine affection, with its occasional anomalies. 
 
 More, perhaps, than any other point, is it important to under- 
 stand the diagnosis between the genuine and the spurious disease, 
 and no great attention is usually required to decide it with proper 
 discrimination. It may facilitate the comprehension of the dis- 
 tinctions between them, to bring the two affections into imme- 
 diate contrast. 
 
 1st. In the legitimate disease, there is no evidence, ordinarily, 
 of successful infection till the close of the third day, and then we 
 are presented with a minute and elevated pimple, having a defi- 
 nite margin and flattened umbilicated surface. The spurious, on 
 the contrary, shows itself, very soon, in the form of a phlegmon, 
 with considerable inflammation and itching. 
 
 2d. The pimple, in the genuine disease, gradually increases 
 till about the sixth day, when it is converted into a vesicle, con- 
 taining pellucid lymph— retaining the same figure and construc- 
 tion — whereas, in the spurious, with its original phlegmonous 
 character, it reaches maturity before this period, and becomes 
 an abscess filled with pus. 
 
 3d. In the genuine disease, the vesicle changes to a pustule 
 from the ninth to the tenth day, at which time it is surrounded 
 by a very regular areola. But, long before this period, the ab- 
 scess, in the spurious, has ruptured and scabbed, or degenerated 
 into a ragged sore, and, in place of a defined areola, has about 
 it a diffusive erysipelatous blush. 
 
 4th. The pustule of the genuine disease, when at its height, is 
 round or oval, and elevated, with a perfectly definite margin, 
 flattened surface, and a central depression, resembling a button 
 mould bound tightly by the skin, to which it has, indeed, been 
 compared. The reverse are the figure and condition of the local 
 affection in the spurious, which now, and from the beginning, 
 looks like a common fester or boil, being conical or pointed. 
 
 5th. Nor is the areola at all alike — in the genuine, swollen, 
 circumscribed and well-defined, and, in the other, an extensive 
 
76 EXANTHEMATOTJS FEVERS. 
 
 erysipelatous blush, sometimes running up the arm to the shoul- 
 der, or there may be no areola whatever. 
 
 6th. An equal difference is perceivable in the cicatrix or scar, 
 left behind. In the genuine, it is small, striated and cellulated, 
 and very definite. That of the spurious, on the contrary, being 
 scarcely perceptible, or very large, smooth, and polished, with 
 irregular or ragged edges. As to the general or constitutional 
 affection, the same difference exists. That of the genuine is, as 
 already described, mild and regular in its progress — the spurious 
 being the reverse, or exceedingly anormal, and by no means 
 unfrequently of far greater severity. 
 
 No difficulty of discrimination could well be experienced, were 
 the two states of the disease always orderly in their course, and 
 thus strongly characterized. But it occasionally happens, from a 
 feebler development, or some injury done to the vesicle or pus- 
 tule, or by some other cause, its aspect and condition are so 
 changed, as extremely to embarrass a decision regarding its 
 nature and protective efficacy. Examples to this purport are 
 found, especially in vesicles or pustules of much smaller than the 
 usual dimensions, of a paler or more pearly colour, or wanting an 
 areola, or with a very slight one, or, on the contrary, unusually 
 extensive and undefined, like an erysipelatous suffusion, or so 
 rubbed or torn as to be deprived of their distinctive signs. Cases 
 of such ambiguity occurring, or, in short, where, for any reason, 
 there is the slightest doubt of the success of the operation, it be- 
 comes our duty to repeat it without delay. 
 
 The prognosis is always favourable — no instance of death, so 
 far as I know, having happened from the disease, or, indeed, of 
 any danger attending it. The anatomical characters are, hence, 
 confined to the pustule itself, and here I may refer to what was 
 said in regard to that of small-pox, they being essentially the 
 same in the two affections — so far, at least, that, in each, there is 
 the peculiar cellulated structure formerly described. 
 
 In the progress of this inquiry so much of the pathology of 
 this disease has been given, that scarcely any thing remains to 
 be added. I shall confine myself, indeed, to a single remark. 
 Two views, I repeat, are still entertained of its nature. Conform- 
 ably to Jenner and his disciples, it is, truly, variola disarmed of 
 its violence, without losing any of its identity, by passing through 
 the bovine system, and, according to others, directly the reverse, 
 
EXANTHEMATOUS FEVERS. 77 
 
 or an original and totally distinct and independent disease, ope- 
 rating to the prevention of small-pox, by a species of counterac- 
 tion or antagonism. Gregory is the most authoritative of those 
 of the present day, by whom the latter doctrine is maintained, 
 and which he has done with distinguished ability. The facts 
 and arguments of the parties in the controversy, have been 
 sufficiently detailed already to enable any one to form his own 
 conclusion, and I shall dismiss the subject without a further 
 remark. 
 
 Of the treatment of the disease, it may be observed that chil- 
 dren are seldom so sick as to demand medicine, or even any 
 material change of diet. Evacuations of the bowels by the mildest 
 laxatives, and, occasionally, small doses of the dulcified spirit of 
 nitre, or antimonial wine, I have found sufficient in the worst of 
 their cases. But should an attack assume a more violent shape, 
 which now and then, it is said, occurs in grown people, the ma- 
 nagement is to be conducted on ordinary principles, and by the 
 customary means, suited to the particular indications. 
 
 The local affections, however, oftener call for attention. To 
 allay excess of inflammation, cold water, or water and vinegar, 
 or the diluted acetate of ammonia, or a weak solution of acetate 
 of lead, or a saturnine poultice, may be applied — and to arrest or 
 heal the ulcer, the common dressings are to be used. In some 
 of these latter instances, however, I have found the blue mer- 
 curial ointment, or the citron ointment, or simple cerate with 
 calomel mixed in it, singularly serviceable. 
 
 Nothing is required to prepare the system for the reception of 
 the disease, or its subsequent purification, as is vulgarly believed, 
 from the taint which it imbibes. This part of the subject I shall 
 conclude, with advising that, after using all the precautions 
 already directed, the patient is to be visited, on the appearance 
 of the vesicle, at its maturity, in the pustular state, — and on its 
 declination, — watching, to determine whether it goes through 
 these several stages with regularity, and, finally, to examine the 
 cicatrix. 
 
 The question may here be very properly asked, in conse- 
 quence of recent and multiplied reports to the prejudice of vacci- 
 nation, whether, on the whole, it is still entitled to confidence ? 
 Even in the season of its greatest triumph, allegations were 
 made of the occasional failure of the process. But, perhaps, in 
 
 7* 
 
78 EXANTHEMATOUS FEVERS. 
 
 a fair estimate, such instances amount to little, and may be so 
 explained, as not materially to affect the value of the practice. 
 Different and far more serious objections to it have, however, 
 since arisen, as will be hereafter shown. 
 
 The sources of miscarriage, incident to the process at all times, 
 I shall endeavour to indicate. These are thought mainly, though 
 not altogether, to proceed from the use of impure matter. 
 
 1st. The udder of the cow, we are told by Jenner, is liable to 
 two species of pustules, bearing an analogy to each other — the 
 one secreting genuine, and the other a spurious virus, having no 
 preventive efficacy against small-pox. An ignorance of this fact 
 led to some failures in the early period of vaccination. The 
 illegitimate disease in the cow is characterized by nearly the same 
 circumstances as in the human subject, both as to the local and 
 constitutional affections.* 
 
 2d. The vesicle, in our own species, may be originally spurious 
 from several causes, among which the practice of deriving virus 
 from an individual who had previously undergone the variolous 
 or vaccine disease. It was a common opinion, at an early period 
 of vaccination, that the genuine vaccine pustule might be induced 
 in a system thus circumstanced. The repetition of the process 
 of vaccination was, indeed, as well as I recollect, recommended 
 by Jenner himself, as the best means of transmitting the virus to 
 distant regions. But the fallacy of the opinion has long since 
 been exposed. As demonstrated by an infinity of trials, the 
 vaccine and variolous matter has, on such a system, only the 
 power of creating local inflammation, or, at most, a phlegmon, 
 like that excited by other irritants or poisons. Once exposed to 
 their specific operation, it loses, for a time at least, its suscepti- 
 bility to their influence — or, if instances to the contrary occur, 
 they are mere exceptions, not affecting the general principle. 
 Labouring under the error to which I have alluded, practi- 
 tioners did much to spread an illegitimate disease. 
 
 3d. The vesicle may be spurious, from its existing in a dis- 
 tempered subject. By Jenner, the power of certain cutaneous 
 disorders over vaccination, was early detected, and has since 
 been more particularly pointed out by some other writers. Bate- 
 man says, " the most frequent cause of the deterioration of the 
 
 * Good, 395, vol. ii. 
 
EXANTHEMATOUS FEVERS. 79 
 
 lymph, seems to be the presence of chronic cutaneous eruptions, 
 or the concurrence of eruptive fevers or other febrile diseases. 
 The chronic cutaneous affections, which sometimes impede the 
 formation of the genuine vaccine vesicle, have been described 
 by Jenner, under the indefinite term, herpes, and tinea capitis. 
 But in the more accurate phraseology of Willan, they are herpes, 
 (including the shingles and vesicular ringworm,) psoriasis and 
 impetigo, (the dry and humid tetter,) the lichen, and most fre- 
 quently the several varieties of porrigo, comprising the contagious 
 eruptions, "as the itch especially." We are further told by 
 Tierny, that ulcers, as well as recent wounds, are also mischie- 
 vous in their tendencies. 
 
 Even slighter occurrences, in the opinion of Jenner, have an 
 effect. Not long before his death, in 1821, he declared, in a 
 circular letter addressed to the profession, that " mere abrasions 
 of the cuticle, such, for example, as are found in the nurseries of 
 the opulent, as well as in the cottages of the poor, behind the 
 ears, and on many other parts, where the cuticle is tender," are 
 pernicious in this way. " We find," continues he, " irregularity 
 in the vaccine vesicle, if the skin is beset with herpetic blotches, 
 or even simple serous oozings from an abraded cuticle : a speck 
 behind the ear, which might be covered with a split pea, is 
 capable of disordering the vaccine vesicle." 
 
 This is really ultraism. Could it be established, that vaccina- 
 tion is controlled by such trivial occurrences, it would constitute 
 a more serious objection to it than any which has been alleged 
 by its most inveterate foes. The fact is, that Jenner, latterly, 
 pressed on all sides by the augmented proofs of the fallibility 
 of vaccination, lost his candour, and from a sort of parental 
 partiality for his discovery, sought to vindicate it, or explain 
 away its imperfections, in a manner unworthy of his former 
 reputation for philosophical truth. 
 
 He, however, rendered it probable, by a series of observations, 
 that the vaccine action will enter into combination with certain 
 species of herpes, producing a third disease of a hybridous nature, 
 which may be indefinitely propagated by inoculation, without 
 change of character, though ineffectual to all the purposes of 
 preservation against variola. It was early observed, and which 
 lends confirmation to this statement, that vaccination, practised 
 in situations simultaneously exposed to the variolous infection. 
 
80 EXANTHEMATOUS FEVERS. 
 
 the case received a very material modification. Thus, at the 
 first introduction of vaccination, Woodville, who had charge of 
 the small-pox hospital in London, instituted some experiments 
 in that establishment, with a view of testing the validity of Jen- 
 ner's reports, and found, that in about three-fifths of the cases, a 
 disease was produced, more or less of an eruptive nature, very 
 different from the pure vaccine, and approaching more to variola. 
 This led to a controversy between him and Jenner, which was 
 soon settled by the discovery, that the anomaly could be directly 
 traced to the operation of the variolous effluvia, with which the 
 atmosphere of the wards of the hospital was impregnated, where 
 the patients were placed — though not till great mischief had been 
 done by the dissemination of lymph derived from this polluted 
 source. 
 
 Of the influence of the other eruptive fevers, we are not so 
 accurately informed. It seems, however, that when measles or 
 scarlatina breaks out, the vaccine vesicle is arrested till these 
 fevers abate, when it again resumes, and finishes its progress, 
 with a retention of all its peculiar properties. Examples in 
 verification of this statement have been numerously published. 
 Gregory has lately given an instance where vaccination was 
 retarded for sixteen days, during which time, measles had pos- 
 session of the system. Genuine varicella, on the contrary, he 
 says, does not at all interfere with it — the two affections running 
 their courses harmoniously, which, however, is disputable. 
 
 Matter originally pure may, by keeping, undergo some change, 
 weakening or destroying its qualities. Time, which alone will 
 cause such effects, is much aided by a high degree of tempera- 
 ture. During winter, the pellucid virus, which is more, perishable 
 than the scab, may be preserved for many months : whereas, in 
 summer, it loses its strength in a few days, and in some instances, 
 even in a few hours. Being only impaired, it causes a pustule 
 so imitative of the genuine one, as hardly to be discriminated. 
 The particular in which they chiefly differ, is, that in the former, 
 the scab is said prematurely to fall off, leaving the constitution so 
 slightly affected, that no adequate protection is afforded. 
 
 Baron Humboldt gives an account of a surgeon of Lima hav- 
 ing vaccinated a number of persons with superannuated matter, 
 brought to that city, all of whom apparently did well, though the 
 whole, subsequently, received variola by inoculation, in a very 
 
EXANTHEMATOUS FEVERS. 81 
 
 mild shape. To the same point cases might be cited, from 
 various records, showing that virus, enfeebled by age or other- 
 wise, will excite a simulated affection, which, while it is incapa- 
 ble of an entire resistance, tempers the violence of small-pox. 
 
 4th. An effect not altogether dissimilar is said to follow the 
 use of virus from an immature vesicle. Thus we are informed 
 by Willan, that if lymph be had from a vesicle too early, it often 
 proves totally inefficient, and where it does operate, the genuine 
 disease is not produced. Gregory, however, maintains, that the 
 earlier it is taken, the more active it is. That from a fifth day 
 vesicle, he says, scarcely ever fails. But other objections aside 
 to this notion, it is very seldom, indeed, that a particle of fluid 
 can be extracted at so early a period, according to my experience. 
 
 5th. Matter may become degenerate in a vesicle originally 
 genuine. This often happens from the subversion of the specific 
 action of the vesicle by lacerating it to get the virus, or from its 
 being accidentally rubbed, or otherwise molested in its progres- 
 sion. 
 
 6th. The genuine pustule may be local, extending no security 
 whatever to the system at large, and thus constituting another 
 source of failure. Not the least striking fact of this nature came 
 within my own observation, so early as the year 1804. By the 
 late Dr. Stewart, then physician to the dispensary of this city, 
 a man was vaccinated, who seemingly having the genuine dis- 
 ease, matter was taken from his vesicle, with which several of 
 his children were successfully infected. The father, after awhile, 
 broke out with the natural small-pox, and had it severely — the 
 children, however, escaped, and resisted repeated variolations as 
 well as vaccinations. In the fifth volume of the Medical and 
 Physical Journal, a case precisely similar is related by Dr. Har- 
 rison, and I have no doubt others are to be met with. 
 
 Lastly. There is reason to suspect that certain states of the 
 atmosphere, or other occult physical causes, have an influence 
 over the process. Gregory has correctly remarked, that it occa- 
 sionally happens, that many spurious cases of the disease appear 
 at the same time, and more at the approach of winter, than either 
 in the spring or summer months. The same fact I have observed 
 myself, though, I think, oftener in very hot weather, and have 
 been in the habit of referring it to the well-known operation of 
 heat in the deterioration of the virus. Certainly it is less efficient 
 
82 EXANTHEMATOUS FEVERS. 
 
 under such circumstances, as evinced by the greater difficulty of 
 imparting the disease by inoculation. During a series of ex- 
 tremely hot and dry weather at Turin, in 1829, we are told, 
 indeed, that it was found so impracticable to impart the disease, 
 that the practice was abandoned for a time. 
 
 To establish a test of the efficiency of vaccination, has engaged 
 much attention, and various modes have been suggested, among 
 which revaccination, some three or four days after the first ope- 
 ration, was very confidently proposed. It is said that, if the first 
 vaccination be perfect, or, in other words, the constitution is 
 adequately affected by it, the vesicle of the second will be so 
 accelerated that the areola around each takes place simultane- 
 ously, both moving on pari passu, and fade together.* But, I 
 presume, this proposition involves some fallacy, as it seems not 
 to have been generally adopted, and, for many years, we hear 
 nothing of the practice. Cases of its failure have, indeed, been 
 published. Never had the proposition the confidence of 
 Jenner, and, when originally suggested to him, was scarcely 
 treated with courtesy. Writing to Bryce, in reply to his com- 
 munication of it, he says : " I much admire your precaution in 
 using a test of the certainty of infection, and your ingenuity in 
 the manner in which you employ it. To all young vaccinators, 
 it cannot be too strongly enjoined. The experienced will deter- 
 mine from the character of the pustule." 
 
 To revaccinate, at some period after the case is over, is more 
 common. The system being protected, it loses its susceptibility 
 to the vaccine impression, and, instead of a genuine vesicle, a 
 slight erysipelatous inflammation or small phlegmon ensues, 
 which usually soon subsides. But, in the latter particular, it may 
 be otherwise, and I have seen very sore arms, painful axillary 
 swellings and fever thus induced. Nor can the expedient be 
 entirely trusted. Either from defect of the virus, or peculiar 
 condition of the system at the time, the second operation may be 
 defeated, or run the course I have described. It affords, at best, 
 only negative proof. Yet, on the whole, it is to be preferred. 
 The objection to variolation, as a test, most strongly urged, is, 
 that we must keep up small-pox, to supply matter for the pur- 
 pose, and that it is liable to the same fallacies as revaccination. 
 
 * Bryce on Vaccination. 
 
EXANTHEMATOUS FEVERS. 83 
 
 The scar, so greatly relied on, though it may show that a genuine 
 pustule has existed, affords no evidence of the general disease, 
 or that the system at large is duly protected. That which is 
 most to be regarded, " is distinct, circular, radiated and cellulated, 
 and, above all, is so small that it may be covered with a pea." 
 This is the language of Gregory, who, from his ample experience 
 as physician to one of the large vaccine institutions of London, is 
 well entitled to be heard on the subject. 
 
 Now the practice of the vaccinists of Great Britain more par- 
 ticularly, is to proceed on the supposition that security is best 
 attained by the multiplication of cotemporaneous vesicles. 
 
 "As a general rule," says Mr. Moore,* "it may be advisable 
 to make two punctures in each arm, and, when this is properly 
 done, three vesicles, at least, will commonly arise, and if four 
 are excited, it is never to be regretted. If only two vesicles arise, 
 neither should be opened or disturbed— and, if the vaccine pro- 
 ceeds regularly to the end, the vaccination may be considered 
 complete. When three or more vesicles have been excited, lymph 
 may be taken from the subject. But it is prudent always to 
 leave two complete vesicles to pass through their course un- 
 touched."! 
 
 Though emanating from such high authority, I confess that I 
 do not approve of this practice. Granting that the multiplication 
 of punctures increases the chances of infection, it cannot tend to 
 ensure the production of the genuine disease. The suggestion 
 seems to me to have originated in pathological views altogether 
 false, and is without the sanction of any adequate experience of 
 its utility. The system loses its susceptibility to small-pox, not by 
 the quantity of vaccine virus introduced, but by the impression 
 it creates, and to do which, provided it acts, one particle is as 
 effectual as ten thousand. To believe that the living body is 
 capable of saturation by an excess of matter, as happens in a 
 chemical process, which seems to me to be the foundation of this 
 creed, is a conclusion drawn from a very remote analogy, and, 
 in itself, is futile and absurd. By Thompson, whose inquiries 
 have been so accurately conducted on every point connected 
 with vaccination, it is, also, stated that the failures have been as 
 
 * History of the Practice of Vaccination. 
 
 f These are the directions also of the London Vaccine Establishment. 
 
84 EXANTHEMATOUS FEVERS. 
 
 numerous where three as one pustule was raised.* Extraordi- 
 nary is it, indeed, that such an expedient should have been 
 adopted, after the decided experiments of Camper, formerly re- 
 ferred to, in relation to small-pox, which so conclusively showed 
 that a single inoculation proved as effective, to all intents and 
 purposes, as seven, the number which he tried. As a criterion 
 of constitutional affection in this case, I am apprehensive that we 
 are destitute of any deserving of entire confidence, and that such 
 an attainment is still ardently to be desiderated. 
 
 It has been strongly affirmed that there is no evidence to war- 
 rant the popular notion that vaccination is the parent of certain 
 foul eruptions. The attention of Willan to this point, and his 
 ample opportunity of deciding it are well known. By him we 
 are expressly informed that he is not sensible that any new 
 affections of this kind have been generated since the prevalence 
 of vaccination, or that the old disorders had become more nume- 
 rous or virulent. But directly the reverse, the distemperatures 
 of the skin having diminished. It is, also, a remarkable fact, 
 which he cites to the same purport, that, in Gloucestershire, 
 where the vaccine affection has existed longer than elsewhere, 
 no such complaints are heard of. 
 
 Notwithstanding some objections, it follows, I think, on the 
 whole, from what has been said, that most of the allegations 
 against vaccination are not well sustained, proceeding rather from 
 the carelessness of the practitioner than the demerits or imper- 
 fections of the expedient. We have, in proof of this, the strong 
 fact that, prior to the occurrence of the varioloid epidemic, no 
 instance of failure occurred in the practice of Jenner, and not 
 above eight or ten in that of the National Vaccine Establishment 
 of London, where vaccination was done to an enormous extent. 
 Confirmatory of the same conclusion, we learn, from an official 
 report to the British government, in IS 12, apparently drawn up 
 with care, that, out of two millions six hundred and seventy-one 
 thousand and sixty-two cases of vaccination, only seven of small- 
 pox had occurred. 
 
 Of the alleged failures, some, and perhaps many, were not 
 really so. No one can doubt that varicella may be, sometimes, 
 
 * Thompson on Varioloid Diseases, p. 314. 
 
EXANTHEMATOUS FEVERS. 85 
 
 confounded with small-pox, and the carelessness and unskilful- 
 ness with which vaccination was performed, need not again be 
 told. 
 
 Be it admitted that the latter was always an imposition, or 
 undeserving the praise it once received from innumerable of its 
 cultivators, all experimental inquiry is futile : our senses are illu- 
 sive, medical testimony a fallacy not to be trusted, and we must 
 surrender ourselves up to doubt or absolute scepticism, vacant 
 and unprofitable. We are, henceforward, to contemplate the 
 subject in a far less favourable view — and here a stage in the 
 inquiry is reached, when it becomes proper to introduce some 
 account of the varioloid epidemic. 
 
 VARIOLOID DISEASE. 
 
 The difficulties with which vaccination had to contend in the 
 commencement, and how slow and reluctant were the conces- 
 sions, in many instances, to its validity and usefulness, are suffi- 
 ciently known. To receive, at once, a discovery so novel in 
 itself, of such high pretensions, and opposed, as it was, by the 
 whole tenour of analogy and experience, could not reasonably be 
 expected. It was, accordingly, subjected to the severest ordeal 
 its enemies could suggest, and, in this scrutiny, objections were 
 removed, prejudice after prejudice worn away, till conviction 
 took the place of doubt and hesitation, and its triumph was signal 
 and complete. 
 
 For many years this state of unqualified confidence continued 
 unabated in every enlightened section of the world. Now and 
 then, it is true, an instance of failure would occur, from causes 
 not at all to impeach its general power of protection, by which 
 some clamour against it was raised and some temporary popular 
 distrust created. The profession, however, with some immaterial 
 exceptions, seemed insensible to such impressions, and remained, 
 with wonderful consistency, steadfast in its faith. Confiding, 
 indeed, too implicitly, our discernment to real imperfections 
 became impaired, and even a disposition approaching to intole- 
 rance arose, which made it reproachful to seem incredulous, much 
 less to express doubts as to the infallibility of the process. But 
 now, under a sort of panic terror, we are hastening into an 
 8 
 
86 EXANTHEMATOUS FEVERS. 
 
 opposite extreme, prepared to confess our errors, and renounce 
 that practice which had been cherished and defended with the 
 vehemence and intensity of blind devotedness. Can such a 
 course be reconciled to what is due to our dignity, to the cause 
 we have heretofore so warmly espoused, or to that community 
 which look up to us to guide them in this momentous concern, 
 by our science and deliberative wisdom? Every obligation, pro- 
 perly operative in the case, directs us to pause, — to retrace calmly 
 our steps, and dispassionately to survey the whole subject, — to 
 contemplate it in its various lights, — to contrast its merits with 
 its demerits, and studiously, by every help, to endeavour to 
 arrive at a just decision. 
 
 That vaccination has often proved inefficient is not now denied 
 even by its warmest advocates. To this point evidence has, by 
 degrees, accumulated, of such force and certainty as not to be 
 resisted. 
 
 The sources of many of these failures I have, in a preceding 
 lecture, fully developed, and shown that, for the most part, they 
 are under our control, and, as proceeding from ignorance or 
 negligence, may, by proper care, be hereafter avoided. 
 
 In relation to the subject, such was pretty generally the senti- 
 ment, when a disease broke out in Europe, which has led to some 
 new views, and ultimately, as must be confessed, to a much 
 lower estimate of vaccination than formerly. 
 
 This disease seems to have prevailed, for the first time to any 
 extent, at Edinburgh, in the winter of eighteen hundred and 
 eighteen. It had previously shown itself in several provincial 
 towns of Scotland, and, though exciting some curiosity, com- 
 manded no serious attention. Contemporaneously, or nearly so, 
 it raged in England, particularly at Norwich, as well as on the 
 continent, in France, at Geneva, in Italy, in Holland and Ger- 
 many. 
 
 Emanating from these points, it progressively spread through- 
 out Europe, scarcely any one portion of which escaping. Crossing 
 the Atlantic, it appeared the next year among us, diffusing itself 
 over the United States, thence invaded Mexico, South America 
 and the Antilles — subsequently the East Indies, and seems, in a 
 greater or less degree, to have pervaded nearly the whole world, 
 affording an instance of one of the most extensive epidemics on 
 record. 
 
EXANTHEMATOUS FEVERS. 87 
 
 The foreign writers describe it as assailing three classes of per- 
 sons — those who had passed through small-pox naturally or arti- 
 ficially, — those who had been vaccinated, and those who had 
 been subjected to neither of these processes. 
 
 By Professor Thompson, of Edinburgh, an elaborate treatise 
 has been published, embracing a formal and systematic history 
 of the disease. Declining, for obvious reasons, to follow him in 
 detail, I shall attempt to present, in a mere summary, some of the 
 leading and most important of his matter. 
 
 In persons, having had neither small-pox nor cow-pox, the 
 eruption is represented as preceded by fever, commonly of great 
 violence, though sometimes comparatively moderate, continuing 
 for three days, and eventuating in a variolous eruption of various 
 gradations of severity. Of two hundred and five persons, whom 
 he saw in this form of the epidemic, fifty died, making a propor- 
 tion of one in four, which, independently of other evidence, 
 shows its uncontrollable nature. In those who had previously had 
 small-pox, the eruptive fever, in very many, was severe, and in 
 others so mild as scarcely to be perceptible. The eruption, for 
 the most part, resembled the chicken-pock in its several varieties, 
 though in some instances, it had the appearance either of the dis- 
 crete or confluent small-pox. Of this form of the disease, he saw or 
 heard of seventy -one cases, three of which died, giving the pro- 
 portion of one in twenty -three. It is worthy of remark, that in 
 two of the fatal cases, the attack recurred in a few weeks after 
 small-pox. 
 
 The disease, in persons previously vaccinated, seems not to 
 have differed materially from that under the immediate pre- 
 ceding circumstances. Describing it, he indeed employs nearly 
 the same language, though, on the whole, it may, I think, be 
 collected, that such cases were milder. Even when the fever 
 was ever so violent, it almost uniformly ceased on the appear- 
 ance of the eruption. Now and then, however, it assumed the 
 shape of some of the worst species of small-pox, and ran a 
 protracted course. It would be very interesting to determine, 
 whether the system, in these inveterate cases, had been pro- 
 tected by vaccination faithfully done. We are aware to how 
 many contingencies is that process exposed. Be this as it may, 
 it is consolatory to learn that of three hundred and ten indi- 
 viduals affected after vaccination, only one perished, and whose 
 
88 EXANTHEMATOUS FEVERS. 
 
 death can hardly be ascribed to this cause. Of the above num- 
 ber, forty had the disease a second time — only a single instance 
 is mentioned of its returning a third time, and repetitions of 
 attack were distinguished by no peculiarities. It is observable 
 that a large proportion of those who were seized with the dis- 
 ease after vaccination, had been, in the intervals, inoculated 
 with small-pox, or exposed to its agency without being affected. 
 From the accounts in my possession, there was such an essential 
 uniformity, as it prevailed generally abroad, that what I have 
 stated may suffice to convey an adequate notion of the epidemic. 
 
 As it appeared in various sections of the United States, 
 my knowledge is not very precise. The accounts, however, 
 which were furnished me at the time, by two of my correspond- 
 ents at Lancaster, in this state, where it first occurred, show it in 
 one aspect very differently from its exhibition in Europe. It 
 broke out in November, 1818, and was alleged to be traced to 
 some German emigrants, who disseminated it in passing through 
 that city into the interior of the country. The disease, it is 
 true, attacked indiscriminately the variolated, the vaccinated and 
 unprotected, though not in the same proportions. Of the first 
 description, or those who had previously had small-pox, there 
 were six cases, of whom none died — of the second or vaccinated, 
 forty, two of whom, very young children, died in convulsions — 
 and of the third or unprotected, three hundred and fifty, among 
 whom there were four deaths. This slender mortality, with 
 some other facts, led me to suspect that the disease was varicella. 
 It may be remarked particularly, in confirmation of this sus- 
 picion, that chicken-pock seems everywhere to have preceded 
 or accompanied the more formidable epidemic. 
 
 From Baltimore, where it prevailed in the winter of 1821, and 
 still more violently in 1S22, my intelligence is still more defective. 
 It is stated, however, to be the common impression that it was 
 imported from Liverpool — though this is doubted — and we learn 
 that it occasionally attacked both the vaccinated and variolated, 
 I presume in a mitigated shape, since no death occurred under 
 such circumstances. The unprotected suffered much, many 
 being affected, attended with a mortality of about one in six or 
 seven cases. From New York I received an account very 
 similar, in regard to the origin and character of the disease. 
 This is the substance of various communications which reached 
 
EXANTHEMATOTJS FEVERS. 89 
 
 me, separated from a mass of vague and contradictory state- 
 ments. 
 
 In this city, so early as June, 1823, an eruptive fever, which 
 was considered as ordinary varicella, made its appearance and 
 spread very extensively. Contemporaneously prevailed also 
 scarlatina, rubeola and erysipelas, with a variety of anomalous 
 cutaneous affections. Measles, especially, was very rife, and 
 generally of a highly exasperated character, so that former 
 attacks of the disease, in several instances, afforded no protec- 
 tion. During the existence of these exanthemata, some time in 
 July, four cases of very strongly variolous character occurred 
 nearly at the same time in widely separated parts of the city, no 
 intercourse whatever having taken place between the persons, 
 the origin of which could not be traced to any known contagion. 
 Cases of this description gradually multiplied, and by the com- 
 mencement of November, they had become numerous, though 
 almost exclusively confined to Southwark, one of our suburbs, 
 among the poorest class of our population. 
 
 It was about this period that some alarm was excited by the 
 occasional occurrence of it in persons who had been previously 
 vaccinated, and such failures daily increasing, no doubt was 
 longer entertained that the same epidemic, which elsewhere pro- 
 duced so much solicitude, had visited us. The disease hence- 
 forward ran its course, and, in most of its features, conformed 
 to what has been observed in regard to it in other places. It 
 attacked the variolated, the vaccinated and unprotected, occasion- 
 ing those modifications, under the several circumstances stated, 
 which are so accurately described by the foreign writers. As 
 far, indeed, as came under own my immediate observation, there 
 was no material difference. Every degree was presented from 
 that of the mildest varicella to the most malignant small-pox. 
 Generally it was of the former character. Commencing with a 
 slight fever, which endured from one to three days, the eruption 
 appeared sometimes merely as an efflorescence, — though usually 
 as minute papulae, many of which speedily dried away, while 
 others ran on to the formation of vesicles or pustules. The latter 
 were of diverse shapes, conoidal, lenticular, oval, circular, flat- 
 tened on the surface, with a central depression, and an imperfect 
 areola around some of them, bearing, on the whole, a resem- 
 blance more or less to the vaccine or variolous pustule. 
 
 S* 
 
90 EXANTHEMATOUS FEVERS. 
 
 Great difference existed as to the extent of the eruption, and 
 the manner in which it came forth, in some instances confined, 
 and that very sparsely to the head, — in others, the whole hody 
 was covered pretty thickly, breaking out simultaneously, or in 
 successive crops, occasionally of one uniform character, or ex- 
 ceedingly diversified, being papular, vesicular or pustular, &c. 
 Commonly, all febrile excitement subsided on the manifestation 
 of the eruption, and copious as this might be, it was not followed 
 by any secondary fever. The eruption rapidly faded away. 
 Even when consisting of pustules, these began to desiccate, in 
 two or three days, into thin darkish scabs, which soon after fell 
 off, leaving a smooth, florid surface, with, perhaps, here and 
 there a pit or indentation, or a small fungoid excrescence. 
 
 But this account regards only the benignant form of the affec- 
 tion, in its several gradations. As intimated, it sometimes exhi- 
 bited a much more formidable aspect, having every feature, in its 
 progressive stages of discrete or confluent small-pox, and under 
 circumstances, too, of an antecedent subjection of the system 
 to variolation or vaccination by the most skilful practitioners. 
 Taking place without the mitigating influence of these processes, 
 it was nearly always apparently variola, and generally in its 
 most malignant typhoid shapes, proving as incurable as probably 
 ever was known. 
 
 But in some further particulars the epidemic differed, and 
 among which the protective powers of vaccination proved with 
 us infinitely less than elsewhere. From data tolerably authen- 
 ticated, it is computed that between four and five thousand 
 failures of this process took place, and I have not been able 
 to collect more than thirty instances of alleged secondary small- 
 pox, and very few where the previous attack was in the natural 
 way, or so violent by inoculation as to have left any marks 
 behind. 
 
 Curious is the fact, that neither Dr. Physick nor myself, on this 
 or any other occasion, ever met with an unequivocal instance 
 of secondary small-pox; Many of the cases reported to be such 
 I visited, and detected a source of deception which ought to be 
 guarded against in the investigation of the subject. The disease 
 chiefly prevails among the most stupid and ignorant classes of 
 society, by whom the term inoculation is only employed, and 
 
EXANTHEMATOUS FEVERS. 91 
 
 hence they are apt to report themselves, as having been vario- 
 lated, when really the act was that of vaccination. 
 
 The following table, taken from the report of Drs. Mitchell and 
 Bell, who had charge of the small-pox hospital, is interesting in 
 several views. It furnishes a statement of the results of one 
 hundred and forty-eight cases of the disease. 
 
 "There were forty-seven cases in persons who had been pre- 
 viously affected by vaccination, none of which died. Eight 
 cases occurred in persons previously affected with small-pox, of 
 whom four died and four recovered. Ninety-three cases were in 
 persons who had not had either disease before, of which fifty- 
 two died and forty-one recovered. 
 
 " Of the whole number, sixty-nine were whites and seventy- 
 nine persons of colour. Two out of the eight persons who had 
 suffered from small-pox a second time, took it the first time 
 naturally or without inoculation. Eight of those vaccinated 
 were so during the prevalence of the epidemic, and some of the 
 mildest cases were in the persons of those who had been vacci- 
 nated upwards of twenty years before/' 
 
 This table includes the results only to the 14th of January. 
 The relative proportions, however, subsequently, in every re- 
 spect, were pretty nearly the same. 
 
 The record of our board of health up to the same time, shows 
 that little more than three hundred died of small-pox, and four 
 only of the varioloid disease, whether the last followed variola- 
 tion or vaccination, does not appear. 
 
 No instance, at this period, or for several years afterwards, 
 came within my knowledge of any repetition of attack in the 
 same person as noticed in Europe. But, subsequently, I have 
 seen it in three families, to the amount of seven cases. 
 
 The disease, in conformity with most others dependent on a 
 specific contagion, gradually declined on the accession of warm 
 weather, and by the first of June entirely subsided. Next win- 
 ter, however, it reverted, though sparsely, and thence ceased, 
 with, perhaps, here and there a separate case, till the succeeding 
 winter, when it again returned very much in the same manner 
 as before. From 1825 to 1827, so little was seen of it that hopes 
 were entertained of its disappearance, when it once more re- 
 visited our city to a considerable extent. During the next two 
 years, it became nearly extinct, and so continued till the winter 
 
92 EXANTHEMATOUS FEVERS. 
 
 of 1830, on which occasion, numerous cases occurred. Not 
 much was heard of it after that period, though occasionally soli- 
 tary instances were met with. But in 1833, it again revived, and 
 spread widely, since which, with the exception of the year 1840, 
 we have had scarcely any of it, and probably the epidemic has 
 become exhausted. Each of its renewals has been marked 
 by nearly the same phenomena, varied chiefly by gradations 
 of violence, and in every instance preceded by varicella, scarla- 
 tina, rubeola, as well as by an infinity of other cutaneous affec- 
 tions. It is not to be supposed that we were exclusively the 
 victims of this disease. Nearly all our cities, and many portions 
 of the country, have been exposed to its ravages, during the 
 same period, though probably not in the same degree. 
 
 Connected with this inquiry, the facts are now sufficiently laid 
 open to enable me to enter on those speculations which imme- 
 diately grow out of the subject. The question primarily arising 
 relates to the precise nature of the epidemic, whether it really be 
 small-pox, or some other affection not obedient to exactly the 
 same laws. 
 
 Two hypotheses have been advanced, and each maintained 
 with much ingenuity and force of argument. The predominant 
 opinion in Europe, as well as in this country, supposes it to be 
 genuine variola, which, operating on a system that has under- 
 gone the variolous or vaccine impression, produces comparatively 
 a mild affection, to which the title modified small-pox, or varioloid 
 disease, is applied. 
 
 In support of this view, it is alleged, that the most lenient and 
 worst forms of the epidemic, in some instances, reciprocally pro- 
 duce each other, either by inoculation or in the natural way, 
 and this is held forth as the experimentum crticis, from which 
 there is no escape. But it seems to me to be rather a petitio 
 principii, in which the variolous character of the case is assumed, 
 and not demonstrated. The fact of their mutual communica- 
 bility, admitting it to be true, which I am not disposed to do, as 
 regards the disease particularly among us, surely does not prove 
 the identity with small-pox, since another disease, in its different 
 forms, may have the same property of reciprocity of production. 
 Never have I known the varioloid miasm to induce variola, nor 
 is there any positive evidence, within my own experience, of its 
 being infectious, causing a disease even like itself. That a con- 
 
EXANTHEMATOUS FEVERS. 93 
 
 trary opinion exists, 1 am aware, though I think it has been 
 hastily formed, and is not entitled to much respect. Nor, so far 
 as I have seen, was small-pox or any near approach to it, the 
 result of inoculation with the virus. Most of the attempts to 
 propagate it in this mode have utterly failed. Experiments, 
 however, made here in 1823, show that the varioloid virus, 
 introduced into a system neither variolated nor vaccinated pre- 
 viously, occasions a vaccine-like vesicle, around which are soon 
 thrown a number of pimples, which run into each other and into 
 the vesicle, after which the latter degenerates into an irregular 
 phlegmon, followed by fever and a slight eruption: — whereas, 
 on a protected system, only a local vesicle is induced, resem- 
 bling the vaccine, which perishes prematurely on the sixth day. 
 These experiments, originally made by Dr. Darrah, of this city, 
 have since been confirmed on repetition by M. Genderin of Paris, 
 who, however, says that the same protective effect is derived 
 from varioloidation as by variolation or vaccination, which latter 
 has not been substantiated. 
 
 Whatever may have been the disease elsewhere, it is hardly 
 possible to conceive that, as it originally existed at Edinburgh, 
 and especially in this city, it could have been pure small-pox. 
 There are several discrepancies hardly reconcileable with such 
 a supposition. Not to dwell on minor points of difference, it 
 seized indiscriminately, though not in an equal degree, on the 
 vaccinated, the variolated and unprotected, by either of these 
 processes, and, in some instances, there were two or three reite- 
 rations of attack in the same person, within a very short time, — 
 circumstances unprecedented in the history of variola. 
 
 Exigetically, it is suggested that, at all times, such occurrences 
 were more common in regard to small -pox than suspected, and 
 especially during an epidemic prevalence of it. For this allega- 
 tion there is, perhaps, some foundation. The conviction was 
 very general, among the early writers on the disease, that it 
 might be repeated in the same person. This doctrine was, 
 indeed, asserted, with few exceptions, till arraigned by Mead in 
 a very confident tone, by whose weight of authority it came to 
 be subverted, or, at all events, very much shaken. Cases mili- 
 tating against his views were henceforward, till lately, denied, for 
 the most part, to be of a variolous nature, and explained away as 
 some other distinct eruption. But the ancient notion has again 
 
94 EXANTHEMATOUS FEVERS. 
 
 been revived, and it is now maintained that the eruptions called 
 chicken-pock, swine-pock, horn-pock, stone-pock, water-pock, 
 chrsytalline-pock, are really the variolous disease, thus variously 
 modified by the system having before been partially affected by 
 small-pox or vaccination. Conformably to this hypothesis, which 
 Professor Thompson has espoused, all these affections, including 
 the varioloid, have one common parent in small-pox, and though 
 somewhat dissimilar in aspect and other qualities, retain enough 
 of general resemblance to betray their consanguinity or relation- 
 ship. As the sea-nymphs, of whom Ovid says : 
 
 "Facies non omnibus una, 
 Nee divina tamen, qualem decet esse sororem." 
 
 Their faces, though not the same, are so much alike, that they 
 might be known to be sisters. Granting, however, all that is 
 contended for in this respect, which I have shown that I am 
 not prepared to do, it seems to me, every other objection aside, 
 that the repetitions of small-pox so far exceed all former experi- 
 ence, as to be utterly irreconcileable with the explanation now 
 attempted. Consult the whole history of the disease, and no 
 parallel instance can be found,— prevailing, as it has done, epi- 
 demically, at various times, in a shape quite as formidable. Nor 
 have we found, on the subsidence of the epidemic, here or else- 
 where, which ought to have happened, according to this notion, 
 any correspondent change in the character of the disease. 
 
 By others it has been held that the epidemic in question was 
 really a malignant or highly aggravated state of varicella. It is 
 admitted, as before mentioned, though generally there is no diffi- 
 culty in distinguishing the two diseases, that occasionally vari- 
 cella, in some epidemic prevalences of it, assumes an aspect so 
 imitative of variola, as readily to be confounded with it. Till 
 within the last half century, indeed, they were, on this account, 
 considered as the same disease, the latter being somewhat modi- 
 fied. 
 
 As regards our recent epidemic, it is indisputably true, that on 
 its original appearance, the prelusive cases of it were decidedly 
 of a varicellous nature. These were in summer, and it is not 
 utterly unreasonable to surmise, that when, on the accession of 
 cold weather, by the concentration of the contagion, the disease 
 may have been gradually exacerbated into the malignancy which 
 
EXANTHEMATOUS FEVERS. 95 
 
 it ultimately assumed. Moreover, neither variolation nor vacci- 
 nation affords any security against the attacks of varicella, in 
 which particular it corresponds, to a certain extent, with the epi- 
 demic in this city. Nevertheless, the hypothesis is met by such 
 insuperable objections, that I think it must be abandoned, and 
 especially by the fact that varicella cannot be propagated by 
 inoculation, in this respect differing from the epidemic in its un- 
 modified state. 
 
 Taking all the circumstances into view, I am half inclined to, 
 though not absolutely willing to adopt the opinion, which alleges 
 that this recent epidemic, if not some other disease, was a very 
 altered state of small-pox. The conjecture is, at least, ren- 
 dered plausible by the consideration of the impossibility of re- 
 conciling the multiplied failures which have taken place, as well 
 in vaccination as variolation, with all preceding experience of 
 the infallibility, or nearly so, of these two processes. What be- 
 comes, on any other supposition, of the evidence deduced from 
 the infinity of experiments in the early stage of vaccination for 
 the purpose of determining its efficacy. Numerous individuals, 
 we are told, were exposed, after having gone through this opera- 
 tion, to the most concentrated contagion of small-pox in hospitals 
 and elsewhere, with entire impunity. These experiments were 
 made to a very great extent in London, Paris, Vienna and this 
 city. It was the practice, too, for a series of years, to subject all 
 cases of vaccination to variolation, as a criterion of the efficiency 
 of the former — and the result of these multiplied trials was as I 
 have stated. From Jenner we learn that, "in the year 1801, of 
 the six thousand persons vaccinated, the greater number were 
 thus tested, and subsequently exposed to the infection of small- 
 pox in every rational way that could be devised, without effect." 
 No point was seemingly better established than that an in- 
 dividual having had vaccination was rendered for ever unsus- 
 ceptible to the action of small-pox. But now, the fact is other- 
 wise, or that this expedient affords a very precarious protection. 
 It has been urged, I am aware, in explanation of these failures, 
 that small-pox, when vaccination was introduced and its efficacy 
 tested, so far from being of the envenomed character it. subse- 
 quently assumed, had become so remarkably mild and benignant 
 that its contagion possessed little force. The suggestion would 
 be entitled to more attention, did not the same degree of fallibility 
 
96 EXANTHEMATOUS FEVERS. 
 
 in the process continue to the present moment, when the epi- 
 demic has lost its intensity. 
 
 Conceding, however, its plausibility in regard to vaccination, 
 I do not see how it can apply to variolation. To the period of 
 which I am speaking, small-pox once thoroughly acquired in 
 this mode or naturally, little or no solicitude was entertained of 
 any future recurrence of it. Not to cite authorities superfluously 
 on this point, let us take a single one, from countries where the 
 subject was probably best understood. The estimate of Heber- 
 den, in England, of secondary small-pox, was one in five thou- 
 sand, of Condamine, in France, of one in double this number, by 
 Van Swieten, of Germany, it was denied altogether, and the 
 late Professor Kuhn, of this university, informed me that, in 
 a practice of fifty years, he had never met with a single in- 
 stance of such an occurrence. But now, the lengthened and 
 accumulated evidence which sustained its efficacy is gone, and 
 we are released from a creed which, slowly and cautiously 
 adopted, was cherished with idle credulity for more than a 
 century. Difficult as it may be to suppose that we were labour- 
 ing all this time under so gross a deception, it unavoidably follows, 
 should the disease prove to be genuine small-pox. But presum- 
 ing the contrary, or that some new, or exasperated, or otherwise 
 altered old eruption, with the general variolous aspect, though in 
 some particulars of a different character, has appeared, we are 
 supplied with an infinitely more satisfactory solution of this 
 problem. 
 
 Nor do I perceive why we should, without investigation, 
 refuse our assent to this hypothesis. Change is as incident to 
 some diseases as any thing else, and while many are gradually 
 modified or wholly extinguished, others are suddenly brought 
 into existence. We shall presently see that there is some reason to 
 suppose that the vaccine affection itself has already experienced 
 such an alteration. Not, however, to insist on this, I shall cite 
 the venereal distemper as an exceedingly pertinent example. 
 Developed by a fortuitous combination of causes, it has, in the 
 progress of time, undergone a most striking revolution in its cha- 
 racter and treatment. From the early writers on the subject it 
 may be learnt, that, when that disease first appeared, it had the 
 character of a general febrile eruption, propagated by an infec- 
 tious effluvium, and not particularly by sexual intercourse, or 
 
EXANTHEMATOUS FEVERS. 97 
 
 confined, in its primary aggression, to the genital organs as in 
 later times. 
 
 Nothing more extraordinary is there in the varioloid than the 
 syphiloid affections. That inoculation should no longer afford 
 absolute security against this modified contagion is not more 
 surprising than the inefficiency of mercury in most of the modern 
 forms of syphilis. 
 
 Dismissing this part of the inquiry, it may be remarked as very 
 curious, that a similar conjecture was some years ago thrown out 
 by Southey the poet. In a dialogue purporting to be between 
 Sir Thomas More, who lived in the reign of Henry the Eighth, 
 and a personage of the present day, the latter is rebuked for too 
 arrogantly asserting the superiority of modern discoveries and 
 improvements, and especially in relation to small-pox. " What," 
 says More, "if small-pox, which was vainly supposed to be sub- 
 dued, should assume a new and more formidable character, and as 
 there seem grounds for apprehending, instead of our being pro- 
 tected by vaccination from its danger, it should be ascertained 
 that inoculation itself affords no security?"* This, in some mea- 
 sure, may have proved the language of prophecy. 
 
 From my own observations, I should say, that of any given 
 number of individuals, as usually vaccinated, who might be 
 exposed to the concentrated infection of small-pox, not one- 
 third would escape the disease, in some shape or degree — and in 
 this estimate, I am entirely supported by several of my medical 
 friends. To persons of adult and more advanced age, I have 
 more immediate reference. Children not being admitted into 
 the hospitals I have attended, where contagion is most active, 
 my experience in regard to the operation of it on them is 
 infinitely less. Especially have I remarked the affectability of 
 the members of the medical class, whose average age is about 
 that of the legal majority, to such attacks. 
 
 It must be deduced, on the whole, I am apprehensive, what- 
 ever may be our reluctance to do it, that vaccination, as a pre- 
 vention of the epidemic among us, has proved so inefficient as 
 scarcely to deserve to be considered at all in this light. 
 
 Throughout Europe the same distrust of the security furnished 
 by vaccination at present exists, as appears from many of the 
 recent publications. The testimony of Gregory is very emphatic. 
 
 * Vid. Southey's Dialogues. 
 9 
 
98 EXANTHEMATOUS FEVERS. 
 
 and from his position as physician to a large vaccine establish- 
 ment in London, particularly authoritative. Honestly does he 
 confess, that the failures of vaccination in the prevention of 
 small-pox, have been steadily on the increase for some years 
 past, and that small-pox, after vaccination, is far more frequent 
 than instances of secondary small-pox. From the register kept 
 in the hospital, we learn that in the year 1813, the proportion of 
 cases of small-pox succeeding vaccination, to the whole number 
 of admissions, was as one in thirty — in 1815, was one in seven- 
 teen — in 1819, as one in six — in 1821, as one in four, and during 
 the year 1822, as one in three and a half." 
 
 In 1837-8, small-pox again recurred epidemically in London: 
 the admissions into the hospital were double the usual number 
 previously to the practice of vaccination, and two-fifths of which 
 were after a subjection to that process.* Further, it appears, 
 at a late meeting of the Royal Medical and Chirurgical Society, 
 of London, Gregory stated "that, in the middle of November, 
 1837, there had been a sudden and marked increase in the num- 
 ber of patients admitted into the hospital, and which had con- 
 tinued up to the present time. From the first of January, 1838, 
 six hundred and eighty-one cases had been admitted, and of 
 these two hundred and eighty-one had previously been vacci- 
 nated. Startled at this increase, he had made inquiries at vari- 
 ous sources, and found that the disease was spreading in the 
 same fearful manner throughout England, scarcely a town or 
 village having been free from it since last November, and the 
 increase throughout Europe had also been great: but on the 
 continent the alarm had been taken, and revaccination prac- 
 tised to a great extent. In 1833-34 small-pox was very pre- 
 valent at Copenhagen, and in twenty months one thousand 
 patients were admitted into the hospitals, of which nine hun- 
 dred had been vaccinated. These are important facts, bearing 
 on the prevalence of small-pox, and the present failure of the 
 vaccine lymph as a prophylactic measure, and, should these 
 statements be borne out, will show the necessity for the imme- 
 diate adoption of sanitary measures to prevent the spread of so 
 dreadful a disease." 
 
 The subsequent proportion, in the London institutions or else- 
 where, I am without the means of determining. But it seems to 
 
 * Library of Practical Medicine. 
 } 
 
EXANTHEMATOUS FEVERS. 99 
 
 be the creed into which the medical mind everywhere is fast 
 settling down, that vaccination is chiefly valuable as preserving 
 life, by tempering the violence of small-pox. Even thus limited, 
 its utility is great, as will appear more conspicuously, when the 
 fact is proclaimed, that upwards of one-half died at first, in this 
 city, of the epidemic in the unprotected system, and not more 
 than one in the thousand where vaccination had been properly 
 received. 
 
 On the reports of our Board of Health, which warrant such a 
 conclusion, I think, however, we are not too implicitly to rely. 
 It was then, it continues to be, and has ever been, much the 
 practice of the profession to endeavour to maintain the reputa- 
 tion of vaccination by false modes of reasoning and other sub- 
 terfuges. Death happening, or a case assuming the character of 
 decided variola, after vaccination, it was pretty uniformly re- 
 ferred to the operation having been unskilfully performed, and 
 never admitted as proof of the fallibility of the expedient. 
 Many such instances I suspect were never reported, or if re- 
 turned, they were as malignant varicella, of which several came 
 within my own knowledge, it being then not an uncommon 
 opinion that the epidemic was really of this nature. Neverthe- 
 less, it must be admitted that vaccination proved wonderfully 
 conservative of life. 
 
 From the same amiable weakness, truth has been disguised in 
 another way. Eager to sustain vaccination, the opposite dispo- 
 sition has, at all times, prevailed to disparage variolation. Every 
 thing militating against it was sought after, and reported with 
 no proper care of investigation, nor apologies offered, as in the 
 other instance, for its alleged failures. But, surely, the two pro- 
 cesses, in this respect, should be placed on the same footing: what 
 is allowed to the one, in all fairness to be extended to the other, 
 in order to reach a just comparison of their merits. Neglect, or 
 ignorance, or incompetency, I have shown, renders vaccination 
 nugatory, and not less so does variolation suffer from the same 
 causes. 
 
 Notwithstanding these and other remarks, I wish it to be 
 understood, that I am not, at least in the present uncertainty of 
 the subject, for abandoning vaccination, and still less for revert- 
 ing to the process of variolation. Excepting in the degree of 
 prophylactic power, which seems to be much in favour of inocu- 
 
100 EXANTHEMATOITS FEVERS. 
 
 lation, the superiority, in every other view, is indisputably with 
 vaccination. Exclusively of diverse considerations, by which it 
 is recommended, too obvious to be noticed here, it is a process 
 mild in its general character, rarely inducing unpleasant conse- 
 quences, and never proves fatal. But of inoculated small-pox 
 we are told by Willan, one in two hundred and fifty dies, and 
 several distinguished English writers have made it as one in a 
 hundred. But these statements, I presume, have reference to 
 the results among the out-door poor of England, with whom no 
 advantages can be commanded. Certainly much greater success 
 has been attained in the small-pox hospitals of that and other 
 countries, and in private practice among persons in comfortable 
 circumstances, where proper skill and attention were exercised, 
 the fatality of the operation had become exceedingly inconsider- 
 able, as before mentioned. Distinct from its mortality, it may 
 be objected to variolation, that it occasionally entails the most 
 lamentable effects, developing scrofula, phthisis, and other loath- 
 some diseases, causes the loss of sight, and is destructive by its 
 disfiguration of personal comeliness. 
 
 By variolation, supposing the disease in this form to be infec- 
 tious, the sources of contagion are, moreover, multiplied, each 
 case proving a new point from which the disease may emanate, 
 so that, though individuals were benefited by the mitigating 
 influence of the process, the aggregate of mischief was actually 
 increased. Computations made by Heberden, without any refer- 
 ence to this question, show that, subsequently to the introduction 
 of inoculation, 7iinety-five persons died of small-pox, in London, 
 out of every thousand, whereas the average number, antecedently 
 to it, was only seventy in the thousand. Corroborative of this, 
 it is shown that, in Spain, where the practice of inoculation was 
 scarcely ever admitted, small-pox has caused less mortality, in 
 proportion to the population, than any country in Europe. Can- 
 dour, however, compels me to acknowledge that an opposite 
 view is entertained. Many have denied the general fact, and 
 Adams, then at the head of the London Small-pox Hospital, has 
 plausibly shown, by a different mode of calculation, a diminution 
 of deaths from the disease since the more extensive adoption of 
 inoculation. This, with other evidence which might be cited, 
 goes far to weaken, if not to invalidate, the conclusion drawn 
 from the preceding statements, and in some degree to sustain the 
 
EXANTHEMATOUS FEVERS. 101 
 
 hypothesis formerly noticed of the non-infectious nature of the 
 inoculated disease. Even in this state of amelioration, however, 
 the extent and kind of mischief of which small-pox was product- 
 ive were enormous. 
 
 Nearly fifty thousand individuals annually did it destroy in 
 Great Britain only, occasioning every fourth death in the king- 
 dom. Lettsom computed the mortality in Europe at two hun- 
 dred and ten thousand, and Bernouille, an Italian authority, 
 throughout the world at six hundred thousand annually. By 
 vaccination, though limited by vulgar prejudices, this frightful 
 expenditure of human life was greatly abridged. What was the 
 extent of its whole effects in this respect I have no means of 
 determining. But we have some striking facts in relation to 
 particular countries, where vaccination was enforced by law. 
 From official reports, it appears that in Copenhagen the mortality 
 had been reduced from five thousand five hundred in twelve 
 years, to about one hundred and fifty-eight in sixteen years, and 
 finally small-pox became extinct in Denmark. The same hap- 
 pened in the principality of Anspach. In Prussia the number of 
 deaths was diminished from forty thousand to three thousand 
 annually, and in Bavaria only five persons died of the disease in 
 eleven years. 
 
 An extension of the plan by which small-pox was eradicated in 
 some of these countries, has been thought would as certainly do it as 
 regards the whole world, and, by a wise and cordial co-operation 
 in this mighty work of benevolence, this terrible scourge of hu- 
 manity might, in a few years, be so completely annihilated as to 
 leave behind only its name and the story of its former ravages. 
 Even Jenner himself, in the glow of his enthusiasm, ventured 
 such a prediction. These hopes were not well-founded. Distinct 
 from the difficulty of enacting, and, still more, enforcing penal 
 provisions against inoculation or other modes of introducing 
 or continuing the disease, under free governments, there is an 
 insuperable obstacle to its extinguishment in the circumstance 
 not adverted to, that it occasionally arises, as it were, de novo, in 
 an epidemic shape, which no regulations can prevent or even 
 repress. This very city, admitting the late epidemic to have 
 been small-pox, affords an illustration of the force of this objection 
 to the scheme. For a long period it escaped the disease by a 
 common agreement of the physicians not to variolate, aided in 
 
 '9* 
 
102 EXANTHEMATOUS FEVERS. 
 
 the design by strict quarantine and some other regulations to 
 exclude it, when the epidemic burst, out among us and rendered 
 ■at once nugatory all our well-meant efforts. The same has 
 happened in those countries of Europe which, by similar means, 
 enjoyed for a time a like immunity. Nevertheless, what cannot 
 be altogether prevented may be mitigated — and so far it is our 
 duty to exercise our influence, and especially by discouraging 
 the practice of inoculation. 
 
 Every other objection aside to variolation, I should be exceed- 
 ingly distrustful, in the present state of our knowledge of the 
 subject, of the genuineness of the virus now to be procured. No 
 one denies that of the precise nature of the epidemic some doubts 
 may reasonably be entertained, and who can foresee whether it 
 shall prove a security against real small-pox? 
 
 As to vaccination, we have an assurance of its virtue, so far at 
 least, as regards the preservation of life, and it seems to me that 
 common prudence requires that it should not be exchanged till 
 all uncertainty is removed. 
 
 Not without plausibility, it has, within a few years, been stre- 
 nuously urged in explanation of the fact of the augmentation of 
 the failures of vaccination, that it is a process temporary only in 
 its effects, — the system, however protected for a period by it, 
 ultimately reacquiring its susceptibility to small-pox. An ap- 
 prehension of the kind was early avowed by Jenner himself, 
 though soon disclaimed, and in 1809, Brown, a surgeon of Mus- 
 selburgh, Scotland, preferred this charge against it on evidence 
 afforded by his own observations, which ought to have been 
 heeded. But vaccination was then completely at the point of its 
 culmination — and the medical profession being unwilling to have 
 its glory tarnished, or, still more, perhaps its utility lessened, by 
 the creation of any popular distrust of it, treated the discovery as 
 an idle endeavour of its author to acquire notoriety, and himself 
 with contempt and ridicule ! Different, very different indeed, is 
 the case at present. Emanating from the highest anthorities, 
 such a mass of similar and stronger facts has accumulated, as to 
 have reversed very generally the preceding views. 
 
 Gregory has stated that, for about five years after a successful 
 vaccination, the system appears to be wholly insensible to a 
 repetition of the process. But at the expiration of ten years, the 
 skin becomes irritated on an insertion of the virus, followed, in a 
 few days, by a pointed or accumulated vesicle, with an areola of 
 
EXANTHEMATOUS FEVERS. 103 
 
 irregular figure, — the whole prematurely perishing. Much con- 
 stitutional disturbance, attended by swellings of the axillary 
 glands, on some occasions takes place. Cases, however, occur 
 under these circumstances, where the revaccination runs a regu- 
 lar course, both as to the local and general affection, and matter 
 is furnished by the vesicle, capable of propagating the genuine 
 disease. To these facts others may be added of equal or greater 
 force. 
 
 Frequent occurrences of small-pox after vaccination, in the 
 armies of the German states, induced, some time ago, several of 
 the governments to direct a general revaccination of the troops. 
 As regards those of Wurtemburg with whom the process began, 
 it is said by Professor Heim, "that, in sixteen hundred and eighty- 
 three individuals in whom the operation was repeated in thirty- 
 four in each hundred, it completely succeeded — in twenty-two 
 with modified results, and in forty-four it utterly failed. Of five 
 hundred and seventy-seven who were revaccinated with entire 
 success, two hundred and ninety-three had perfect cicatrices, — ■ 
 in one hundred and sixteen, imperfect, — and in one hundred and 
 sixty-eight, there were no scars at all. Three hundred and thirty- 
 six, revaccinated with unsatisfactory results, had good marks, — 
 one hundred and thirty -four defective traces only,— and thirty, 
 no vestiges of the kind. Finally, seven hundred and forty of the 
 revaccinated, without any effect, three hundred and twenty-two 
 showed good — two hundred and twenty-two imperfect, and one 
 hundred and thirty-six no cicatrices." 
 
 The results are equally striking as to Prussia. Lochmeyer 
 reports that, of the military vaccinations in that country, up to 
 1833, out of forty thousand cases, thirty-seven thousand presented 
 "plain traces of previous vaccination, — fifteen thousand had the 
 disease afresh, — twelve thousand imperfectly, and twenty-one 
 thousand not at all. Of these last, seven hundred contracted 
 cow-pox, being vaccinated afresh, and three thousand not. Fifty- 
 four out of those successfully revaccinated, took varicella, — fifty, 
 other varioloids, and twenty-three, small-pox." 
 
 To proceed further with these details in relation to other coun- 
 tries were superfluous, as there is an essential correspondence in 
 the whole of the official returns which I have seen. 
 
 The inquiry has been very slenderly aided in the United States, 
 so far as I can learn. For the last twenty years, however, as is 
 
104 EXANTHEMATOU5 FEVERS. 
 
 well known, I have annually revaccinated a considerable portion 
 of the class of our medical school, with a view of testing the effi- 
 ciency of the former operation. Many, at all times, and some 
 even with proper cicatrices retook the disease perfectly,— though 
 in this respect a marked difference was observable in different 
 years, owing to variations in the degree of susceptibility to infec- 
 tion. What this depended on I cannot say. Nothing was there, 
 apparently, in the character of the seasons or other circum- 
 stances to which it could be ascribed. The average of successful 
 revaccinations was about a third, and this has been gradually 
 increasing. Certain considerations, however, detract from the 
 value of any deductions from these cases. No small portion, 
 perhaps a majority of our class, come from parts of the country 
 where vaccination is practised irregularly, and under great dis- 
 advantages. The matter procured from the venders of it in our 
 large cities, the common sources of supply, is not always good, — 
 and the operation is seldom superintended with sufficient care 
 and vigilance, from the distance of the residence of the patient, 
 or the meanness of the compensation. But it appears that, in 
 1840, small-pox having again assumed an alarming shape in this 
 city, Dr. Kirkbride, physician to the House of Refuge, and the 
 Institution for the Instruction of the Blind, resorted to revaccina- 
 tion of the inmates of these establishments as means of security. 
 Two hundred and nine children, with proper cicatrices, all others 
 being excluded from the experiment, were subjected to the opera- 
 tion, of whom about twenty-one per cent, had the disease per- 
 fectly. Considering the period of life, this is a very large propor- 
 tion, and is one of the facts calculated to create distrust of the 
 operation of all dates and at every age. 
 
 The ensuing document which I derive from a Parisian journal, 
 is too interesting to be withheld. 
 
 "The Minister of Public Instruction requested the Academy 
 of Medicine to enlighten him on the following points: — 1st. 
 Whether the preservative virtue of the vaccine matter be not 
 impaired proportionably to the time elapsed from the process of 
 inoculation? 2d. Whether the decrease of efficacy does not 
 render re vaccination necessary? 3d. Whether it would not be 
 desirable to cause the pupils of all the colleges to be revaccinated 
 according to dates, &c. 
 
 " The academy solved the three questions in the negative, and 
 
EXANTHEMATOUS FEVERS. 105 
 
 begat a controversy which rages in the common newspapers not 
 less than in the medical repositories. Physicians of note imme- 
 diately addressed protests to the minister, styling the decision 
 of the academy rash and baneful, and arguing all the points in 
 the affirmative, by facts and authority, which the doctors of the 
 academy are accused of having utterly overlooked or disdained." 
 
 M. Dezeimeris has just published a copious memoir, and M. 
 Gaultier de Claubry, a large pamphlet, in favour of revaccina- 
 tion. These writers and a crowd of others on the same side 
 cite numberless cases and opinions drawn from Great Britain, 
 the north of Europe and America, — and they finally concur in 
 this general inference, that experience and reason render it an 
 obligation of law to prescribe revaccination, and to propagate it 
 with the same zeal as original inoculation. Their special views 
 are : — 1st. " That vaccination loses its preventive power after some 
 years, so that it no longer prevents small-pox from reappearing 
 — taking the regular course and proving fatal. 2d. That revac- 
 cination has the same original power and final decline as vacci- 
 nation — and that it succeeds the more certainly in proportion as 
 the time is remote at which the patient has had the vaccine dis- 
 ease." 
 
 Copious as my extracts have been, I cannot forbear to indulge 
 in one more. It is stated by Dr. Stewart, of Kelso, Scotland, in 
 his correspondence with Dr. Gregory, just published, "that his 
 opportunities of seeing small-pox have been large, and particu- 
 larly when it prevailed epidemically in 1834-5, it having then 
 attacked many vaccinated and unvaccinated." From the expe- 
 rience thus obtained, he ventures to draw the following conclu- 
 sions : — " That vaccination affords but an imperfect protection 
 against small-pox at all periods of life: — that the protection be- 
 comes more imperfect as the individual advances in life : — that, 
 at the age of puberty, the influence of vaccination, provided it 
 has been had recourse to in infancy, nearly ceases, — or at any rate, 
 in a majority of cases, at the age of twenty, vaccination ceases 
 to exercise any protective power whatever." To revaccination 
 he was therefore led, pursuing it extensively for the last twelve 
 years, and found, as he anticipated, " that it was successful exactly 
 in proportion to the time which had elapsed from the first ope- 
 ration." He tried the experiment on four persons in whom he 
 knew the previous operation had been carefully conducted, — 
 
106 EXANTHEMATOTTS FEVERS. 
 
 aged fourteen, sixteen, nineteen and twenty. In the first the 
 modification was considerable, — in the second less, — in the third 
 still less, — and in the fourth perfect cow-pock, and it went 
 through all the stages quite regularly. There was a difference, 
 too, in the progress of the pox. The first came to a height on 
 the fourth day— the second on the fifth — the third on the seventh 
 — and the fourth on the eighth day." 
 
 Now, from these data it is probable, perhaps certain, that by 
 time the system, regains, in many instances, at least, its sensibility 
 to the vaccine infection, and it may be presumed, in the same 
 way, to that of small-pox. The lesson is hence inculcated, to test 
 it in all cases by revaccination. No apology, indeed, can be 
 made for the omission. To do it is our bounden duty, and any 
 neglect on our parts may be deemed a flagrant misdemeanour 
 for which we must be held responsible. 
 
 Deliberately do I believe that there never was a more serious 
 call on professional exertion. By the laws of epidemics, strik- 
 ingly illustrated in relation to the variolous, we may with cer- 
 tainty look for a speedy return of such an affliction. Experienced 
 already in Europe, after the usual suspension, why should we 
 calculate on an exemption ? Come when it may, unprepared as 
 we are at present to meet it, and it will be a most terrible 
 calamity. Much have we to apprehend that vaccination may 
 not prove either as a prophylactic or mitigator of the disease so 
 effectual as on the former occasion. Diminution of its power, in 
 each respect, seems steadily progressive, as was conspicuously 
 displayed in the recent epidemic prevalences of small-pox in 
 England, France, Germany, &c. Be it admitted, however, that 
 it may preserve life as formerly, it is still to be remembered, that 
 it frequently does it at the expense of great suffering to the indi- 
 vidual, and of anxiety and terror to friends. Not rarely have I 
 seen varioloid attacks which, in these particulars, might be 
 compared to the graver forms of the variolous affection itself. 
 Equally alarming is the preliminary stage, — the force of fever, 
 with disorder of the brain, stomach, lungs, &c, the only dif- 
 ference between them being, that in the former, there is no 
 secondary fever, and the whole goes off more abruptly, as an 
 abortion, seemingly, owing to defective vigour to carry on the 
 case farther regularly through the successive steps to its final 
 termination. 
 
EXANTHEMATOITS FEVERS. 107 
 
 Let us hence proceed, as they are now doing abroad, to the 
 performance of revaccination without delay, to bring it to the 
 criterion of a well-conducted trial, and then reject or retain the 
 expedient according to its ascertained merits. The operation is 
 simple, and no detriment can possibly ensue from it. For the 
 repetition of the process, the precise period, however, seems not 
 to be determined. Gregory, as we have seen, intimates that, at 
 the expiration of five years, after the first operation, some change 
 takes place favourable to the renewed action of the vaccine virus, 
 and probably not less to that of the variolous, — though, on the 
 whole, he thinks it need not be attempted prior to the tenth year, 
 and the most urgent season for it is between puberty and con- 
 firmed manhood. 
 
 Following out the notion of Leo Woolf, previously advanced in 
 a memoir on the subject, published in this country, Heim, of Ger- 
 many, whose experience is so ample, — maintains that, owing to 
 the change which the constitution undergoes at maturity, the 
 general organism is so deeply affected that the antecedent condi- 
 tion from the impression of vaccination is done away, and sus- 
 ceptibility to small-pox restored. This may be a just view, and 
 still it were prudent not to restrict the practice to any period of 
 life. Carelessly as vaccination has been pursued, who can tell 
 the number of cases of imperfect execution? Every age I 
 would hence include, and in going over the whole ground, mark 
 whatever is defective, and endeavour its rectification. Thou- 
 sands of persons, vaccinated this very year, I cannot doubt, 
 were the operation now to be repeated, would betray the incom- 
 pleteness of the preceding one ! 
 
 That a disposition to small-pox is more apt to be reacquired at 
 some distant interval is proved by the circumstance of the greater 
 liability of grown persons than children to its recurrent attacks 
 after vaccination. Few very young persons, it appears from the 
 report of the London Small-pox Hospital, have been received 
 into that establishment, and those few almost invariably with the 
 mild modifications of the disease : —on the contrary, nearly the 
 whole of such presenting the severer forms of it had been vacci- 
 nated from fifteen to twenty or more years. Can any thing 
 further be required to show the gradual diminution of the pro- 
 tective power of vaccination, and of the imperative necessity, 
 
108 EXANTHEMATOUS FEVERS. 
 
 with a view of keeping it in force, to renew the operation from 
 time to time as may hereafter be determined? 
 
 It has also, of late, been affirmed that the virus now in use,, 
 having become effete or less active, a resort for a supply to the 
 original source should be had. No satisfactory determination o 
 this question has hitherto been made, and very opposite opinions 
 still prevail in reference to it. Formerly, however, the proof of 
 the virus retaining its powers unimpaired was very decisive. 
 By Professor Thompson it is stated "that the virus used at the 
 Royal Dispensary, at Edinburgh, for eighteen years, was still as 
 efficient as first collected — though it had passed, during this pe- 
 riod, through a succession of at least nine thousand individuals." 
 Marshall, whose work was published much more recently, de- 
 clares in relation to the virus employed in London, " that the same 
 taken from a cow in 1799 has ever since been kept up, and pro- 
 bably transmitted through some hundreds of thousands of systems 
 without any evident deterioration." This is likely the source of 
 most of the matter now in the world. During the same year, 
 four thousand cases were propagated from it, which furnished a 
 supply to the whole British empire, including the army and 
 navy, and also to other countries whither it was liberally de- 
 spatched. 
 
 We are assured by Griva, chief of the vaccine establishment 
 at Turin, that in 1829, when epidemic small-pox existed in that 
 city, "no difference was to be traced between the aspect and 
 progress of the old and the new,— the primitive and the long 
 humanized virus." 
 
 From Germany, where this experimental course was conducted 
 on a very extensive scale, between the years 1S31 and 1836, 
 similar reports were received. The several vaccine establish- 
 ments of London, and, perhaps, of Britain, seemed to continue 
 their confidence in the matter they had originally employed, and 
 such was the case throughout this country. " For one year," 
 says Watson, in his admirable work on the Practice of Physic, 
 « I had a seat as senior censor of the College of Physicians, at 
 the National Vaccine Board, and I then had opportunities of 
 satisfying myself, that lymph, which had been transmitted with- 
 out interruption from person to person ever since the time of 
 Jenner, continued to generate as perfect a cow-pock vesicle as 
 at first." 
 
EXANTHEMATOUS FEVERS. 109 
 
 Confirmatory testimony might readily be collected to any 
 amount from every quarter, up to 1836. But henceforward, it 
 dwindles in cogency and extent, — and some of an opposite cha- 
 racter appears, by which medical opinion on the point has be- 
 come materially affected. Fresh matter was procured from the 
 cows of the dairies of Passy, a village near Paris, at this period, 
 which, after adequate trials, was generally pronounced of supe- 
 rior quality. Next year the National Vaccine Institution of 
 London was induced to substitute new for the old matter, and 
 with the same acknowledgment. No great while afterwards, 
 Mr. Estling, surgeon at Bristol, England, discovered the disease 
 among the cows of that neighbourhood, and the virus was freely 
 distributed, some of which reached this city, and produced the 
 same conviction of its excellence in those by whom its effects 
 were witnessed. 
 
 It seems, on the whole, to be agreed among those who have 
 had opportunities of judging, that the primitive matter, wherever 
 obtained, proved more active and operated with greater cer- 
 tainty. The local inflammation, as well as the constitutional dis- 
 order, was more violent, and a manifest improvement exhibited 
 in the vesicle and subsequent pustule, areola, &c. How far this 
 representation is correct I cannot say from my own observa- 
 tions, every attempt which I made with the Bristol matter having 
 been unsuccessful. 
 
 The experiments to which I have alluded are very defective. 
 They show only greater energy in the new virus, leaving the fact 
 of the capability of the impression created by it to protect against 
 small-pox immediately or remotely in absolute doubt. Nor does 
 the mere circumstance of higher intensity of action, local or gene- 
 ral, or even of more perfect development of the pustule prove 
 very conclusive. The spurious disease, in many instances, as pre- 
 viously intimated, is remarkably distinguished by the two former 
 particulars, and the occasional fallacy of an unexceptionable local 
 affection, in every respect, as to its commencement, progress, 
 maturity and declination, is universally admitted. Examples, 
 without number, of the failure of vaccination, and when per- 
 formed, too, by the most experienced, have occurred with every 
 favourable indication. Much remains to be accomplished in this 
 investigation to the ascertainment of truth. 
 
 There are some, I am not ignorant, who deny the possibility 
 10 
 
110 EXANTHEMATOUS FEVERS. 
 
 of the degeneracy of the virus, as contrary to facts and to all 
 analogy. Neither part of the averment is correct. The facts 
 already adduced, and which have rapidly increased, and will 
 probably go on to increase, are surely too imposing to be disre- 
 garded by the medical philosopher or mere practitioner — and, 
 indisputably, the history of our science furnishes sufficient in- 
 stances of diseases, even of some specific diseases, having gradu- 
 ally abated in force or virulence till they became exceedingly 
 changed or totally extinct. Grave obstacles, however, oppose 
 the inquiry. The cow, which at all times precariously supplies 
 the matter, I have reason to believe, does not at all, at the pre- 
 sent moment, — and may not again for years. As the disease has 
 hitherto prevailed, too, and its future recurrences, it is to be 
 anticipated, will be marked by the same feature, the genuine has 
 invariably been associated with spurious forms of the affection, 
 demanding greater skill of discrimination than will, I fear, be 
 bestowed on the subject. I have said that the existence of a 
 spurious pustule in the cow was early known, of which Keim 
 declares that, in his subsequent inquiries, he detected five different 
 varieties, each capable of propagating an illegitimate and unpro- 
 tective affection, all, however, closely simulating the genuine 
 one. The perplexities which Jenner and the other primitive 
 cultivators of vaccination experienced in this respect, and the 
 mischief occasioned by the mistakes committed, are not to be 
 forgotten. 
 
 It is impossible to contemplate the present posture of vaccina- 
 tion without perceiving the doubts and difficulties with which it 
 is encompassed. By the revolutions which it has undergone, 
 nearly all once believed to have been determined, it is subverted, 
 or thrown into a very unsettled and questionable shape. 
 
 The subject must again engage our most assiduous attention, 
 to clear up every vexed point, by a candid and dispassionate 
 examination of facts, directed solely to the ascertainment of truth. 
 Especially should we endeavour to determine more accurately 
 than hitherto has been done the nature of the varioloid epidemic 
 in its several relations. Next, how far the original vaccine virus 
 has lost its efficacy by successive transmissions, or retaining its 
 active properties, — whether its effects are limited only to a cer- 
 tain period. Having our knowledge thus rectified, vaccination 
 must be committed exclusively to the profession with such a 
 
EXANTHEMATOTJS FEVERS. Ill 
 
 compensation as shall secure proper skill and fidelity, in the prac- 
 tice of it, which heretofore, I am persuaded, it has never com- 
 manded. 
 
 From the proposed inquiry, should it appear that the recent 
 failures are owing to any or the whole of the causes mentioned, 
 the corrective may, perhaps, be supplied, and the pristine confi- 
 dence in the process fully restored. 
 
 Disappointed, however, in this respect, a recurrence ought 
 again to be had to variolation, and it also fairly tried. To a 
 correct appreciation of it, we must determine, among other points, 
 the exact security it affords in the present state of small-pox,— 
 how long this endures, the degree of mortality from the process, 
 and whether it be infectious, so as to multiply and spread the 
 disease. The medical men of Europe are turning their attention 
 to this expedient, — though slowly and reluctantly. McCormac, 
 one of the most distinguished of them, after deploring the causes 
 of the depreciation of the process, adds, "that the inference 
 appears clear, that unless the benefits attendant on vaccination 
 be further improved and perfected, it would seem preferable to 
 resort to inoculation afresh."* Even Gregory himself, the last, it 
 might have been supposed, to have used such language, exclaims, 
 in the correspondence formerly referred to : " Well, then, what 
 is to be done to fortify the public mind in the matter of vaccine 
 security? How long are we to go on thus showing annually the 
 increase of our practical distrust of vaccination ? The sooner 
 we come to a decision on the subject the better. There is one 
 and only one way in which this can be done. Not by revac- 
 cination, but by inoculation at distant periods from the date of 
 vaccination." 
 
 The necessity of the alternative, I do not, however, very gravely 
 apprehend. Duly attended to on our parts, and with liberal 
 public support, I am inclined to believe, and fondly trust, that all 
 difficulties maybe overcome, all cavils silenced, and all prejudices 
 removed on the subject. By adverting to the loose and indis- 
 criminate manner in which vaccination has been practised by 
 the heads of families, by the clergy, by old women, and other 
 benevolent, though very incompetent personages, we ought rather 
 to be surprised that the number of failures have been so small, 
 
 * Methodus Medendi, a new work on the Practice of Physic, of great merit. 
 
112 EXANTHEMATOUS FEVERS. 
 
 in a process which, from its delicacy, requires to be superin- 
 tended by all the powers of discrimination and skill. Every 
 good is interwoven with some portion of evil. The singular 
 mildness of vaccination, by taking it out of professional hands, 
 has undoubtedly very much detracted from its utility and ex- 
 posed it to some very unjust imputations. No one was more 
 culpable for the injury which in this way accrued, than Jenner 
 himself. Too eager to spread the value of his discovery and to 
 popularize it, as it were, he for a time became a sort of medical 
 demagogue, addressing himself to a class of people who ought 
 never to be appealed to in any matter of professional concern, — 
 representing vaccination as an affair of such simplicity as to be 
 comprehended and practised by any one of common intelligence. 
 To secure a general co-operation in the scheme of vaccine propo- 
 gandism seems to have been his design. The invitation to unite 
 with him in it was too flattering not to be promptly and nume- 
 rously accepted, and especially by the description of individuals 
 I have mentioned. But soon was he awakened to a sense of 
 the error he had committed, and never ceased endeavouring its 
 counteraction by a frank confession of the evil of which it was 
 productive. Now, however, a reformation may probably be 
 instituted in this respect. Considering how much our pride is 
 interested in a discovery which so gloriously illustrates the cha- 
 racter of the profession, it is among our first and highest obliga- 
 tions to vindicate it against the caprices of fashion and fluctua- 
 tions of opinion, till it is firmly established, to be transmitted to 
 posterity unimpaired, as the noblest contribution ever made by 
 science to the purposes of human benefit and happiness. Nor 
 are our obligations less to the memory of Jenner. The column 
 once erected to it is daily suffering from dilapidation, and must 
 speedily fall into ruins, if its defects be not repaired, and greater 
 security given to its foundation. Be this our grateful office. The 
 mode of executing the task has already been indicated. Even 
 should we be disappointed in establishing the merits of his dis- 
 covery to the extent originally conceded, we cannot fail, by a 
 just exposition of his services, to throw around his name impe- 
 rishable renown, and enrol it enduringly with those 
 
 "Inventas aut qui vitam excolure per artis unique sui memores alios fecere 
 merendo. 
 
EXANTHEMATOUS FEVERS. 113 
 
 RUBEOLA, MORBILLI, OR MEASLES. 
 
 Formerly, rubeola was written rubiola or rubiolo, it being 
 derived from the Spanish rubio, and came to be changed to 
 rubeola, as directly proceeding from the Latin rubeo, to be red, 
 or to blush. Morbilli or morbillo is a term also of Spanish 
 origin, being a diminutive of il morbo, the plague, though it was 
 employed, it is said, to designate the disease as a lesser degree of 
 small-pox, the greater malady then having the same title with 
 which it had been confounded. Meaning mottled or speckled , 
 the term measles, which is an old English word, was obviously 
 applied to the affection from its presenting such an appearance. 
 
 Notwithstanding the allegation of some writers of the antiquity 
 of measles, it seems now to be generally admitted that the dis- 
 ease was brought into Europe at the same time, and probably 
 from the same place as small-pox, and ran so nearly the same 
 course, that it was supposed, as already intimated, to be merely 
 a modification of the latter, and as such is described by the 
 Arabian writers, who were the first to notice it. As late, indeed, 
 as the period of Diembrenbroeck and Moreton, both of whom 
 have given accounts of it, the notion of the identity of the two 
 diseases was still entertained. To Sydenham, the contemporary 
 of these writers, we are indebted for the earliest accurate and 
 discriminating history of measles, and to which, excepting the 
 later contributions of Watson, who wrote in 1763, and the still 
 more recent inquiries of Willan, by each of whom a supposed 
 variety or modification of the disease is pointed out, nothing 
 scarcely has been supplied. 
 
 Measles exhibit several varieties or modifications, and may 
 be either of an inflammatory or passively congestive or malig- 
 nant character, in each of which states I shall notice it. 
 
 The more common form of it, entitled rubeola vulgaris, will 
 first claim our attention. For the most part it is decidedly an 
 inflammatory affection, ushered in by alternate chilliness and 
 heats, languor, pains in the loins and limbs, soon succeeded, in 
 many instances, by anorexia, thirst, sickness of stomach or vomit- 
 ings, with whitish tongue, fulness or aching of the head, cough, 
 or rather defluxions from the nostrils and eyes, which latter 
 
 10* 
 
114 EXANTHEMATOUS FEVERS. 
 
 are somewhat swollen and red, — in the whole resembling the 
 incipiency of catarrhal fever complicated by gastric irritation. 
 These symptoms, in different cases, vary in the order of prece- 
 dence and in degree and combination. Either the gastric or 
 pulmonary may be anticipatory, or the two simultaneously burst 
 forth, or the one preponderate, or an equality exist between 
 them — and, in other respects, there are diversities. 
 
 Nearly from the commencement, the fever which quickly fol- 
 lows is usually considerable, though, at times, for the second or 
 third day, light, becoming higher, with a stronger and fuller pulse 
 and more pulmonary oppression, and is particularly marked by 
 an increase of heaviness and somnolency before the eruption, 
 which mostly appears about the fourth day. Cases, however, 
 are recorded, and some I have met with, of its taking place with 
 little premonition — others, in twelve or twenty-four hours, and 
 many, of its being postponed to the sixth or seventh day. Twice 
 I have seen it appear on the tenth day, the fever having distinctly 
 intermitted, and Buckholtz has reported a case where it was 
 delayed till the twenty-first day. 
 
 The eruption is primarily displayed on the face, particularly 
 the cheeks and around the eyelids, nose and ears, where it is 
 always most prominent — next on the neck and breast — thence 
 on the arms and hands, successively on the different parts of the 
 body, and finally the lower extremities. It comes out in small 
 reddish spots, distinct, circular or rather elliptical, a little elevated 
 above the skin, and more florid in the centre than the edges. 
 These gradually enlarge, and, by a confluence or running into 
 each other, form patches of a crescent or semilunar shape, with 
 considerable spaces between them, where the skin preserves its 
 natural colour. In the middle of some of these maculae a slight 
 vesicle is occasionally observable, and I have known the erup- 
 tion, in several instances, to approach in aspect an imperfect 
 varicella. Generally, on the trunk and extremities, it differs from 
 that on the face in being merely an efflorescence in patches with- 
 out any elevation. It also may partially come out as welts, 
 resembling the infliction of the rod or whip, which anomaly, 
 though not usually noticed, I have repeatedly met with, and uni- 
 formly in concurrence with regular measles elsewhere on the 
 body. 
 
 By some writers it is declared that the exantheme may extend 
 
EXANTHEMATOUS FEVERS. 115 
 
 to all the passages of the interior to which the atmosphere has 
 access. They describe it on the gums and throughout the mouth 
 and fauces, and on the surface of the pharynx, oesophagus, larynx 
 and trachea — and, by one of them, as even on the occluded 
 contents of the thoracic and abdominal cavities. But the latter 
 clause of the statement I entirely distrust. That it may exist in 
 the throat I am satisfied from my own observations, and can 
 discern no reason why it might not be in the windpipe. May 
 not, indeed, the croupy affection, incident to the second or more 
 advanced stage of the disease, be caused by it? 
 
 The eruption retains its redness, which, I have, said is seldom 
 or never of a bright hue, for two or three days, and then assumes 
 a fainter colour, when it gradually vanishes altogether and is 
 followed by a mealy or branny desquamation. But a peculiarity 
 has been indicated with regard to the termination of the erup- 
 tion, to which I must advert. It sometimes happens that, about 
 the seventh or eighth day, the rash becomes livid, with a mixture 
 of yellow, continuing for ten days or longer. This is the rubeola 
 nigra of Willan, by whom, I believe, it was first remarked, though 
 not as an alarming circumstance. 
 
 The eruption, in every variety of the disease, is rarely followed 
 by an immediate abatement of the febrile symptoms. An ex- 
 acerbation, indeed, oftener takes place, manifested by an increase 
 of the pulse, heat of surface, more embarrassed respiration, cough 
 and soreness of the chest and abdomen — by greater turgescency 
 of countenance, headache or stupor, and, in children especially, 
 by a croupy hoarseness or watery diarrhoea. The nausea, vo- 
 miting and other gastric or prsecordial distress usually cease as 
 soon as the eruptive stage is over. Mostly the fever continues, 
 in some degree, until the desquamation is completed, and may 
 even to a later period. Yet the cough, which forms such a pro- 
 minent symptom, is ordinarily still more protracted — lingering, 
 at times, with great obstinacy. In some cases, so violent is the 
 thoracic affection as to amount to bronchitis or pleurisy or peri- 
 pneumony, and croup has been noticed frequently in children. 
 These may take place in any stage, and especially by an impru- 
 dent exposure to cold about the period of convalescence. 
 
 Measles, though ordinarily more purely inflammatory than 
 any of its affiliated affections, assumes, on some occasions, a cha- 
 racter directly the reverse, — the fever being really typhoid, and 
 
116 EXANTHEMATOUS PETERS. 
 
 may be little short of typhus gravior, which form of the disease 
 has been called putrid or adynamic measles. It was first de- 
 scribed by Watson, and commonly prevails as an epidemic. The 
 most remarkable instances of its occurrence of which I have read, 
 were at Plymouth in 1745, in London in 1763, and at Edin- 
 burgh in IS 16. Extreme debility is represented early to super- 
 vene, with restlessness, — a constant propensity to vomit, and 
 much disturbance of the cerebral functions, — sometimes fierce 
 delirium, though more commonly coma,— a dry, hard, or loaded 
 and black tongue, swelled and mahogany-coloured fauces, with 
 an imperfect eruption of a livid complexion, so much disposed 
 to recession, that it takes place several times in the twenty-four 
 hours. 
 
 Not improbable, however, as has been conjectured, the disease 
 to which this description applies, and particularly that of Watson, 
 who still held the identity of the two affections, was really scar- 
 latina, having, in regard to the lesion of the throat especially, a 
 greater resemblance than to measles. Nevertheless, that the 
 latter may assume the congestive state, is neither unreasonable 
 to suppose, nor wanting in positive proof of its actually occurring. 
 But it was chiefly distinguished, as I have seen it, by a colder 
 and paler collapsed skin, more gastric and cerebral disorder, by 
 a greater sense of oppression, a less perfect development of the 
 eruption, and which was of a fainter hue than ordinary, with an 
 almost irresistible tendency to recede. Cases of it I have indeed 
 sometimes met with in which there was little or no catarrhal or 
 other pulmonary affection, the alimentary canal and brain seem- 
 ing exclusively to suffer, — and here, vomiting or purging, or 
 both, as in cholera, with stupor and low delirium, and a purplish 
 or livid eruption, interspersed by petechias and vibicis, and some- 
 times passive haemorrhage were the prominent characteristics. 
 
 There is a further modification of the disease, or so it is con- 
 sidered by some, termed rubeola sine catarrho, to which atten- 
 tion was first called by Willan. It occasionally prevails in this 
 country, and is recognized by the familiar title of French measles. 
 Characterized by many of the symptoms of genuine measles, it 
 differs from it in the absence of catarrhal affections, as its name 
 imports, the earlier appearance of the eruption, which is diffused 
 in specks over the surface, and not arranged in a succession of 
 definite crescents, by a more transient continuance, usually sub- 
 
EXANTHEMATOUS FEVERS. 117 
 
 siding in twenty-four hours, and altogether in comparative mild- 
 ness. It may exist separately or in conjunction with common 
 measles, and I have seen an attack of it succeeded by one of the 
 latter in the course of eight or ten days. Not affording any pro- 
 tection in this respect, I presume it to be an efflorescence of 
 another nature, dependent on some very different cause, or if at 
 all of a morbillous character, it is illegitimate, and, in this view, is 
 aptly called rubeola spuria. Nor am I more disposed to admit 
 as a distinct species of the disease, the febris morbillosa sine 
 exanthemate of some of the late German writers. Thus oc- 
 curring, which has long been known, it is, I suspect, always 
 when the case terminates abruptly in an early stage, and, there- 
 fore, an inchoative or imperfect disease — or where the system 
 not being adequately protected by a previous attack, a fever 
 with catarrhal defluxions only, is induced by a subsequent ex- 
 posure to the rubeolous contagion, neither of which conditions 
 has claims to be viewed in the light alleged ! ! 
 
 What were the circumstances under which measles was gene- 
 rated, we know as little as of the origin of its kindred affections, 
 and scarcely more of the cause of its periodical visitations. It 
 sometimes occurs sporadically or sparsely, more commonly as 
 an epidemic, according to Sydenham, "breaking out at the begin- 
 ning of winter, increasing till the vernal equinox, and dying away 
 towards the summer solstice." No season of the year, however, 
 escapes, having seen it thus to appear in summer, and it is 
 often the precursor or concomitant of variola or scarlatina or 
 some other of the exanthematous fevers. 
 
 That it returns regularly once in seven years has been main- 
 tained, and in support of the opinion, facts are adduced. As a 
 result of a thorough research into the subject, Professor Caldwell, 
 now of the Louisville College, affirms "that, beginning in 1772, 
 and passing down to a period including fifty years, it prevailed 
 epidemically in this city and vicinity, about every sixth year. 
 How far this statement is correct, or on what data it is founded, 
 I have no means of determining. Certain it is, however, as to 
 the later portion of this series of time, the fact has been other- 
 wise. During the last thirty-five years, I do not think that we 
 have had an exemption, for any long interval, from the disease. 
 It may have been suspended for a year or more, though almost 
 annually it might be met with, either sporadically or generally. 
 
118 EXANTHEMATOUS FEVERS. 
 
 Excepting influenza, measles spreads, perhaps, more rapidly 
 and diffusively in some instances than any other epidemic. Not 
 to cite other evidence of it, in 1801, in a few months, it overran 
 nearly the whole of the United States, and in 1823 was scarcely 
 less pervading. Nor is it improbable that, in such instances, its 
 influence is extended to the brute creation. During its preva- 
 lence just alluded to, it is said many of the domestic animals 
 suffered severely from fever with catarrhal defluxions. But 
 though thus observant of the epidemic character, there is still 
 sufficient reason to suppose that the immediate cause of the dis- 
 ease is a specific contagion, proving more or less operative, 
 according to the constitution of the season, in this particular 
 conforming to other analogous affections. Let me repeat here, 
 that because a disease is an epidemic, it is not necessarily uncon- 
 tagious, in proof of which, among other instances, small-pox, the 
 most conspicuously dependent on contagion, very frequently 
 assumes this character, spreading rapidly and widely. 
 
 Existing epidemically, measles may be taken without any 
 communication with the sick, or breathing the air of a room con- 
 taminated by such having recently occupied it. The atmosphere 
 seems, to a great extent, to be infected during the wide preva- 
 lence of the disease, and the inhalation of it anywhere, within 
 the vitiated limits, may adequately operate to this end. Facts are 
 wanting to show decisively whether it can be disseminated by 
 fomites, though I can scarcely doubt it. Nor is it better ascer- 
 tained at what stage of the disease the contagious property is 
 evolved, or when it attains its greatest activity. Most probably, 
 in each particular, it is subsequent to the eruption. 
 
 Notwithstanding the evidence to the contrary, I cannot think 
 it one of those affections capable of propagation by inoculation. 
 Experiments, I am aware, are appealed to, instituted by Home, 
 then professor at Edinburgh, who asserted that inoculation suc- 
 ceeded with great certainty, and produced a milder disease. 
 This he effected by an application of cotton dipped in the blood 
 of a patient with measles to a scratch or slight incision in the 
 skin. The fever, we are told, followed in six days, was com- 
 paratively light and without any disorder of the pulmonary 
 organs. These experiments, however, seem never to have been 
 confirmed, and their accuracy is questioned by most writers, and 
 pointedly by Cazenave, in his late work on cutaneous diseases, 
 
EXANTHEMATOUS FEVERS. 119 
 
 Confirmatory evidence, however, is not wanting. Willan cites the 
 testimony of a Mr. Wachsel, an English surgeon, who asserts that 
 he succeeded in several instances, where the operation was per- 
 formed with the fluid of the vesicles. More recently, too, we have 
 the declaration of Sperenza, of Italy, to the same effect, and, above 
 all, the sweeping averment of Von Katona, of Hungary, of his suc- 
 cess by inoculating with a drop of the fluid from the vesicle, and 
 the same amount of the tears mixed. Eleven hundred and twenty- 
 two cases were thus treated, in which there was a failure of seven 
 per cent, only, all the rest having the disease mildly, the eruption 
 appearing about the tenth day. 
 
 To this point such is the only proof, so far as I know, and my 
 researches have not been limited. That it is not satisfactory may 
 be made, I think, very readily to appear. Evidence of an oppos- 
 ing character is not less abundant and forcible. Willan reports that 
 he inoculated three children with the vesicular fluid without any 
 effect. Thurman and Tilligen utterly failed in their numerous 
 trials in the same mode, and We learn that experiments instituted 
 in our dispensary, in 1801, in which the blood, the tears, the mucus 
 of the nostrils and bronchi, the eruptive matter on the cuticle, 
 properly moistened, were all unavailingly tried. Not unlikely, in 
 the instances of alleged success by inoculation, the individuals 
 had been previously exposed to the infection of the disease, and 
 to this mode may its production be properly ascribed, the coinci- 
 dence being mistaken for the effect, one of the most common 
 sources of vitiation of our medical inductions. Could inoculation 
 be practised with the certainty and the benefit attained in the 
 mitigation of the disease which are asserted, why, I demand, has 
 not the expedient been universally adopted, as was formerly the 
 case in small-pox ? Does not this fact alone sufficiently invalidate 
 the averments on the subject ? 
 
 The common opinion is, that the latent period of the morbil- 
 lous contagion, or, in other words, that the disease breaks out 
 after an exposure to its cause, in about eight days, though, on 
 this point, there is not unanimity, — Willan, for instance, making 
 it from ten to fourteen days. Careful and extensive observation 
 has satisfied me that the last is the incubative period, in this, too, 
 among some other particulars, resembling small-pox. 
 
 Can measles be had a second time ? That it is contrary to the 
 
120 EXANTHEMATOUS FEVERS. 
 
 tenour of the disease is well established. Yet anomalous cases do 
 occur, among the most authentic of which, an account is given 
 by the celebrated Baillie, of eight persons in the same family. 
 As prelusive to the varioloid epidemic, in 1823, measles prevailed 
 of a very malignant kind, very extensively in this city, and on 
 that occasion, several repetitions of it were observed. Failures 
 of protection, however, may, perhaps, to a certain extent, be 
 ascribed to the former attacks being of that variety of the dis- 
 ease entitled rubeola sine catarrho, which does not impair the 
 susceptibility to genuine measles. Nevertheless, Willan and 
 others have remarked, that, under circumstances of epidemic pre- 
 valence, it is not uncommon for those who previously have had 
 the genuine disease to be seized by a rubeolous fever, without 
 any, or at all events, a very slight eruption. It, on the whole, 
 may be in this respect assimilated to small-pox. 
 
 Curious is it that measles takes so firm a possession of the 
 system, that its peculiar action is not readily supplanted by dis- 
 eases apparently more violent, in proof of which the case of 
 small-pox may be adduced. Generally it has happened, that 
 where the two affections co-existed, measles in a short time ac- 
 quired the ascendency, and, after running its course, small-pox 
 was re-developed. Examples, however, are recorded by Russel, 
 De Haen, Vogel, Pinel, Willan, Bateman, &c, of the two dis- 
 eases passing through their regular stages, without impairing the 
 force, or in any way affecting or modifying each other. But the 
 most striking instances, perhaps, are those related by Dr. King, 
 who tells us, that he inoculated with variolous matter, forty -three 
 children in the Foundling Hospital of Dublin, of whom sixteen 
 sickened with measles, four or five days afterwards, and the 
 small-pox appeared in due season, without apparently being at 
 all influenced by the circumstance. These and many other facts 
 of a similar kind completely refute the dogma which once pre- 
 vailed in the schools, of the incompatibility of two morbid actions 
 coexisting in the same system. Hunter was probably the author 
 of it, and Rush the warmest of its defenders. As well, he ex- 
 claims, could a horse trot and gallop at the same moment as any 
 part of the body entertain simultaneously two distinct actions. 
 True as the proposition may be in the main, exceptions to it 
 cannot be doubted. 
 
 Measles is readily recognized in most instances. The sup- 
 
EXANTHEMATOUS FEVERS. 121 
 
 posed modification of it, without catarrh, approaches nearest to 
 it, and the distinctive signs between them were formerly indi- 
 cated. As to scarlatina and some other affections, occasionally- 
 bearing an analogy to measles, I shall postpone my remarks on 
 their respective peculiarities, till I arrive at the consideration of 
 these diseases. 
 
 Not very serious in its ordinary prevalence, provided it is 
 exempt from certain complications, measles, when epidemic, is 
 usually at first more so, and has on some occasions in this shape 
 proved so dreadfully fatal, as to have received the title of a little 
 plague. Existing in this mode it presents chiefly the typhoid or 
 malignant, or some very anormal characters. Far more formi- 
 dable does it prove in Europe than this country, owing to the 
 poverty and wretchedness of the lower class of people. Espe- 
 cially do the bills of mortality of London show a fearful destruct- 
 iveness of life from it. 
 
 The disease is milder in childhood than in adult or in earlier or 
 more advanced life, it being often extremely unmanageable in 
 infancy and old age. The danger in pregnant women, which is 
 represented as great, has probably been overrated. Two cases 
 attended by me under these circumstances did well, and Heber- 
 den, whose experience was very extensive, informs us that he 
 never knew a woman to miscarry or seemed to suffer more from 
 the disease on account of her situation in this respect. 
 
 Typhoid measles, under any circumstances, is always to be 
 dreaded, and very frequently proves mortal in spite of our best 
 efforts. Certain symptoms are uniformly of very bad import, as 
 the eruption coming out slowly or imperfectly, or of a pale or 
 livid hue, with petechias or vibices, or the sudden recession of it, 
 attended by vomiting or purging, with extreme tenderness of the 
 epigastric or still lower regions of the abdomen — impeded respi- 
 ration, however occasioned, by lesions of the lungs or the trachea, 
 or low delirium, with coma or spasms or convulsions. The latter 
 occurring, especially in a child, during dentition, " magnum peri- 
 culum portendum," is the language of a great authority. As, 
 indeed, the gastro-enteric, cerebral or pulmonary affections are 
 violent, and especially when passively congestive, the case may 
 be deemed alarming. Further may it be remarked, that where 
 any predisposition exists to pulmonary or laryngeal affection, 
 11 
 
122 EXANTHEMATOTTS FEVERS. 
 
 the disease is to be dreaded in its immediate or remote conse- 
 quences. 
 
 Nevertheless, the most sudden and unexpected conversions 
 sometimes take place in the disease, by exposures to cold, or by- 
 other ill management, changing altogether its character, render- 
 ing a state of things which had been mild and favourable, very 
 much the reverse, or, as I have seen, extremely perilous; so that, 
 under all circumstances, such contingencies are to be guarded 
 against by proper vigilance and care, or a safe issue to any case 
 cannot be confidently prognosticated. 
 
 The attack having been decidedly inflammatory, evidence of 
 such a state is conspicuously discernible on dissection, in the 
 trachea and its terminations, or the substance of the lungs, or the 
 pleural coverings, the one or the other or the whole being more 
 or less affected according to circumstances. Essentially are the 
 appearances the same as when inflammation of the parts is 
 induced by cold or any of the ordinary causes. Connected with 
 these lesions, or independent of them, similar ones are often found 
 throughout the alimentary canal, with sometimes an implication 
 of the liver, or the collatitious viscera generally, and even of the 
 brain or its envelopes. Different, however, is it in the typhoid 
 or malignant form of the disease. Equally pervading, the in- 
 flammation is of the weakest species, coupled with heavy passive 
 engorgements of the organs of the great cavities, and not unfre- 
 quently attended by diverse extravasations. But though all 
 these structures may become involved, the proper and immediate 
 seat of the disease seems to be the mucous membranes, and after 
 the eruption takes place, the rete vasculosa of the skin. 
 
 Touching the pathology of measles, it might almost be sufficient 
 to refer to what was said of that of small-pox. Excepting one 
 particular, there is no material difference. The fever in the 
 former does not subside on the coming out of the eruption, as in 
 the latter affection, which is owing to a retention of the irritation 
 in the interior surface, relieved in small-pox by a translation of 
 it to the skin. 
 
 From the prominent affection of those organs, measles has 
 been usually presumed to have its original seat in the lungs and 
 appendages. Considering, however, its similitude to variola in 
 so many features, it seems to me much more probable that it is 
 radicated in the primae vise, and that other structures are brought 
 
EXANTHEMATOUS FEVERS. 123 
 
 secondarily into participation. Be it alleged that many of the 
 symptoms are catarrhal or pneumonic, it may be replied that the 
 alimentary canal and the parts with which it immediately sym- 
 pathizes, as the brain, are even more disordered in the early 
 stage. Do we not know that measles very frequently commences 
 with nausea, vomiting and tenderness of the epigastrium, accom- 
 panied by great distress of the head, sometimes eventuating in 
 delirium or coma, and still more so in diarrhoea ? It is true that, 
 on dissection, the pulmonary organs exhibit morbid phenomena, 
 and so do the stomach and bowels to a considerable extent. Ex- 
 amples are numerous of diseases beginning at one point displaying 
 themselves in their progress more prominently in other sections of 
 the body. This is strikingly illustrated in measles, where, nearly 
 always, the gastric symptoms abate or subside much sooner than 
 those of the lungs, and hence the reason that, in post-mortem 
 examinations, greater lesions are detected in the chest. 
 
 In the treatment of small-pox, so much was said which is not 
 less appropriate to that of measles, I shall not permit the latter 
 long to detain us. The lightest form of the disease requires 
 scarcely any thing to be done. An avoidance of exposure to 
 cold, some gentle laxative and low diet will be found usually 
 sufficient. But, in attacks of greater severity, the course must be 
 more energetic and decisive. 
 
 The leading object should be to evacuate the alimentary canal, 
 and, when not contra-indicated by reasons presently to be noticed, 
 an emetic may be directed, especially in the cases of children, in 
 whom vomiting is an easier, and, at the same time, a more effi- 
 cacious process. It proves exceedingly useful in relieving the 
 irritations or oppressions of the pulmonary system, usually so 
 deeply concerned in their attacks, and, by its action on the skin, 
 prepares the way for the reception of the efflorescence. An 
 emetic, however, though so serviceable, is not ordinarily an es- 
 sential remedy, and, where there is an absence of the pulmonary 
 affections mentioned, purging may be substituted, for which pur- 
 pose castor oil or the saline laxatives are preferable. Yet neither 
 mode of evacuation is admissible where, instead of pulmonary, 
 gastro-ent eric irritation exists to any extent. This is to be allayed 
 by measures, which have been previously so fully pointed out 
 that they need not be recapitulated. The condition being thus 
 rendered fit for their exhibition, the mild diaphoretics and diluent 
 
124 EXANTHEMATOUS FEVERS. 
 
 drinks next become proper to promote the eruption, and also in 
 reference to other purposes. 
 
 Fever, however, rising to any height, with an active pulse 
 and local phlogosis, whether in the lungs or primes vise or any- 
 other structure, either before or after the eruption, venesection 
 must be freely practised, to which are to be added, as auxiliary 
 to the design, leeches or cups and blisters, with whatever else 
 enters into the management, ordinarily, of such a case of com- 
 plicated inflammation. But, above all, venesection is efficient 
 under such circumstances, and no period of life, whether of 
 infancy or extreme age, should forbid it — taking care only to 
 regulate it by the condition of the individual. Greatly was it 
 commended by Sydenham, and subsequently by Mead, Cullen, 
 Heberden and other able practitioners. Few, indeed, are there 
 of any authority, who do not coincide in this estimate of the 
 remedy. 
 
 Typhoid measles is treated differently. Cutaneous action is 
 here first to be excited. This indication may be met by sponging 
 the surface with tepid diluted spirits, or by the warm bath in 
 greater emergencies, — aided by moderately stimulating diapho- 
 retics and warm drinks. The lancet is withheld, or very cau- 
 tiously employed. But topical bleeding may be advantageously 
 substituted to remove the congestion of organs. Evacuations of 
 the stomach and bowels are indispensable, commencing with an 
 emetic and then a mercurial purge, which contributes to the same 
 end. 
 
 As the appearances of exhaustion supervene, we are to resort 
 to the sulphate of quinine, or to the diffusible stimuli, among 
 which the carbonate of ammonia or camphor is best, alone or 
 with an opiate, as the latter may seem to be demanded by nervous 
 inquietude or insomnolency. Excitement is also to be sustained 
 or renewed by sinapisms or blisters, and a large one over the epi- 
 gastrium is sometimes productive of great effect, by bringing out 
 the eruption or changing it to a more healthy character. 
 
 In the cure of measles, the regulation of the temperature of the 
 chamber and of the drinks is of considerable consequence. The 
 weather being hot, and the attack decidedly inflammatory, the 
 most refreshing ventilation is required, with cold beverages— and, 
 reversely, in winter, and particularly in the typhoid state of the 
 disease, such a degree of heat should be preserved as to favour 
 
EXANTHEMATOUS FEVERS. 125 
 
 cutaneous excitement, without causing restlessness or febrile dis- 
 turbances, and the drinks moderately warm. The more induced 
 am I to mention this, since some practitioners attempt to identify 
 the treatment of measles with that of small-pox, in which a low 
 temperature is found most beneficial. Carrying out the analogy, 
 even cold affusions have been used, and, from the alleged suc- 
 cess, strenuously recommended. This view seems to me false, 
 and the practice it. dictates must be pernicious, except where the 
 lungs escape an affection, and the skin is exceedingly dry and 
 hot. Even here, sponging only is warrantable. But the pul- 
 monary apparatus is nearly always implicated in the case, and 
 it is well known that cold is tolerated by no one of its morbid 
 conditions, it never failing, indeed, to prove an aggravating 
 agency. 
 
 Measles is singularly prone to sequelae or consequent affections, 
 among which are catarrh and pneumonia, ophthalmia, aphonia, 
 diarrhoea and some other more chronic derangements. Even 
 when a predisposition only exists, it is exceedingly apt to ripen 
 the tendency into actual disease, and particularly scrofula and 
 phthisis, to which some writers add hepatitis. Nothing, how- 
 ever, very peculiar characterizing the management of the gene- 
 rality of these secondary affections, I shall scarcely notice them 
 farther. It may be sufficient to say that the whole of them are 
 to be treated by those remedies the best adapted to subacute or 
 chronic inflammation, which is their true pathological condition. 
 Yet diarrhoea, from the extreme debility often associated with it, 
 is apt to lead to a deception, and which, on this account, may 
 require to be specially designated. 
 
 Too commonly, under such a delusion, a resort is had to 
 the astringent and testaceous preparations, which are both in- 
 effectual and mischievous. The lax, in this case, is the result oi 
 inflammation of the mucous coat of the intestines, and can only 
 be relieved by the measures I have intimated. It was Syden- 
 ham who first made known this fact, and subsequent experience 
 has abundantly confirmed it. Bleeding, general or topical, in 
 moderation, with ultimately a blister to the abdomen, and the 
 Dover's powder exhibited at night, with an occasional recurrence 
 to the warm bath, constitute the proper means. Continuing 
 obstinately, however, calomel or the blue pill, in minute doses. 
 
 11* 
 
126 EXANTHEMATOTJS FEVERS. 
 
 with opium or otherwise, becomes necessary, and more espe- 
 cially where the liver is concerned, which sometimes happens. 
 
 It remains to remark, that the black appearance occasionally 
 taking place at the close of the eruption, giving to the disease the 
 title of rubeola nigra, is said to be speedily removed by the in- 
 ternal use of the muriatic acid. But, for the most part, as spon- 
 taneously subsiding in a short time, it may be disregarded. 
 
 My wish, in closing the subject, is further to urge the importance 
 of more circumspection in the treatment of measles than it usually 
 receives. We have seen that, in its graver states, how many organs 
 it involves and the serious injuries inflicted. As much, perhaps 
 more to be dreaded, are such lesions than the disease itself. That 
 the affections it entails or develops are the results of imperfect 
 cures, and hence might be obviated by better practice, is my 
 deliberate opinion. Being decidedly inflammatory in its com- 
 mon nature, it obviously exacts the antiphlogistic course in all its 
 details, and especially the loss of blood, to the neglect of which 
 I am disposed to ascribe mainly the mischief so lamentably ex- 
 perienced. Never have I known a case of inflammatory measles 
 to resist adequate bleeding. But our care must not stop here. 
 Caution should be enjoined, even after the disease is seemingly 
 cured, and still more during convalescence, against any exposures 
 to cold, or improper indulgences, or trespasses of any kind. 
 
 SCARLATINA VEL FEBRIS RUBRA.— SCARLET 
 FEVER. 
 
 From the peculiar floridness of the skin incident to it, this dis- 
 ease is so denominated. The first of these terms is Italian, and 
 has been much objected to by the sticklers for a purely classical 
 nomenclature as a barbarous interpolation. For it, the second is 
 one of many titles which have been proposed to be substituted, 
 among which, is exanthisma roseola or exanthesis roseola. 
 Neither these nor any other I have met with have been hap- 
 pily selected, — the whole being founded on a single appearance 
 — and which is not a uniform one, or existing sufficiently ex- 
 pressive of the nature of the disease. Especially, too, may it be 
 objected to the latter, that roseola is appropriated already to a 
 distinct cutaneous affection, on which several accounts, I shall 
 
EXANTHEMATOUS FEVERS. 127 
 
 retain the old and more familiar designation of scarlatina. It is 
 here proper to correct a very popular error that scarlatina is 
 intended to express a milder or mitigated state of scarlet fever. 
 Equivalent in meaning, these terms vary only in belonging to 
 different languages. 
 
 Doubtless, scarlatina is a disease of modern date. Certain pass- 
 ages have been cited from some of the ancient writings, thought 
 to refer to this, and its affiliated affections, which, on a more 
 careful examination, will not bear such an interpretation. Its 
 introduction into Europe is commonly traced to an importation 
 from Africa, and is said to have first broken out in Spain, in 1610, 
 whence it spread to Naples, where it prevailed eight years after- 
 wards, as an epidemic, with unexampled violence. Fifty thou- 
 sand persons are said to have died of it in that city, and half 
 a million in the Neapolitan and adjacent territories, before its 
 cessation. 
 
 By Sydenham, and subsequently Moreton, some account was 
 given of it as prevailing in London in 1689. But so widely do 
 their descriptions differ, that they can hardly be supposed to refer 
 to the same disease, the one representing it to be very mild, and 
 the other as directly the reverse. 
 
 In 1735, it made its appearance in New England, gradually 
 diffusing itself, to a greater or less extent, over this continent. 
 Much confusion, however, exists in the history of the disease, 
 owing to the want of a just discrimination in those by whom it 
 is described, and especially at an early period. No distinction is 
 made in most of these records between it and measles, or even 
 small-pox, except as to gradation of violence, — and so lately as the 
 time of Moreton, and even of Watson, the latter of whom wrote 
 about the middle of the last century, the identity of it and measles 
 was maintained. Bateman declares " that Withering's publica- 
 tion of it in 1778, or rather the second edition of it in 1793, may 
 be considered as the date of the correct diagnosis of the disease." 
 
 No inconsiderable share of attention has scarlatina occupied, 
 and to which it is entitled, being frequent in its recurrences, 
 extensive in its prevalence, and often exceedingly fatal in its 
 ravages. 
 
 Nosologists divide it into three forms, which, however, are to 
 be regarded as the same disease, presented in different aspects. 
 In this state of subdivision, it has received the denominations of 
 
128 EXANTHEMATOUS FEVERS. 
 
 scarlatina simplex, scarlatina anginosa, and scarlatina maligna, 
 the two latter sometimes also called cynanche maligna, or cy- 
 nanche putrida, and the last, in our own language, malignant 
 or putrid sore-throat. 
 
 Not necessary is it to enter into any discussion to establish the 
 identity, except as to degree of severity, of these three forms. 
 Cullen, I think, has satisfactorily effected this, when designing 
 to prove the contrary. Endeavouring to show that scarlatina 
 anginosa and cynanche maligna are specifically different, he has 
 proved their sameness. The several states of the disease have 
 prevailed simultaneously even in the same family, one child 
 having scarlatina simplex, a second scarlatina anginosa, a third 
 scarlatina maligna, — and hence, the common origin of these 
 varieties may be inferred. By the late Professor Gregory, of 
 Edinburgh, who had seen it, this has been stated, and I believe 
 that similar occurrences are not very uncommon, having met 
 with them myself. The several grades of the disease are related 
 to each other, as distinct and confluent small-pox, typhus mitior 
 and gravior, or as autumnal fever in its several modifications. 
 Discerning no more reason, therefore, for thus dividing scarlatina 
 than most other diseases, which are equally marked by grada- 
 tions of violence, or occasional deviations in some prominent 
 symptom, or affection, I shall disregard the accustomed arrange- 
 ment, and treat of it as phlogistic or passively congestive, con- 
 ceiving this to be a much more simple and correct distribution of 
 the subject, and particularly as concerns practical convenience. 
 
 An attack of the first or inflammatory description of the dis- 
 ease is mostly preceded by gastric disturbance and precordial 
 anxiety, lassitude and weariness, some uneasiness of the head, 
 and depression of spirits, chilliness, pains in the loins and limbs, 
 followed by fever, with more than ordinary heat of surface and 
 acceleration of pulse. Contemporary, or nearly so, with these 
 phenomena, soreness of the throat, rigidity of the jaws and dif- 
 ficulty of swallowing, are sometimes, though not invariably 
 complained of, and where such exist, redness and swelling of 
 nearly the whole of the lining membrane of the fauces may be 
 perceived. These affections progressively increase, as the case 
 becomes more developed, the fever being higher, the pulse more 
 vigorous and rapid, the pain of the head, especially in the direc- 
 tion of the frontal sinuses aggravated, the temperature of the skin 
 
EXANTHEMATOUS FEVERS. 129 
 
 so raised as to amount, in some instances, to 108° or even to 
 110° of Fahrenheit, according to Currie and Willan. Nausea or 
 vomiting, or both, considerable tenderness of the epigastrium, 
 and more precordial uneasiness, with jactitation and delirium, 
 or tendency to it, are apt to take place, especially on the exacer- 
 bation in the evening, which usually happens. 
 
 Examining the throat at this time, where the anginose state is 
 prominent, the affection of it will be seen to have correspondingly 
 augmented, the velum pendulum paiati, uvula, tonsils, and, in 
 short, the whole of the fauces more intensely florid and tumefied, 
 which state extending up the Eustachian tubes, hearing is im- 
 paired, with often severe earache. Considerable as the difficulty 
 of deglutition may be, it is not so great as might be supposed, 
 and seems to be owing more to an affection of the muscles sub- 
 servient to the process than the throat itself. The tongue, which 
 nearly from the beginning is furred, now presents clean polished 
 edges, with a thick, tenacious coating of the root and centre, and, 
 in some instances, florid elongated papillae projecting through the 
 incrustation, resembling a sort of vegetation, — while, on other 
 occasions, 1 have seen it perfectly clean, and of a fiery red 
 appearance. 
 
 The eruption appears at the close of forty-eight hours, though, 
 in some cases, it is more delayed, even to double or treble this 
 period, while, in others, its occurrence is exceedingly sudden, 
 with scarcely any premonition, and may, indeed, be the earliest 
 manifestation of the disease. First it comes out on the face and 
 neck, thence successively on the trunk and extremities, and be- 
 comes very conspicuous about the loins, bendings of the joints, 
 and on the hands and fingers, which are stiff and swollen. Espe- 
 cially, in the simple variety of the disease, does it also appear on 
 the surface of the interior of the mouth, the palate and fauces, of 
 the same speckled or punctated character as that of the exterior, 
 by which circumstance and the absence of tumefaction, it is dis- 
 tinguishable from the real anginose affection. As to the dif- 
 fusiveness of the exantheme, there is great difference, sometimes 
 it being nearly universal, and at other times partial or in patches. 
 It consists of a multitude of small points, originally of a pale or 
 dingy red, gradually assuming the scarlet hue, which spread and 
 apparently coalesce, so as to exhibit a blush of tnore or less 
 extent, of so deep a colour as to "resemble that of a boiled 
 
130 EXANTHEMATOUS FEVERS. 
 
 lobster," the comparison used in one of the best descriptions of 
 it. But carefully examined, the efflorescence will still be per- 
 ceived to be made up of specks, shaded off from the centre to 
 the edges. The skin continues hot, and is itchy, sore and some- 
 what swelled. 
 
 Not very sensibly influenced is the fever by the appearance of 
 the exantheme, — sometimes, however, it abates, with great relief 
 to the stomach and head, though often it is otherwise, and may 
 be increased. Frequently it remains, in some degree, till the 
 desquamation is completed, which may be very tardily per- 
 formed. Both the eruption and affection of the throat are also 
 very much controlled by the fever, which early abating, each is 
 moderated, and more speedily subsides. But where it is main- 
 tained, the reverse happens, and the throat especially becomes 
 worse. The swelling is greater, and on its surface, aphthas may 
 appear, sometimes ragged and irregular, soon degenerating into 
 gray or ash-coloured sloughs, or an exudation of lymph takes 
 place, in small portions, or so extensively, as to form an adventi- 
 tious pellicular covering. By the spreading of the inflammation, 
 and its consequences to the windpipe, a very fatal variety of 
 croup is produced. The result, on the contrary, promising to be 
 favourable, the sloughs as well as the membrane separate, and 
 are detached about the eighth or tenth day, leaving the surface 
 beneath clean and healthy. 
 
 What has been said is applicable to an average of the inflam- 
 matory state of the disease. But it is sometimes infinitely milder, 
 and with little or no affection of the throat, — while on other occa- 
 sions, it presents a far graver and more complicated aspect, all 
 the symptoms, general and local, being highly exasperated. 
 
 Congestive scarlatina, though retentive of the common cha- 
 racteristics of the disease, receives the complexional hue which 
 is always bestowed by the operation of the typhoid influence 
 or condition. Commencing with many of the initiatory phe- 
 nomena, noticed under the preceding head, the peculiarities of 
 this mode of attack are soon manifested. For the most part, 
 reaction is exceedingly feeble or imperfect, and may not at all take 
 place. The collapsed state is marked by a weak pulse, cold 
 skin, doughy countenance, — the head rather stupid than aching, 
 —the stomach dreadfully distressed, the respiration laboured, 
 with deep sighing,— the whole attended by extreme debility, and 
 
EXANTHEMATOUS FEVERS. 131 
 
 a disposition to syncope. It may, however, happen that, after a 
 while, the system emerges from such heavy oppression, or it 
 being less, some vigour is displayed by a full, soft, compressible 
 pulse, an intensely hot, dry surface, amounting even to the calor 
 mordax, with pain in the head, suffused eyes, turgid counte- 
 nance, of a somewhat purplish hue, — tenderness of the epigas- 
 trium, or of a lower portion of the abdomen, accompanied by 
 vomiting or purging, or both. But this excitement, usually 
 evanescent, is succeeded by a sudden and alarming prostration 
 of vital power. 
 
 Be the early stage as it may, the subsequent career of these 
 cases does not materially vary. As they proceed, the typhoid 
 condition becomes more confirmed. The tongue, at first heavily 
 furred, is now thickly coated of a dark brown colour, at the root 
 and middle, with the vegetations formerly mentioned, while the 
 edges are red, clear and dry. The face is bloated, and may be 
 livid, the eyes fatuous as in inebriation, the intellectual faculties 
 depraved by low delirium, attended by nervous tremors and 
 automatic motions of the hands. Convulsions are here common, 
 sometimes in rapid succession, ending in coma, or, at least, in 
 heaviness or stupor. Excepting the brain be deeply implicated, 
 when the pulse is slow, it is very rapid and weak, and the stomach 
 evidently suffers, sometimes without vomiting, its powers being so 
 paralyzed, as it were, as to prevent it,— though its contents, consist- 
 ing of a dark, granulated or floculose fluid, are ejected by a sort of 
 spasmodic effort of the diaphragm analogous to singultus. More 
 generally, in this modification of the disease, are the pulmonary 
 organs involved. Early betrayed by cough and hoarseness, with 
 defluxions from the eyes and nostrils, these are speedily followed 
 by very embarrassed breathing, with wheezing and rattling, from 
 the immense secretion of vitiated mucus. In the state of ex- 
 citement which has been noticed, though the eruption may come 
 out very quickly, even earlier than in the inflammatory form of 
 the disease, it is oftener postponed to a longer period, — alter- 
 nately appears and recedes, — is in patches of a pale, rapidly 
 changing to a mahogany or livid purple colour, forming the 
 scarlatina purpura of writers, — in some instances becomes widely 
 diffused, and in others it never appears. The same may be said 
 of the anginose affection. During the prevalence of the disease 
 in the winter of 1834, in this city, more than a dozen cases came 
 
132 EXANTHEMATOUS FEVERS. 
 
 under my observation, and in one family three persons, whom 
 I attended with Professor Jackson, without either affection. 
 Each sunk in a few hours, under the oppression of the early or 
 collapsed stage. These cases were known to be scarlatina from 
 the disease unequivocally developed, co -existing in the same 
 house. Commonly, however, the throat seriously suffers, and 
 very often independently of the skin. The epidemic to which I 
 have just alluded, abounded in such examples, as well as of the 
 contrary, or the efflorescence alone appearing. 
 
 In the character of the throat affection there is some difference 
 from that of the inflammatory disease. Equally pervading, less 
 tumefaction, however, prevails, and it is of a darker complexion. 
 Much more apt, too, is the surface to be covered by a membrane 
 which here is usually thick, soft and pultaceous, and should 
 aphthous ulceration exist, this very rapidly and widely spreads, 
 discharging an acrid, ichorous fluid, which, passing out of the 
 mouth or nose, or both, excoriates the parts it touches, and the 
 faetor oris is excessive. Concomitantly the voice is hoarser, the 
 respiration extremely oppressed — deglutition more difficult, with 
 increased rigidity of the jaws, and there is a constant though 
 ineffectual effort to disengage and bring up the irritating matters. 
 This state of things not being arrested, heavy stupor supervenes, 
 with sometimes petechias or vibices and passive haemorrhage or 
 colliquative diarrhoea — the pulse so diminutive as scarcely to be 
 felt, and finally death takes place from absolute exhaustion, if 
 not more abruptly by some cerebral, laryngeal or pulmonary 
 affection. 
 
 The duration of the disease is from a few hours to eight or ten 
 days, according to the nature of the attack, being, in this respect, 
 subject to many deviations. Going through its career with regu- 
 larity and benignantly, it will be mostly found that, on the fourth 
 day, it has attained its height, on the fifth the efflorescence begins 
 to decline, on the sixth it has nearly faded, and on the seventh 
 entirely gone, leaving the skin dry and rough. In some rare 
 instances, however, which have been recorded, there has taken 
 place, just in anticipation of the disappearance of the rash, an 
 eruption more or less vesicular or pustular, sometimes resembling 
 varicella, and, on other occasions, variola so closely, as to have 
 been denominated scarlatina varioloides. No such have I ever 
 met with, and whether it be the consequence of the original dis- 
 
EXANTHEMATOUS FEVERS. 133 
 
 ease, or a distinct affection developed on the subsidence of the 
 preceding one, I cannot say. 
 
 From scarlatina mostly prevailing as an epidemic, its produc- 
 tion has been assigned to the occult and mysterious agency of 
 such diseases. But, however its propagation may be promoted 
 or its character affected by an influence of this kind, there can be 
 little doubt that its immediate cause is a specific contagion, con- 
 forming, in this and other respects, to the diseases to which it is 
 most closely allied. Like these, it destroys the susceptibility to 
 a second attack. By Withering and Willan this is positively 
 asserted, they never having witnessed an instance to the contrary 
 — and Bateman states that the fact is fully ascertained and accre- 
 dited. Nevertheless, the infallibility of the protection has been 
 denied, and examples of failure are cited by respectable writers, 
 among which is Richter, who avers that a second and even a 
 third repetition of attacks have been noticed. None such have 
 come under my own observation. But I have sometimes seen 
 the attendants on the sick, though previously having had the 
 disease, to be seized with sore throat, without any eruption, and 
 which, I believe, is no uncommon event. Considering the resem- 
 blance of several of the eruptive fevers to scarlatina, and the 
 uncertainty of the diagnosis, it may be conjectured that not a few 
 of the alleged repetitions of the disease were not really so, the 
 antecedent or subsequent attack being of some other of the imi- 
 tative affections. But admitting the fact of such recurrences, 
 scarlatina still rests, in this respect, on the same footing with 
 variola and other diseases of acknowledged contagiousness. 
 
 It is questionable at what stage scarlatina acquires this pro- 
 perty, prior to, or after the eruption. Many believe that it is most 
 active during the desquamation, and, at all events, it seems to 
 retain it till this process is completed, — the scales being impreg- 
 nated with the virulent secretion of the skin. Yet the disease 
 cannot be propagated by inoculation with matter procured from 
 this or any other source. Contrary statements have been made, 
 I am aware, though on no good authority. To fomites of vari- 
 ous kinds it adheres very tenaciously for a long period, with 
 an entire preservation of its efficiency, in proof of which, we 
 have some striking facts. My friend, the late Dr. Percival, of 
 Dublin, imputes the introduction of scarlatina into that city to a 
 12 
 
134 EXANTHEMATOUS FEVERS. 
 
 box of toys from London, which had been exposed to the con- 
 tagion. That the disease was propagated in this way, however, 
 is hardly to be credited, and the story seems to me very like 
 the famous report of Hildebrand, who assures us, that as soon 
 as he arrived in Padolia, scarlatina broke out and spread most 
 widely, which he ascribes to the retention of contagion in a coat 
 he had worn in the disease a year previously in Vienna. Never- 
 theless, the long continuance of infection in apartments where 
 the disease has existed, though every purification be practised, 
 is unquestionable. Elliotson, of London, states, in confirmation 
 of it, "that all the children admitted into a particular ward in a 
 hospital under his care, were seized with scarlatina for nearly 
 two years, in consequence of a patient with the disease having 
 been in the ward at that remote period, and this in despite of 
 white-washing and other cleansings." 
 
 Extraordinary as this may appear, it is by no means incredi- 
 ble, and is supported both by some further facts and by analogies. 
 Not to refer to other instances, in the summer of 1834, 1 attended 
 a boy in the disease, whose parents being exceedingly anxious 
 that their other children should escape it, had them all imme- 
 diately sent away. Every article of the furniture of the room, — 
 the carpet, the bed, &c, and his clothes were removed. Besides 
 this, the freest ventilation was practised, and the fumes of the 
 chlorate of lime filled the whole house for several days. Not- 
 withstanding these precautions, twelve weeks afterwards, on the 
 return of the children, three of them became speedily affected 
 through the medium of some domestic fomites, probably, as they 
 were not knowingly elsewhere exposed to the contagion. 
 
 Nothing more occurred here than has been reported again and 
 again of variola, typhus, and even of puerperal fever. Five or 
 six years ago, the latter broke out in the lying-in ward of our hos- 
 pital, and though, on its cessation, every means of purification 
 was adopted, no sooner was a woman delivered in the ward than 
 it reappeared, and in a very fatal shape. Each successive year, 
 for three terms, was the ward closed against admissions, the pro- 
 cess of purification again repeated, and still, on the reintroduction 
 of parturient women, after a protracted interval, the result was 
 the same, and the ward was finally abandoned. 
 
 As to the sphere in which the contagion of scarlatina operates, 
 we have no precise information. But it may be presumed to be 
 
EXANTHEMATOUS FEVERS. 135 
 
 similar to that of variola and the other diseases of the same class, 
 which is very limited. 
 
 The incubative period of the contagion is said to be from five 
 or six days. My own conviction is, that it is usually greater, 
 though I speak diffidently on the point, having been unable to 
 satisfy myself in regard to it. Equally subjected apparently to 
 infection, I have seen individuals break out with the disease, 
 from the third to the eleventh day, and we have had some cases 
 lately reported, where, in a family of eight, the interval varied 
 from the seventeenth to the twenty-sixth day, the average being 
 seventeen days. 
 
 No season is exempt from scarlatina, though it is most apt to 
 prevail in winter or spring. But I have seen it during the hottest 
 weather, and, indeed, at all seasons. Children are chiefly liable 
 to it, as they are to every similar affection, for no other reason, 
 probably, than that persons in more advanced life have pre- 
 viously had it. Yet I have never known a very young infant 
 to take it, however exposed. By Sir Gilbert Blane it is asserted, 
 that "he never saw an individual, except one, affected by it 
 turned of forty." I have met with it several times in people 
 much older, and once with the late Professor Dewees, in a very 
 aged man near eighty. As one of the peculiarities of the disease, 
 it has, too, been observed, that, on some occasions, it is restricted 
 to children, and others to adults, and those a little more advanced. 
 Emphatically does Reil declare, that he had witnessed an epi- 
 demic scarlatina which was almost exclusively confined to per- 
 sons between fifteen and twenty-five. Females are represented 
 to be more liable to it than males, on no adequate evidence, how- 
 ever, I suspect. The annexed table, which is formed from a 
 register of the Fever Hospital, of London, of two hundred cases 
 of scarlatina, has been cited by some to show the relative fre- 
 quency of the disease in the two sexes at different ages. But it 
 is very imperfect in these respects. Children under six years, we 
 know, are excluded from the hospital, and there may be some 
 other regulation or circumstance which determines, in a greater 
 degree, the admissions of females.* 
 
 Age. 
 
 Males. 
 
 
 Females. 
 
 
 Total. 
 
 From 6 to 10 
 
 7 
 
 « 
 
 8 
 
 « 
 
 15 
 
 « 10 to 15 
 
 8 
 
 « 
 
 15 
 
 « 
 
 23 
 
 " 15 to 20 
 
 17 
 
 u 
 
 40 
 
 u 
 
 57 
 
136 EXANTHEMATOUS FEVERS. 
 
 The difficulty that may exist relative to the diagnosis of scar- 
 latina must arise chiefly from its occasional similarity to measles. 
 Even here, embarrassment can seldom be experienced, should it 
 be recollected that, in measles, the symptoms are more con- 
 spicuously ophthalmic, catarrhal or pneumonic, that the eruption 
 comes out usually on the fourth day in blotches somewhat ele- 
 vated, so that the surface does not exhibit a uniform blush, and 
 that these blotches, running into each other, assume a crescent 
 shape, the whole being of a faint reddish complexion : while, on 
 the contrary, that scarlatina is preceded by gastric and cerebral 
 derangement, — that the eruption occurs in half the time, consist- 
 ing of minuter specks, seldom at all raised, is infinitely more dif- 
 fused and of a scarlet colour. The case being of an anginose 
 nature, all ambiguity ceases, for though the throat is sometimes 
 sore in each disease, it is in a manner so different as not readily 
 to be mistaken. Generally, in measles, it may be perceived to be 
 merely an extension of the exantheme of the surface to these 
 parts. Much reliance may also be placed on the singular appear- 
 ance of the tongue, and the extreme acceleration of the pulse in 
 scarlet fever. 
 
 As bearing an analogy to scarlatina, it ought also to be men- 
 tioned that an efflorescence, frequently with sore throat, is to be 
 met with, especially in children, having the popular title of 
 scarlet rash. From it, however, it differs, in the first place, in 
 being usually occasioned obviously by suppressed perspiration 
 or disordered stomach, from an excess of food, or certain pecu- 
 liarly offensive articles, and secondly, by the speedy occurrence 
 of the eruption without much or any previous ailment, and is 
 rather a blush or suffusion than speckled. But I have seen it, on 
 several occasions, dotted like scarlatina, and, owing to some unin- 
 telligible cause, of a pretty wide prevalence, several of a family 
 
 20 to 25 
 
 14 
 
 (« 
 
 39 
 
 « 
 
 53 
 
 25 to 30 
 
 8 
 
 (« 
 
 21 
 
 « 
 
 29 
 
 30 to 35 
 
 6 
 
 a 
 
 10 
 
 a 
 
 16 
 
 35 to 40 
 
 1 
 
 u 
 
 2 
 
 a 
 
 3 
 
 40 
 
 1 
 
 a 
 
 
 
 u 
 
 1 
 
 42 
 
 
 
 u 
 
 1 
 
 a 
 
 1 
 
 48 
 
 
 
 u 
 
 1 
 
 u 
 
 1 
 
 57 
 
 
 
 a 
 
 1 
 
 «« 
 
 1 
 
 62 138 200 
 
 Cyclopedia of Practical Medicine. 
 
EXANTHEMAT0T7S FEVERS. 137 
 
 being attacked in rapid succession, and still further spreading 
 through the community. This is probably a variety of roseola, 
 which is not contagious, or gives any security against scarlet 
 fever. Nearly always, too, does it occur in very warm weather, 
 and particularly during protracted droughts. Moreover, I have 
 met with repeatedly in winter, and uniformly, I think, when 
 snow was on the ground, an affection bearing a still closer 
 resemblance to scarlatina. Children acquire it mostly, or per- 
 haps exclusively, by becoming heated from playing in the 
 snow, and then suddenly chilled. The collapse is often very con- 
 siderable, followed ultimately by febrile reaction, much cerebral 
 disturbance, delirium, stupor, and sometimes convulsions, sore 
 throat, nausea and vomitings, and by an eruption so scarlatinous 
 in its aspect, that it may be readily mistaken for that disease. 
 Nor is it scarcely less fatal. Death I have known to take place 
 from it even in a few hours, from an inability to arouse the 
 system out of its torpor, or by convulsions. 
 
 In simple scarlatina, little danger is ordinarily to be appre- 
 hended. Yet, in some instances, it most unexpectedly becomes 
 alarming, when apparently it had been doing perfectly well, by 
 a sudden sinking of vital energy, or by its being raised into an 
 exasperated state with diverse complications. No disease, indeed, 
 is more treacherous, or which requires greater vigilance. Two 
 children, whom I attended in consultation, on different occasions, 
 died almost immediately after our leaving them, though at the 
 time of our visits, they appeared to be doing well, the first in 
 the early, and the second in the advanced stage of the disease. 
 Examples of a similar kind are numerously recorded, and are 
 probably familiar to every practitioner of large experience. 
 
 The other varieties of scarlatina are always to be dreaded, and 
 the malignant condition of it, especially when epidemically pre- 
 vailing, is sometimes as fatal as the plague itself. The memo- 
 rable occurrence at Naples of such mortality has already been 
 referred to, and I may now add those subsequent recurrences of 
 the disease described by Moreton, Huxham, De Haen, Sims, 
 Fothergill, &c. We are, indeed, told that when it prevailed in 
 Paris, in 1743, so indomitable did it prove that not a single indi- 
 vidual recovered, and numbers perished within the short space 
 of a few hours. But, on the contrary, it sometimes appears epi- 
 demically in the character of extreme mildness, as recorded by 
 
 12* 
 
138 EXANTHEMAT0US FEVERS. 
 
 Moreton, Sydenham and other authorities. It is one of those 
 diseases that very conspicuously appears to have its cycles in 
 which the most opposite character is presented. The whole 
 history of it warrants this conclusion. It has so prevailed from 
 the earliest settlement of our country. Nearly half a century 
 ago I recollect it as the terror of our community, and so it con- 
 tinued for some time. But, from about 1801 to 1830, it recurred 
 at certain intervals, uniformly with such extraordinary benignity 
 that it rarely gave any trouble or anxiety in the management. I 
 have heard the late Professor Physick declare that, during this 
 lengthened period, he did not lose a patient in it. For the last 
 ten years, ho wever, it has proved very much the reverse, some 
 seasons highly malignant and frightfully fatal, as well immedi- 
 ately among us as elsewhere. 
 
 An attack indicates a happy issue, whatever may be the form 
 of the disease, where the eruption comes out in due season, is 
 widely spread, of a bright red, regularly passing through the 
 several stages to desquamation. The throat being aifected, it is 
 of favourable import to have the tumefaction considerable and 
 florid, with painful deglutition— and, should any exist, white 
 instead of gray or dark sloughs, the whole attended by mode- 
 rately inflammatory fever. Every thing, in short, depends on the 
 degree of reaction, the want of which almost invariably proves 
 fatal, and, when present, a different result may as confidently be 
 anticipated from skilful management. 
 
 Feeble exertion of the vital forces, with heavy, passive conges- 
 tions, the common consequence of it, or intense fever with com- 
 plications, is very unfavourable, though the former infinitely the 
 more so. Any material deviation in the efflorescence from its 
 common character and order — the eruption too early or late, or 
 alternately coming out and receding, or its appearance in blotches 
 only, or an entire absence of, or permanent repercussion of it, or 
 its having a pale or livid or mahogany colour, or its rapidly 
 changing from the one to the other of these hues, or if attended 
 by petechias or vibices, or passive hemorrhage, are all of the 
 worst imports. 
 
 To have the throat affected, without any eruption, is bad, it 
 denoting a concentration of the disease on the internal organs, 
 and especially when the lesions are extensive and the aspect 
 dark, with aphthous ulcerations. Even more so, however, is the 
 
EXANTHEMATOUS FEVERS. 139 
 
 affection of the windpipe, from which recoveries very rarely take 
 place. Nor scarcely less to be dreaded is a deep implication of 
 the cerebral and nervous systems, or of the pulmonary or abdo- 
 minal viscera, or a gangrenous state of the fauces, or diarrhoea 
 of acrid matter, or copious discharges of pallid urine, with an 
 exceedingly quick and diminutive pulse, anxiety, jactitation and 
 inquietude. These symptoms, indeed, indicate imminent peril, 
 and mostly prove the immediate precursors of death. By Reil 
 it is said that a white streak passing down on each side of the 
 nose and encircling it below, is a mortal sign, which, however, 
 no one else has observed. I have only to add, on this point, as 
 a fact of importance, that, whenever the disease is excited by an 
 exposure to cold, it is prone to present the malignant congestive 
 form, and is very difficult of cure. 
 
 Not much is recorded of the anatomical characters of scarlatina. 
 Yet it may be collected, from the dissections which have been 
 occasionally reported, that the mucous tissue of the prima? vise, 
 particularly of the stomach and upper intestines, is highly in- 
 flamed, and scarcely less frequently are the lungs, with the brain, 
 in their substance and membranes, in the same condition. More 
 recent researches have also revealed similar derangements in the 
 follicular structure of the bowels, to those previously discovered 
 in several other diseases, and especially that form of typhoid fever 
 now receiving the title of dothinenteritis. Louis tells us that in 
 five subjects, the only ones which he had examined, he found, in 
 the lower portion of the ileum of the whole of them, the solitary 
 glands affected, and hence is inclined to infer that such, if not a 
 uniform, is a pretty constant lesion. But, from what I have ob- 
 served myself, I suspect that, in this city at least, it is a very rare 
 and purely accidental occurrence, having no necessary connec- 
 tion whatever with the disease. 
 
 Cases, on the contrary, are met with, where, with some slight 
 and weak phlogosis, the heaviest passive congestions are detected 
 in nearly all the organs of the great cavities, and diverse effusions 
 and extravasations are common events. These differences of 
 appearance are referable to the opposite conditions which the 
 disease presents in its most fatal forms. 
 
 Extensive sphacelation, in the anginose variety, is found in 
 the fauces, and instances are mentioned in which it partially 
 existed throughout the alimentary canal. Lately some contro- 
 
140 EXANTHEMATOTJS FEVERS. 
 
 versy has arisen as to the precise state of the throat, whether the 
 appearances hitherto supposed to be sloughs from gangrenous 
 inflammation be really so, or are exudations of coagulate lymph, 
 from the inflamed surface, imitative of sloughs. Either may 
 undoubtedly exist. Deep ulcerations I have witnessed, and also 
 the coating of lymph, counterfeiting sloughs so accurately as 
 readily to lead to the deception. There is here sometimes a 
 perfect membrane, which, dipping into the larynx, has traveled 
 down through the trachea into its final ramifications. This 
 adventitious production, however, to such an extent must be a 
 rare occurrence, it being, at least, as I have seen it, uniformly 
 restricted to the larynx, and much oftener in pieces, than as a 
 whole lining of that structure. It differs from a mere pellicle, 
 to a coating of considerable thickness and softness, even some- 
 times of a pultatious consistence and aspect. These are the 
 principal lesions hitherto noticed, in which little peculiar or dis- 
 tinctive is to be remarked. Dissection, indeed, has as yet shed 
 no light on the nature of scarlatina, or the other exanthematous 
 fevers. The fact, indeed, is sufficiently confirmed, that sometimes 
 nothing whatever was detached of an anormal character, owing, 
 most probably, to death taking place from the immediate effects 
 of the poison, or before it could produce any appreciable changes. 
 From its analogy to that of the exanthemata of which I have 
 treated, I mean to say not much concerning the pathology of this 
 disease. Like its congenera, the primary impression is mainly 
 on the primae vise, and the subsequent implication of other 
 organs must be referred to a sympathetic or actual extension. 
 The argument by which this view has already been sustained, 
 in relation to the other cutaneous affections, might be applied 
 with equal force to it. Much of the peculiarities, as well as the 
 grades of violence of the disease, is owing to the difference of 
 intensity in which its specific contagion operates. It is a poison 
 from the effects of which the system endeavours to extricate 
 itself, and according to its resources is the result. They being 
 energetically applied, we have an open, inflammatory form of 
 the disease, and conversely, a low congestive state, should they 
 be feebly or incompetently exercised. Death, which is thought 
 by many to be occasioned in the anginose variety of it, by the 
 state of the throat, does not seem to me to be justly assigned. 
 This topical affection can rarely be productive of such an event, 
 
EXANTHEMATOUS FEVERS. 141 
 
 except when it is extended to the larynx. The disease is singu- 
 larly pervading, characterized by great sensorial and nervous 
 disturbance, and by an almost unexampled derangement from 
 inflammation or congestion, or both, of nearly all the important 
 organs. By such lesions it is that the constitutional powers 
 become impaired, and ultimately extinguished. The throat suf- 
 fers in common, runs into gangrene from the loss of vitality, and 
 perishes with the rest of the body. 
 
 Little else is required in the cure of mild scarlatina than the 
 ordinary antiphlogistic regimen, — watching, at the same time, its 
 tendency to those unfavourable changes formerly pointed out. 
 None die of it, says Sydenham, except from too great omciousness 
 in the practitioner. This may be too strongly predicated, though 
 it is still true, that the "nimia medici diligentia," here, as well as 
 in the exanthematous fevers generally, is mischievous. Nature 
 has established, in all these cases, a certain mode of relief, con- 
 sisting in the exoneration, in part or wholly, of the internal tissues, 
 by translating the irritation to the skin ; — and where she appears 
 to be adequately effecting this end, it were better not to interfere 
 with her endeavours. It is on such occasions that the old maxim 
 applies, " Nulla medicina, aliquando optima medicina." Cer- 
 tainly I have witnessed, again and again, from the harassing 
 effects of active measures, the very worst consequences, convert- 
 ing what was originally mild and proceeding well, into a fearful 
 degree of exasperation and danger. 
 
 Nevertheless, in the several presentations of the disease, either 
 of a decidedly inflammatory or congestive character, the practice 
 must be correspondently energetic, and, in order to succeed, be 
 accommodated to these respective conditions. Let us first con- 
 sider the course adapted to its phlogistic form. 
 
 The initiatory step depends on the stage of the case. Consulted 
 early, or while there is rather irritation than positive inflamma- 
 tion, it will be well to commence with an emetic. Commended 
 highly by Tissot, Stoli and the generality of writers, I have 
 reason to believe it proves exceedingly influential in mitigating 
 the future career of the case. It is said, indeed, by Dr. Richard 
 Harrison, who, I understand, is an eminent practitioner of London, 
 that the effect was so strikingly manifested in the disease, during 
 an epidemic prevalence of it in that, city some years ago, that, by 
 many, the practice was reluctantly pursued, since the prematura 
 
142 EXANTHEMATOUS FEVERS. 
 
 eradication of one attack was usually followed by another in a 
 few days, and hence it was deemed better to postpone the emetic 
 till the disease had taken such hold of the system as to do away 
 any susceptibility to a future renewal of it. 
 
 My own observations, though decidedly in favour of this prac- 
 tice, do not corroborate this statement to the extent here made. 
 Withering, however, who is one of the best writers on scarlatina, 
 goes almost as far. " In the very first attack," says he, "a vomit 
 seldom fails to remove the disease at once; if the poison has 
 begun to exert its effects upon the nervous system, emetics stop 
 its further progress and the patients quickly recover; if it has 
 proceeded still further, and occasioned that amazing action in the 
 capillaries which exists when the scarlet colour of the skin takes 
 place, vomiting never fails to procure a respite to the anxiety, the 
 faintness and delirium." But whatever difference of opinion 
 may be entertained as to the general use of emetics, I think there 
 can scarcely be any concerning their applicability to the anginose 
 form of the disease, and especially when complicated with the 
 affections of the windpipes or lungs, the most ample experience 
 having demonstrated their singular adaptation to such cases. 
 
 Next in importance are evacuations of the bowels by mild 
 laxatives. Febrile excitement, however, being developed, and the 
 more so, when accompanied by any prominent topical affection, 
 the loss of blood by venesection can no longer be postponed, to 
 be proportioned to the degree of the emergency. Yet it must be 
 confessed that great difference of opinion prevails among writers 
 as to the propriety of venesection. Most of those of the conti- 
 nent of Europe are in favour, while the preponderance of English 
 authorities is opposed to it, as reducing strength without affording 
 any relief. This is the language of Sims, Withering, Clarke and 
 Willan, the latter of whom declares that he never saw a case of 
 scarlatina in which blood-letting seemed to be indicated. Excep- 
 tions, however, exist among the English to this condemnation of 
 the practice. Moreton pursued it, Cullen seems not indisposed to 
 it, and Armstrong enjoins it where there is visceral inflammation. 
 
 This contrariety of sentiment, in relation to the remedy, I pre- 
 sume must be referred to its having been applied under opposite 
 circumstances of the disease, and, of course, attended by very 
 different results. Directed with discrimination, it cannot fail, ac- 
 cording to my experience, to be beneficial, and often even indis- 
 
EXANTHEMATOUS FEVERS. 143 
 
 pensable. Convinced of this, my own practice, indeed, and 
 which is that of our physicians generally, is to bleed in nearly 
 every case of high and active excitement. Yet it is true that the 
 loss of blood has no direct curative tendency in the disease, it 
 only abating action, without changing or subverting it, and as 
 usually not well borne to any great extent ;— it is not safe to 
 detract it with the same freedom as in the more purely phleg- 
 masial affections, or, perhaps, to the amount that the existing 
 indications in the case itself would seem to demand. Collapse, 
 frightful and sometimes even fatal, I have repeatedly seen to 
 result from an abuse of the practice, and it is always hazardous 
 in an advanced stage of the disease. Local affections merely 
 may be removed by leeches or cups. 
 
 More, perhaps, than in any other disease is this state of scarla- 
 tina characterized by heat of surface, and here cold applications 
 are obviously called for, and prove immensely serviceable. Either 
 ablutions or sponging I have preferred. Not content, however, 
 with these modes, some of the European practitioners contend 
 for the superior efficacy of aspersions, or even immersions, in the 
 coldest water. But these have always appeared to me as very 
 rash expedients, and I have heard of the latter proving even 
 fatal. By Dr. Roper, of South Carolina, who graduated at Edin- 
 burgh some years ago, I was told that the professor of the practice 
 of physic in that school, to show his confidence in the practice, 
 tried it on one of his own children, who died while in the bath 
 by a sudden recession of the eruption — and a similar result, in 
 another instance, is mentioned by Armstrong, from affusion only. 
 Yet Currie informs us that he was in the habit of stripping his 
 patients and dashing buckets of cold water on them, from which 
 such benefit. accrued that the disease was usually cut short in its 
 progress. Many, at the time, adopted this practice, and bore 
 evidence to its distinguished success. Even Bateman commends 
 it in the very beginning, though subsequently he thinks every 
 advantage may be attained by simply washing the surface. Cau- 
 tion should certainly be observed in this and every other eruptive 
 fever, in the use of the remedy, from the danger of repercussion, 
 and never ought it to be resorted to without just discrimination. 
 
 With me it has been a rule to restrict its application exclusively 
 to the simplest form of the disease, where reaction is complete, 
 the skin steadily warm, and without any serious complication 
 
144 EXANTHEMATOUS FEVERS. 
 
 of the throat or the thoracic or abdominal organs, particularly 
 the bowels. Commonly cerebral affections, whether delirium, 
 coma or convulsions, are eminently benefited by it, and here even 
 ice to the head is sometimes proper. Thus accommodated to 
 the case, I cannot express too strongly my confidence in these 
 applications. Of all remedial means, I think 1 have derived from 
 them the most unequivocal advantage, and often scarcely any 
 thing more was exacted in the cure. Cases, indeed, I have 
 treated successfully by them only. They lower excitement, re- 
 duce the frequency of the pulse, allay the heat of the skin, some- 
 times rendering it soft and perspirable, and seldom fail to relieve 
 the disorder of the brain, calm the general inquietude and com- 
 pose to sleep. But, to prove so effectual, the spongings or 
 washings must be pretty constantly made to the entire superficies 
 of the body, to the trunk and extremities, to be discontinued only 
 when a degree of coldness is occasioned that might be followed 
 by chilliness and collapse, or retrocession of the exantheme. 
 More seems to me ascribable to cold in scarlatina than can be 
 explained by its usual mode of operation. Not improbable is it 
 that, while mitigating undue excitement by its sedative agency, 
 it also proves more directly the corrective of the effects of the 
 specific virus causing the disease. The hypothesis is supported 
 by abundant analogies. Few, indeed, are the affections proceed- 
 ing from a poisonous influence, in which the same sort of counter 
 agency or antagonizing power is not displayed by it. Might 
 not cold enemata, under such circumstances and with similar 
 restrictions, prove useful? They are so in other ardent fevers, 
 and here, from the extraordinary warmth, in some instances, both 
 of the internal and external surfaces, would seem, a fortiori, to 
 be exacted. But, having no experience, I throw out the sugges- 
 tion merely as a plausible conjecture. 
 
 Nothing is to be anticipated from the diaphoretic febrifuges at 
 this period, which, owing to the state of the skin, rarely or never 
 promote perspiration, or in any way diminish febrile action. 
 Failing in the former respect, they are apt to be positively detri- 
 mental by harassing the internal surfaces, leading to a general 
 exasperation of condition, and, such an effect being apparent, 
 they should at once be discarded. It is, however, of the highest 
 importance, at this conjuncture, to restore the cutaneous functions, 
 for, while these are suspended, it is impossible to overcome the 
 
EXANTHEMATOUS FEVERS. 145 
 
 disease or to produce any sensible amendment. Not relieved, 
 the skin, indeed, may have its vitality so far impaired as never to 
 be recovered, and in this mode, I believe, has often proved the 
 cause of death, exactly as happens in small-pox and other similar 
 affections. 
 
 The depleting and evacuant remedies enumerated, as well as 
 the cold applications, are well calculated to effect this great end. 
 But they are sometimes incompetent, and having been fairly 
 tried, without avail, other and opposite methods must be adopted, 
 the best of which is tepid sponging or immersion in warm water, 
 or the vapour bath, repeated from time to time, till coolness, 
 relaxation and softness of the integument are induced. Even 
 these, too, do not uniformly succeed, especially when too long 
 postponed, or the skin is deeply affected, and in such an emer- 
 gency, advantage might possibly be derived from some of those 
 emollient applications employed in erysipelas, scalds, &c. 
 
 In the passively congestive variety of scarlatina, which is now 
 to claim attention, the attack, as formerly mentioned, may be 
 introduced by a very protracted collapse. The leading object 
 here is to arouse the recuperative powers, and to bring on due 
 reaction, the means of effecting which, having been detailed on a 
 preceding occasion of essentially similar character, they need not 
 again be recited with any particularity. Enough may it be to 
 state that they consist of the warm bath, or what is preferred by 
 some, aspersions of the water, to be succeeded by frictions or 
 sinapisms or blisters to the extremities, and, above all, over the 
 epigastrium, with hot cordial beverages, or some of the more 
 active diaphoretics. 
 
 It has occurred to me, extraordinary as it may seem, that even 
 here cold applications might possibly be beneficial. Considering 
 the decisive control they exercise over the deleterious agency pro- 
 ductive of the disease, I was inclined to this conclusion, and the 
 more confirmed in it by the contemplation of some facts lending 
 to it no insignificant support. I had seen, among other striking 
 instances, several cases of Asiatic cholera, which undoubtedly 
 proceeds from some peculiar virulent cause, in the deepest shape 
 of collapse, where, resisting all stimulating and arousing means, 
 readily reacted by frictions with cakes of ice to the whole cuta- 
 neous surface, and the freest consumption of this article inter- 
 nally. The practice, however, I have never ventured to extend 
 to scarlatina. 
 13 
 
146 EXANTHEMATOUS FEVERS. 
 
 Having attained the object in view, namely, perfect reaction, 
 then an emetic, and afterwards purging with calomel, constitute 
 the approved means. These are held to be by some of the 
 highest authorities, as far more appropriate to this than the 
 other form of the disease. They are thought to cleanse the 
 primes vise, prevent or remove congestions and excite the cuta- 
 neous surface. 
 
 To a greater extent, however, than any one else, was Hamilton, 
 the author of a work on purgatives, addicted to purging. " Many 
 years ago," says he, "when the prejudices against purgatives 
 were more decided and prevalent than they are at this time, I 
 continued to prescribe them. My doing so was indeed the neces- 
 sary consequence of the advantage I had experienced from the 
 same remedies in typhus. I had learnt that the symptoms of 
 debility, which take place in this species of fever, so far from 
 increasing, were obviously relieved by the evacuation of the 
 bowels. I was therefore under little apprehension from them in 
 scarlatina. I have never witnessed sinking or fainting, as men- 
 tioned by some writers, and so much dreaded by them : neither 
 have I observed a revulsion from the surface of the body, and 
 consequent premature fading, or, in common language, the strik- 
 ing in of the efflorescence from the exhibition of purgatives." 
 
 Considering how exceedingly vitiated are the secretions usually 
 in this form of the disease, and the irritation which they must 
 create when collected in the alimentary canal, the propriety 
 of removing them seems scarcely disputable. Nevertheless, I 
 suspect the practice has been abused, as well by a too indis- 
 criminate recurrence to it, as by urging it to excess. Restricted 
 to its legitimate purpose, and I think there can be no doubt of 
 its safety and usefulness. 
 
 Less easy is it to decide on the expediency of venesection. 
 The abstraction of blood appears to be required by the loaded 
 state of the organs, and contra-indicated by the depression of the 
 vital energies. My own conviction is, that it should not be 
 hazarded, unless reaction is pretty firmly established, the circu- 
 lation in some force, and the skin warm, and even then is to be 
 resorted to with extreme circumspection. Much safer is topical 
 bleeding by leeches or cups, and under equivocal circumstances, 
 should be invariably preferred. 
 
 The case, however, becoming more unequivocally typhoid, a 
 resort must be had to a combination of calomel, opium and ipe- 
 
EXANTHEMATOUS FEVERS. 147 
 
 cacuanha, repeated every hour or two. The mercurial practice 
 of late so strenuously recommended by some, originated in this 
 country. More than a century ago it was employed by Dr. Doug- 
 lass, of Boston, in an epidemic scarlatina of that city, who extols 
 the superior efficacy of it in a publication on the subject. Com- 
 mencing with calomel as a purge, he next urged it to a salivation. 
 But the latter, in contradiction to his reports, I should think 
 hazardous. It is better to aim only at its alterative effects, and 
 such seems to be the end for which it is now, by common con- 
 sent, directed. The difficulty, indeed, of salivating in this dis- 
 ease is very great, and there are writers who deny that it ever 
 takes place. No doubt it is among the rarest of occurrences in the 
 disease itself, though, on its subsidence, comes forth fully, and if 
 not productive of more lamentable consequences, which it often 
 is, very seriously interferes with the progress of convalescence and 
 the comfort of the patient. I am inclined to suspect that Doug- 
 lass mistook the salivation, which is a common incident to scar- 
 latina, with affection of the fauces, for the mercurial effect. 
 
 While thus conducting the general treatment, the affection of 
 the throat, should it exist, must not be neglected. The best 
 remedies for it in the beginning, are topical bleeding, blistering 
 and warm poultices. 
 
 Whatever may have been the precise character of the disease 
 in the early stages, when exhaustion supervenes, there is con- 
 siderable uniformity as to the plan to be pursued. An appeal is 
 to be made to those means by which the resources of life are 
 renovated or strengthened, and of which carbonate of ammonia, 
 camphor, wine whey or wine itself, or even diluted ardent spirits, 
 and opiates, if not especially contra-indicated, are usually con- 
 fessed to be the most efficacious. But the muriatic acid was at 
 one time exceedingly confided in, having been introduced by Sir 
 William Fordyce, who gave the strongest assurance of its effi- 
 cacy, directing it with some bitter infusion, as that of the bark 
 especially. Limited in its application to the hemorrhagic or pete- 
 chial states of the disease, its utility is presumable, and further, 
 I know not the indication it promises to fulfil. By some of the 
 West India practitioners, the compound infusion of capsicum, to 
 be noticed presently as a gargle, is considered, also, as among the 
 very best of internal remedies, in the dose of two tablespooufuls, 
 occasionally repeated. Nothing, however, have I found at this 
 conjuncture comparable to the sulphate of quinine, alone or with 
 
148 EXANTHEMATOUS FEVERS. 
 
 an opiate, and the dulcified spirits of nitre, as may be indicated, 
 aided by some cordial drink. Not much is here gained by blis- 
 ters or sinapisms. They rarely excite the skin, and when they 
 do, the inflammation is very apt. to degenerate into gangrene. 
 But stimulating frictions are serviceable. 
 
 We must again revert to the anginose affection, which, chang- 
 ing with the progress of the disease, requires a modification of 
 treatment. On the occurrence of the aphthous appearance, mild 
 detergent gargles are to be resorted to, and when sloughing com- 
 mences, those of more activity, such as barley-water, with the 
 sulphuric or muriatic acid, or a decoction of Peruvian bark with 
 these acids, or the tincture of myrrh diluted, or an infusion of 
 capsicum, prepared in the following mode.* Gargles of the 
 chlorate of soda or lime are beneficial. But the best application 
 I have tried is that of the powder of burnt alum. The sloughs 
 being detached, leaving an unhealthy surface, the black mercu- 
 rial wash, or a solution of the sulphate of copper or of the nitrate 
 of silver may be used. If, instead of ulceration, the fauces are 
 covered by a membranous exudation, it is proposed for its re- 
 moval, to apply the lunar caustic or muriatic acid mixed with 
 honey. But I believe here, too, the burnt alum is preferable. 
 These articles are all applied by a mop, or large hair-pencil. 
 Emetics are recommended in each case with a similar intention, 
 or to cleanse the throat, and to institute a more healthy action. 
 The sulphate of mercury has been praised, particularly for this 
 purpose, though I suspect it has no just claims to a preference. 
 Nor is vomiting less deserving of regard as an emulgent of the 
 bronchial structure, when heavily oppressed by accumulations 
 of viscid secretions or other matter. 
 
 This concludes the medical treatment of scarlatina in its several 
 modifications. 
 
 Of regimen I have to observe, that it should harmonize with 
 the remedies. The diet in the decidedly inflammatory states 
 must consist of cold mucilaginous beverages exclusively, and if 
 other drinks be urgently desired, which happens in very heated 
 conditions, water may be allowed of icy coldness, in small quan- 
 tity. Even ice itself is admissible. Let, also, the freest ventila- 
 tion be practised in hot. weather, and the patient very slightly 
 covered. But under other circumstances of the disease, the 
 
 * R. — Caps. ind. Coch. mag. ij.; Sodae muriat. Coch. min. iss.; Aq. bull.ftss.; 
 Acet. acid., ib. Infus. et. collat. 
 
EXANTHEMATOUS FEVERS. 149 
 
 course is reversed. Either the eruption refusing to come out, or 
 showing a disposition to recede, or the skin being cool, the pulse 
 feeble, or any other evidence existing of typhoid prostration, a 
 higher degree of temperature must be observed, the diet more 
 nutritious, and the drinks warm, and, perhaps, cordial and mode- 
 rately exciting. These observations are alike applicable to all 
 the exanthematous fevers. 
 
 During convalescence, in most of these affections, and espe- 
 cially in scarlatina, a susceptibility to disease is retained, readily 
 excited by the slightest cause. Dreadful consequences I have re- 
 peatedly known from exposures to cold, and by improper eating 
 and like indiscretions. Carefully are these to be guarded against. 
 But independently of such imprudence, though occasionally to be 
 traced to it, are certain sequelae or effects to which our attention 
 is often called. Cases are to be met with of enlargement of the 
 parotids or testicles, suppuration of the ears, various pectoral or 
 gastric or enteric affections, hydropic effusion or great derange- 
 ment of the nervous system, expressed by palsy, chorea, hysteria, 
 epilepsy or neuralgia, as well as chronic cutaneous eruptions, 
 mostly herpetic, and the development of scrofula, &c. The most 
 common, however, of these consequent affections is a hot, dry, 
 harsh, unperspirable state of the skin, and especially when de- 
 squamation has not taken place. The functions of the surface, so 
 essential to the order of health, are hence not performed, fever is 
 kept up or revived, with a most harassing degree of itching, pre- 
 ventive of all quietude or sleep, and chiefly occasioning, as I be- 
 lieve, most of those very affections I have enumerated, and parti- 
 cularly, hydropic effusion. As the cause of so much mischief, this 
 condition of the tegumentary tissue should always be removed 
 without delay, and the most effectual means of doing it is tepid 
 bathing, either by the sponge or immersion in a bath, taking 
 special care to avoid any exposure to cold. Yet it may be 
 necessary, where excitement is high, to bleed and purge mode- 
 rately, and next resort to the mild diaphoretics. But from 
 bad management or otherwise, dropsy is so very frequent an 
 occurrence, and as it, of the several affections, alone exacts any 
 peculiarity of treatment, it presents here an exclusive claim to 
 consideration. 
 
 Generally it appears as oedema of the lower extremities or of 
 the face and neck, though there are numerous instances of effu- 
 sion also into the cavities. Bateman truly remarks that when 
 the anasarca becomes general, a sudden effusion occasionally 
 
 13* 
 
150 EXANTHEMATOUS FEVERS. 
 
 takes place into the cavity of the chest, or into the ventricles of 
 the brain, causing death in a few hours. Cases of this kind I 
 have frequently seen. Nay, it sometimes happens in relation to 
 the braiu, without any appearance whatever of dropsy, and 
 under circumstances to preclude even a suspicion of a tendency 
 to it. Examples of the kind are, perhaps, not very unusual, and 
 among others which have come under my own notice, I lately 
 saw a child seemingly well of scarlatina, die in a moment from 
 a convulsion, where the ventricles were filled with water, and a 
 young lady, in consultation with Dr. Morton, deemed to be no 
 less recovered from the disease, who almost as suddenly expired 
 in the same manner. 
 
 Contrariety of opinion prevails as to the management of this 
 secondary dropsy. The fact is, that it is connected with such 
 opposite states of the system, that no one plan is suited to all the 
 cases. Existing, which usually happens, with an accelerated, hard 
 and febrile pulse, unrelenting skin, deficient urinary secretion, the 
 little that passes away depositing a lateritious or pink-coloured 
 sediment, or of an albuminous nature, there ought to be no hesi- 
 tation as to the propriety of venesection, the saline purgatives, the 
 mild diuretics, the nitrate of potash or the cremor tartar espe- 
 cially, with a very low diet. 
 
 Treated differently, it invariably proves obstinate or fatal, of 
 which Burserius gives a very striking illustration. Early in the 
 last century, an epidemic scarlatina prevailed at Florence, followed 
 in nearly every case by more or less oedema, pulmonary oppres- 
 sion, fever and diminished urination. Tonics were for a time tried, 
 under the use of which the dropsy was greatly aggravated and 
 the mortality considerable. Dissection, however, disclosing in- 
 flammation of the lungs, alimentary canal and kidneys, vene- 
 section, with its auxiliaries, was adopted, and the result came 
 to be uniformly favourable. Yet it is no less true that effusions 
 may take place under circumstances directly the reverse of the 
 preceding, or in a weak and highly cachectic condition. Mode- 
 rate purging and the more stimulating diuretics are here the 
 remedies in which confidence is usually placed. But I have 
 found an infusion of digitalis singularly efficacious, and in many 
 instances so much so as to supersede all other measures. 
 
 To restore strength and soundness of constitution, the martial 
 preparations, exercise and a nutritious diet sometimes become 
 necessary, and particularly in exsanguineous or leucophlegmatic 
 states. But where the treatment of the disease has been careful 
 
EXANTHEMATOUS FEVERS. 151 
 
 and judicious, such sequelas are of rare occurrence, and may, 
 perhaps, be entirely obviated. 
 
 As a preventive of scarlatina, the use of belladonna has, of 
 late, attracted some attention. The facts, indeed, bearing on this 
 point, are exceedingly curious, and, coming from respectable 
 sources, ought not to be contemptuously or heedlessly passed 
 over or rejected. Berendt, a physician of Vienna, declares, that 
 by the use of the article, only fourteen out of one hundred and 
 ninety-five children exposed to the contagion, took the disease, 
 and these had it very mildly. We are further told by Professor 
 Herholdt, of Copenhagen, that he found it to preserve several 
 hundred children, during the prevalence of the disease as an epi- 
 demic in that city, — and, on a subsequent occasion, when it ap- 
 peared even more violent, out of nearly an hundred families, all 
 escaped except, one, and of this he is doubtful whether they took 
 the medicine. The testimony of Koreft, of Berlin, is scarcely less 
 decisive, — that of Godelle, who avers that he has never seen it 
 to fail, still more so, and a variety of attestations from other 
 medical men of the continent of Europe, might be adduced. 
 Ten or fifteen drops to children, according to the age, morning 
 and night, of the watery solution of the extract of belladonna, 
 in the proportion of two or three grains to an ounce of water, is 
 the common mode of exhibition. 
 
 To what extent these statements are to be credited, I cannot 
 say from any experience of my own. Distinct from the authority 
 by which they are sustained, when we advert to the powerful 
 impression of the belladonna, we may, on the principle of the 
 incompatibility of two actions simultaneously existing, get an 
 explanation of its modus operandi, and be not altogether incre- 
 dulous. That preoccupying the stomach by food, cordial drinks, 
 and even by certain medicines, as opium, or bark particularly, 
 has proved prophylactic as to intermittent and some other dis- 
 eases, is abundantly demonstrated. Yet, by the assurance of 
 Hahnemann, the author of the homoeopathic doctrines, which, 
 originating in fraud and imposture, and continued by the most 
 atrocious wickedness, that he was equally successful in the in- 
 finitesimal dose of a few drops, daily, of a solution, each drop of 
 which contained no more than the twenty millionth part of a 
 grain of the extract, distrust and even ridicule are cast over the 
 whole affair, and our faith must be withdrawn or suspended till 
 fresh and better evidence is afforded. 
 
H^MOBBHAGIA, 
 
 OR 
 
 HAEMORRHAGE 
 
 Conformably to its etymology, the term haemorrhage em- 
 braces every effusion of blood, however induced. Five modes 
 have been assigned in which it may take place, by rhexis or 
 rupture of a vessel, by diaresis or division of it, by diabrosis or 
 erosion of its coats, by diapedesis or transudation through them, 
 and by anastomosis or dilatation of the mouths of the exhalents, 
 so as to allow the blood to escape. 
 
 Founded, in part, on the supposed modes of its production, an 
 arrangement was early made of haemorrhage into traumatic, as 
 occasioned by wounded vessels, and into spontaneous, when 
 occurring without such vascular injuries. But more accurately 
 expressive of the two distinctions, are the terms physical and 
 vital, lately introduced, these indeed, denoting with sufficient 
 precision, the nature of the lesions on which the sanguineous 
 emissions depend. 
 
 Custom having hitherto resigned the physical haemorrhages to 
 the province of surgery, I shall, in obedience to it, do the same, 
 — limiting the ensuing inquiry, therefore, to the other description 
 of the affection. Corresponding more exactly, in my opinion, 
 with a just pathology of vital haemorrhages than any previous 
 classification of them, it is my intention to distribute the subject 
 under the titles of active, less active, and passive, thereby indi- 
 cating the several gradations of the hasmorrhagic states. The 
 symptoms, of course, vary as connected with one or the other of 
 these conditions, and also by the part whence the effusion may 
 
HAEMORRHAGE. 153 
 
 proceed. My aim, at present, is limited to a very rapid survey 
 of the prominent features only. 
 
 In the first or active haemorrhage, the effusion takes place 
 with little or no premonition, though, perhaps, as frequently it is 
 preceded by a full and somewhat struggling pulse, heat and 
 redness of surface, with a sense of congestion in the part whence 
 the blood is to be eliminated. On other occasions it presents 
 more of the intermittent character, being ushered in by a chill, 
 followed by fever, ceasing with the subsidence of the excitement 
 and reverting on a recurrence of it. The law of periodicity may 
 be very strictly observed in regard to the order of the paroxysms. 
 Cases are recorded of haemorrhage, in all its locations, returning 
 daily, every other day, and at more distant intervals. Generally, 
 however, the febrile condition is steady, or, at least, there are 
 continued manifestations of an increased force of the circulation, 
 and undue local determinations. 
 
 The effects of haemorrhage depend mainly on the quantity of 
 effusion, the rapidity with which it takes place, the part whence 
 it proceeds, and the capacity to bear the debilitating process. 
 No one doubts the influence of the two first causes,— and I think 
 that of the others is scarcely less apparent. Thus, a few ounces 
 of blood from the nostrils or the rectum will sometimes induce 
 syncope or a disposition to it, and by even moderate repetitions 
 of such bleedings in either case, for any length of time, deprav- 
 ations inevitably follow. Coming, on the contrary, from the 
 mucous tissue of the lungs or the uterus, though a much larger 
 amount be lost, there are seldom such results immediate or remote, 
 and certainly not to the same extent. Equally is it true that, 
 while some persons will sustain an immense loss without any 
 ostensible injury, others instantly sink under very slight effusions, 
 or have entailed a lengthened suffering, — and this shall happen 
 where no material difference between them is discernible in 
 vigour or integrity of constitution. The same disparity, in this 
 respect, may be observed in relation to the effect of venesection 
 or topical bleeding, ascribable altogether, as in the former instance, 
 to some idiosyncrasy not always intelligible. Many instances to 
 this purport have I seen. 
 
 Generally, in active haemorrhage, where the flow is moderate, 
 and escapes through the external passages, great relief is afforded 
 to the existing symptoms, and a renewal of the haemorrhage 
 
154 HEMORRHAGE. 
 
 usually prevented. But when the loss of blood is disproportioned 
 to the exigency, and of course still more, when exceedingly pro- 
 fuse or rapidly emitted, the action of the heart and vessels is so 
 reduced as scarcely to be recognized, — the surface becomes cold, 
 collapsed and pallid, the respiration quick and embarrassed, 
 chills or rigors take place, followed by distraction of the senses, 
 dimness of vision, ringing in the ears, with nervous tremors, 
 some cerebral confusion, and ultimately syncope, or, perhaps, 
 fatal convulsions. Yet after a while reaction commonly ensues, 
 attended by a quick, hard, irritated pulse, alternate chills and 
 flushes, or a more permanent and unequal distribution of tem- 
 perature, and very often by repetitions of the haemorrhage to a 
 greater or less extent. Extreme perturbation, however, of body 
 and mind, is sometimes now betrayed, — the countenance be- 
 comes florid or pale in rapid succession, the tongue furred, the 
 skin hot and dry, the whole circulatory machinery acts anormally, 
 — and the pulse simulates by its impetus, its fulness and even 
 its tenseness, the real synochal state. 
 
 Enduring, in this way, for any length of time, the consequences 
 of the haemorrhage are exceedingly serious, amounting nearly to 
 an universal disorder of the functions of the animal economy. 
 The aspect is that of confirmed and inveterate dyscracy, pale, 
 sallow or livid in patches — sometimes bloated, particularly the 
 face — the circulation being accelerated and feeble, though apt 
 still to be tumultuous on any mental or corporeal agitation. 
 Cerebral excitement, indicated by intolerance of light or sounds, 
 or by slight delirium, is, indeed, very common. 
 
 Not arrested, the case rapidly advances with an aggravation 
 of the foregoing symptoms. To increased exhaustion, there are 
 added greater embarrassments of breathing, sluggishness of body, 
 obtuseness of mind, drowsiness, more violent throbbings of the 
 arteries, and palpitations of the heart on any exertion or emotion, 
 with considerable irritation in the mucous lining of the alimen- 
 tary and pulmonary passages, — deficient urination, — and where 
 death does not promptly take place, dropsy of the cellular tissue, 
 or of the cavities, or of both, results, which more slowly leads to 
 the same catastrophe. 
 
 Much of this account is applicable to the less active haemor- 
 rhages. They differ, however, materially in their early symp- 
 toms. Connected, from the beginning, with a reduced, attenuated 
 
HEMORRHAGE. 155 
 
 and frequently depraved state of the system, and rarely preceded 
 or accompanied by any of the signs of the molimen hsemor- 
 rhagicum, the train of secondary phenomena I have noticed are 
 almost constantly evinced by any undue loss of blood, and hurry 
 on with more rapid speed to the final termination which has 
 been described. 
 
 Nothing scarcely need now be said of passive haemorrhages, 
 since the circumstances in which they occur, and the mode of 
 production to be immediately detailed, are calculated to shed 
 sufficient light on them at present, without any formal recital of 
 their history. 
 
 They are mostly the effect of the lowest state of vitality, 
 whether induced by acute or chronic distemperatures, — and 
 occurring in such general pravities of system, are usually very 
 pervading, the effusions coming from several parts, or indeed, as 
 I have seen, from nearly the whole body simultaneously. Lucan 
 says of them : 
 
 " Sanguis erant lacrymae: quaecunque foramina novit 
 Humor, ab his largus manat cruor: ora redundat, 
 Et patulae nares : sudor rubet : omnia plenis 
 Membra fluunt venis to turn est pro vulnere corpus." 
 
 Next, I am to advert to a species or variety of haemorrhage 
 which seems peculiar in its character. My allusion is to those 
 cases where the effusion recurs at stated intervals, sometimes 
 with the exactness of well-regulated menstruation, though per- 
 haps rather incident to males than females — preceded nor at- 
 tended by any manifestation of disease, except the sense of local 
 fulness — nearly always issuing from the same part, and a similar 
 quantity of blood escaping each time, the prevention or checking 
 of which is followed by detriment to health. Examples I shall 
 hereafter adduce of such effusions taking place in many of the 
 organs and structures of the body. 
 
 This habitual haemorrhage, which may be continued through 
 a long life, is not to be confounded with the vicarious, succe- 
 daneous or supplemental discharges sometimes of the rectum, 
 nares, bronchi, &c, though oftener of the uterus, corresponding as 
 they do in their general aspect. Gall, the phrenologist, who had 
 a very large development of nonsense, among other silly notions 
 which he advanced, vehemently contended for the existence of 
 menstruation in males, resting the hypothesis solely on the ana- 
 
156 HEMORRHAGE. 
 
 logy between these two haemorrhages. As well might he have 
 insisted on men bearing children, because an imperfect fetus had 
 occasionally been found in certain portions of their bodies ! Dif- 
 fering in diverse respects, it is mainly in the habitual, being 
 very rare, and the vicarious frequent,— the former happening 
 mostly in males, and the latter in females, — the one arising with- 
 out any obvious cause, and the other consequent on the suppres- 
 sion of some pre-existing discharge, and that, though the habitual 
 may be displayed in various organs or tissues, it is subsequently 
 repeated with great uniformity in the one it originally occupied, 
 — and reversely with regard to the vicarious, it showing so little 
 steadiness of the kind in many instances, as during an attack to be 
 fluctuating or metastatic, in rapid succession altering its position. 
 Both these haemorrhages, however, so far agree, that with few, 
 perhaps no exceptions, they are of the active form, attended by 
 repletion of blood, general or local, and are usually of salutary 
 tendencies. 
 
 To exhibit a complete view of haemorrhage, it were required 
 to notice also the sanguineous extravasations to which occluded 
 cavities are liable. But these have been separated as distinct 
 diseases, and agreeably to established usage, they will be con- 
 sidered by me under the heads of apoplexy, &c. 
 
 Tracing the etiology of haemorrhage, it will be perceived that 
 there is the greatest liability to it about the age of puberty, when 
 a redundancy of blood exists. As on the completion of an edifice, 
 there is left a surplus of materials to be disposed of, so, on the 
 cessation of the growth of the body, an excess of blood remains, 
 sometimes removed in this way. But the tendency of haemor- 
 rhage to its several localities, seems to be considerably influenced 
 by the stages of life. Childhood and adolescence are prone to 
 effusions from the nose, — for some time afterwards they proceed 
 from the lungs, — in middle age, the alimentary canal and the 
 brain afford the outlet— and, from the kidneys or bladder, they 
 are most frequently met with at a still later period. But since, in 
 the progress to maturity, the different parts of the body may be 
 unequally developed, and as, subsequently, changes take place 
 from disease or otherwise, having a similar effect, many excep- 
 tions will be found to this general rule. Nevertheless, peculiar 
 conformations of structure no doubt predispose to particular 
 haemorrhages. Thus, among other instances, the short neck and 
 
HEMORRHAGE. 157 
 
 large head, invite to epistaxis or apoplexy — while the narrow, 
 ill-shaped chest does equally so to haemoptysis. Certain persons, 
 too, are singularly liable to the disease, and from different por- 
 tions of the body, in whom nothing is discernible in the exterior 
 configuration to afford an explanation. Nor is it uncommon for 
 whole families to be thus distinguished, and who in some in- 
 stances seem to derive the peculiarity by inheritance. An unusual 
 want of tone in the coats of the extreme vessels, or some anomaly 
 in their arrangement, — by which their capacity is less to resist the 
 occasional momentum in the movements of the blood, — has here 
 been suspected. Cases of this sort are more frequent in scrofu- 
 lous habits, where laxity in the structure of the vessels usually 
 exists. But without any proof of such diathesis, it occurs occasion- 
 ally — the haemorrhage spontaneously bursting forth, or following 
 the slightest wound, even an incision of the gum or a cut of the 
 finger, and persisting so obstinately as to prove very difficult, or 
 not at all to be restrained. Numerous instances of the kind are 
 recorded — some of which are collected in Andral's work on Pa- 
 thological Anatomy, and in an Essay on the subject, by Dr. 
 Reynei Coates, in the North American Medical Journal. 
 
 As conducive to an increased proclivity to haemorrhagic occur- 
 rences, much is ascribed to an habitual fulness of body, and 
 particularly where the circulation is redundant with rich blood. 
 That such a state tends to this effect cannot be denied, though 
 the reverse is scarcely less true, or that it is frequently inci- 
 dent to attenuated habits, and where the blood is scanty and 
 impoverished. Each condition leads to it, provided the balance 
 in the circulation is prone to subversion, it being under these cir- 
 cumstances, the consequence of unequal concentrations of blood, 
 rather than of its quantity or quality. 
 
 But other pathological states, in which the blood undergoes 
 still greater changes — its consistency being so completely broken 
 down as to be rendered a thinner fluid, easily escaping through 
 the exhalents — dispose, also, to this event, and independently of 
 any previous local accumulations. It is met with in scurvy, 
 low malignant fevers, and various other analogous diseases, or 
 as the effect of accidental inanition, or a penurious diet, de- 
 pressing passions, the want of fresh air or external exercise, 
 or of solar heat and light, or whatever else affects the nerves 
 more immediately concerned in the secretory and nutritive pio- 
 11 
 
158 HEMORRHAGE. 
 
 cesses. Certain articles taken into the system seem especially to 
 exercise a sort of specific operation in causing such a state of the 
 blood. The experiments of Starke show that living long on 
 sugar produces it, and we have reason to suppose that the exor- 
 bitant or continued use of the neutral salts, particularly common 
 salt, as well as the alkalies, have the same tendency. As regards 
 common salt, we see a striking proof of it in the production. of 
 scurvy with blood of this kind. The contrary, I know, has lately 
 been maintained by Stephens, whose authority is to be respected. 
 It is, also, very speedily occasioned by some poisons taken inter- 
 nally, and by the bites of numerous venomous serpents, and even 
 by the stings of several insects, and most promptly by a stroke of 
 lightning. The foregoing are examples of what I mean by 
 jjassive haemorrhage. 
 
 To the causes mentioned, others are to be added of a nature 
 accidental, accessory or exciting, as whatever, indeed, is calcu- 
 lated to invigorate or quicken the circulation, or the reverse, to 
 render it slow or sluggish, so as to direct to, or concentrate blood 
 on any one organ or part of the body. The most prominent of 
 these are: — 
 
 1st. Extreme heat, the operation of which is witnessed on the 
 first accession of the warmth of spring, or during the intense heat 
 of summer, and most conspicuously in persons who carry on their 
 occupations in close stove-rooms, or work immediately over fires. 
 It acts here, in the first place, merely as a stimulant accelerating 
 the circulation, and, secondly, by relaxing the integuments which 
 support the extreme vessels. 
 
 2d. Cold to the surface. The mode of its action is different 
 under opposite circumstances. Being suddenly applied, as in the 
 shower or plunging bath, a vast shock is given to the system, 
 and a corresponding impetus to the circulation with a centripetal 
 direction. But, where the application is gradual, there is an 
 accumulation of susceptibility and a reaction, with febrile excite- 
 ment, on an exposure to heat or any other stimulant. 
 
 3d. Diminution in the weight or density of the atmosphere. 
 The effect of it is illustrated chiefly in the ascent of elevated 
 positions, and which, I am aware, has been imputed merely to 
 inordinate exertion. We are, however, told by De Saussure, 
 who went to the top of Mont Blanc, the highest point of the 
 Alps, that, in a state of rest, among other effects which he expe- 
 
HEMORRHAGE. 159 
 
 rienced from the rare atmosphere, the blood gushed from his 
 nose, ears and gums; — and which is fully corroborated by Baron 
 Humboldt, by whom the mountains of South America were 
 ascended to their utmost pinnacle. It is, perhaps, wholly ascrib- 
 able to deficient atmospherical pressure. 
 
 4th. Exertions inordinately violent and other excitants, con- 
 duce to the same end — as running, leaping, fighting, lifting heavy 
 weights, — or eating or drinking in excess, or vomiting, coughing 
 or sneezing, — or bent positions of the head or body, — or ligatures 
 retarding the return of the blood, — or the suppression of discharges 
 from issues, or setons, or ulcers, — the repercussion of cutaneous 
 eruptions, or vehement gusts of passion, or emotions of any sort, 
 or ardent venereal desires kept from indulgence, &c. Caused, 
 however, in some of these modes, the case might not, perhaps, 
 come within the definition of spontaneous or vital haemorrhage, 
 which, as I have stated, must be independent of external violence. 
 
 5th. Haemorrhage may be owing to various morbid conditions 
 of parts from which it immediately proceeds, or as consequent 
 on similar states of other and remoter organs. Many of the 
 lesions of the lungs operate to this effect, those of the heart still 
 more, and of the liver, spleen, kidneys and uterus, in nearly an 
 equal degree. It is plain that the circulation in the main vessels 
 of an organ being impeded, the capillaries of it must become dis- 
 tended with blood, promotive of effusions. 
 
 6th. Gastric and intestinal irritation, especially from the habit 
 of constipation, exerts a similar influence by inviting an excess 
 of blood to the parts, and that of the mucous surface of the lungs 
 from inhalations of acrid particles, or by other irritants, among 
 which are an elongation of the uvula, enlargement of the tonsils 
 and ulceration of the fauces, by an extension of irritation to the 
 pulmonary tissue. 
 
 7th. As before remarked, haemorrhage is prone to a shifting of 
 position, and thus gushes out of another part — occasioned by 
 the sudden suppression of sanguineous discharges from artificial 
 interference, or by the course of blood being elsewhere solicited 
 by a higher degree of irritation, creating a predisposition to such 
 an afflux, as, among other instances, on checking the nasal, ute- 
 rine, and particularly the haemorrhoidal effusion, haemoptysis, 
 haematemesis or apoplexy, has speedily ensued. This is the 
 
160 HEMORRHAGE. 
 
 haemorrhage from metastasis, which, on some occasions, is very 
 profuse. 
 
 Mostly haemorrhage is referable to some positive lesion. But 
 this is not so in all instances, especially in relation to those ha- 
 bitual discharges to which I have just alluded, so regular in 
 their repetitions and salutary in their tendencies. These seem 
 to be owing to some original, inherent, constitutional idiosyn- 
 crasy, by which a particular organ is made, as it were, an 
 emunctory, to drain off a pernicious excess of blood. 
 
 No disease can be mistaken for haemorrhage where the blood 
 is voided outwards, which is now only mider consideration, and 
 hence, it were superfluous to say a word on the signs of discrimi- 
 nation. It may, however, be useful, in a practical view, to indi- 
 cate the means by which the different pathological states of the 
 affection itself are to be recognized. Even here a very few 
 remarks will suffice. Let it be recollected, as a general guide, 
 that, in the most active form, there is the evidence of a strong, 
 full circulation, with redundant, florid blood, which abounds in 
 crassamentum, and readily coagulates: in the less active, the 
 reverse, in some degree, of these appearances, it being thinner, 
 darker-coloured and seldom firmly clotted — while, in the passive, 
 to extreme debility is united either ensanguineousness, or the 
 blood exhibits a vast excess of serum, or otherwise is more fluid 
 and black. 
 
 Not a little may be learned in speculating on the probable 
 issue of the case from what has been previously said. The cir- 
 cumstances heretofore pointed out as influencing the event should 
 be carefully regarded. But, above all, we must attend to the 
 pathological condition by which the effusion is excited and main- 
 tained. Excepting the emissions be into occluded cavities, an 
 active haemorrhage may mostly be deemed critical and salutary, 
 and can only operate otherwise by excess at the moment, or by 
 too long prevalence. There is ordinarily integrity of constitution, 
 and relief is afforded to an oppressive degree of repletion. For 
 the most part, different are the effects of the weaker haemor- 
 rhages. No further expenditure of blood is here scarcely ever 
 admissible. 
 
 An absolutely passive haemorrhage is always to be dreaded, 
 it denoting a condition of things from which recoveries seldom 
 take place. Chronic haemorrhages, as arising usually from some 
 
HEMORRHAGE. 161 
 
 permanent irritation, are also of evil import — not so much, how- 
 ever, on account of their copiousness, as the organic lesion of 
 which they are the effect. 
 
 The anatomical characters of haemorrhage, as revealed on dis- 
 section, are considerably modified by the causes and the seats of 
 the affection, the gradations of its activity, or its passive nature, 
 and by the duration of the attack. These considerations, with 
 the summary I am now to offer, will suggest a general notion of 
 their appearances, and, on coming to the description of the special 
 haemorrhages, I shall describe them more precisely. 
 
 An acute haemorrhage, when profuse, sometimes leaves the 
 tissue, from which it has emanated, in a natural condition, the 
 pre-existing congestion or inflammation having been removed by 
 the draining out of the blood, or, owing to the same cause, it 
 may be preternaturally pallid and flaccid. Generally, however, 
 the pathological conditions mentioned are met with in various 
 degrees — sometimes the phlogosis is widely diffused, some- 
 times only stellated or streaked — while, on other occasions, the 
 vessels are merely turgid, or ecchymosed blotches, of different 
 sizes, are discoverable. It has been said that similar lesions are 
 pretty constantly found in the brain, though not the seat of the 
 effusion, and which might be presumed from the convulsions and 
 other cerebral affections caused by excessive losses of blood. 
 Experiments, in which animals were bled to death, have indeed 
 shown that the tissues of that organ, as well as those of other 
 structures, and particularly the mucous surfaces, are almost inva- 
 riably engorged, and hence a doubt may arise how far such a 
 state be the cause or consequence of the haemorrhagic effusion. 
 The appearances in the parenchymatous organs are simple en- 
 gorgement or infiltration, or larger extravasations of blood, and 
 seldom any phlogosis. 
 
 Chronic haemorrhages more uniformly present the phenomena 
 of inflammation or its effects, in the thickening or thinning, hard- 
 ening or softening, or other changes of texture, with diverse other 
 structural derangements, considerably influenced by the charac- 
 ter of the organ affected. Not much is known of the lesions of 
 the solids in passive haemorrhage — the most notable alterations 
 in these cases being in the circulating fluids, as previously indi- 
 cated. But they may be conjectured from the nature of the dis- 
 eases on which they are dependent. Designedly I have omit tod 
 
 14* 
 
162 HEMORRHAGE. 
 
 any account of those organic lesions of the heart, the lungs and 
 abdominal viscera, which so often exist. These are to be deemed 
 the causes, and not the effects, of the haemorrhage, and hence it 
 were inappropriate to notice them in this place. 
 
 In entering on the examination of the pathology of haemor- 
 rhage, it is proper to state that, in most instances, though not 
 always, it can be correctly viewed only as an effect of a pre- 
 existing anormal condition, which, in reality, constitutes the dis- 
 ease. Diversified as the causes of it are, they unite so far as to 
 excite an irritation in a part, invitatory of an afflux of blood — 
 and the congestion thus created is usually the immediate pre- 
 cursor to the effusion, and, perhaps, may be deemed its proximate 
 cause. But effusion not happening, phlogosis is apt to be set up, 
 and then a haemorrhage may ensue as one of the incidents to the 
 inflammatory process. This, however, comparatively, is a rare 
 occurrence, and, whenever it does happen, the discharge is small, 
 real and copious haemorrhage being the result of engorgement. 
 Much to the contrary, I am aware, has been said, without, how- 
 ever, any attention to the facts of the case. 
 
 Exactly in the same mode do the less active haemorrhages 
 take place. Local congestion of considerable intensity, and some- 
 times inflammation, may prevail, with general debility. Consi- 
 dering those periodical effusions of blood which, from long habit, 
 seem to become of the nature of a natural discharge, as a haemor- 
 rhage, they are to be embraced in the same view, since, evidently, 
 irritation and fulness are antecedents to the effusion, very analo- 
 gous to what happens in menstruation. 
 
 Of the active forms of this affection, in its several gradations, 
 such is the rationale. Existing, however, under the opposite 
 circumstances, of extreme depression of the vital forces, the emis- 
 sion of blood is usually without either of the pre-existing condi- 
 tions mentioned, flowing out, as it were, by a mere leakage of 
 the exhalents, or congestion ever happening, it is hypostatic, 
 proceeding merely from gravitation of blood into the more de- 
 pending parts of the body, neither of which can hardly be con- 
 sidered as operations of life. 
 
 Genuine or vital haemorrhage, it is now admitted, takes place 
 by anastamosis. No recent writer of any authority adheres to 
 the ancient notion of the rupture of vessels, though it is true that 
 there are some who still credit the conjecture of the transudation 
 
HEMORRHAGE. 163 
 
 of the blood. But this latter hypothesis receives, at present, no 
 general countenance, and the doctrine of exhalation may be 
 deemed amply entertained. This view, originally suggested by 
 Morgagni, was subsequently adopted by the celebrated Bichat, 
 whose arguments in support of it I shall cite from his work.* 
 
 He observes, — 1st. " That in no instance, where he has opened 
 the bodies of those who have died of vital haemorrhage, has he 
 discovered any traces of rupture of vessels, though he employed 
 the nicest care in washing and macerating the surfaces, and 
 examining them with a microscope. 
 
 2d. " That in squeezing the mucous surface of the uterus, in 
 women who have died in hasmorrhage, a number of small drops 
 of blood may be pressed out, which manifestly correspond to the 
 extremities of the exhalent vessels. 
 
 3d. "That haemorrhages sometimes take place from surfaces, 
 as the skin, where the blood indubitably comes from the exhal- 
 ents, and which renders it probable that the same is the case 
 with the mucous membranes. 
 
 4th. "That if rupture always preceded hasmorrhage, the in- 
 ternal surface of the womb would be a mere collection of cica- 
 trices, as we must suppose one or more ruptures to occur at every 
 monthly period. 
 
 5th. "That if in active haemorrhages, where there is evidently 
 a previous congestion of blood, we should admit the possibility 
 of a rupture, how can we suppose it to take place in passive 
 haemorrhage, where the powers of the vessels, almost destroyed 
 by disease, permit the blood to pass freely from their orifices. 
 
 6th. "That it is difficult to reconcile many of the phenomena 
 of haemorrhage, such as the extreme rapidity with which it is 
 sometimes produced, — its appearance in another part, when it 
 has disappeared from that in which it previously existed, and its 
 subjection to the influence of sympathy, — with the supposition 
 that it is produced by rupture. 
 
 7th. "The irregularity of the appearance of the blood in some 
 haemorrhages, — its copious flow in one instance, and its complete 
 cessation the next, and so alternately, many times in the course 
 of a short period, — are difficult to be accounted for on the princi- 
 
 * Anatomie Generate. 
 
164 HEMORRHAGE. 
 
 pie of rupture, for we must suppose the wound to be opened and 
 closed again at every alternation of the discharge. 
 
 Sth. "Comparing haemorrhages allowedly proceeding from 
 rupture, with others, they do not resemble them either in their 
 phenomena or duration — they are independent of all influence 
 from sympathy and the passions, which have considerable effect 
 on the common kinds." 
 
 This view which is here so ably argued, has been since com- 
 pletely established by the inquiries of Laennec, Chomel, Andral 
 and many other distinguished pathologists. 
 
 The usual objection raised against it, of its being scarcely 
 conceivable that so copious a discharge as is sometimes wit- 
 nessed, should proceed merely from exhalation, I do not think 
 has much force. Even from a very limited space the effusion may 
 be very profuse. As one, among many other examples of it, epis- 
 taxis suggests itself where enormous quantities of blood, on some 
 occasions, proceed from a very small portion of the lining of a 
 nostril. The same is predicable of most of the tissues, and is strik- 
 ingly illustrated in many instances by the cutaneous effusions 
 where, limited to a mere point, the loss of blood has been so enor- 
 mous as actually to have caused death. Further, — and with this 
 additional illustration I must be content, — not many years ago, I 
 attended with the late Professor Dewees, a young man, other- 
 wise in good health, who, for three successive days, lost about 
 three pints of blood daily from his gums. Both these and his 
 teeth were remarkably sound, to all appearance. By wiping 
 the gums clean, the blood was seen in a moment oozing out 
 from numerous pores. 
 
 What takes place in the exhalents, to which this effect is to be 
 referred, we do not know. To say, in the language of Bichat, 
 that it is owing "to a change in the activity of the capillaries, 
 as well as in the specific sensibility of the exhalents," were to 
 repeat a phrase meaning no more than that they are in a morbid 
 condition, preventive of the performance of their natural func- 
 tions, which is a mere truism. It is probable the phenomenon is 
 referable to some irregular operation of the nervous system, by 
 which there is a deficiency, inequality or other disorder of inner- 
 vation. Many of the circumstances of haemorrhage sustain this 
 view, which might, indeed, be very plausibly vindicated, had I 
 time to dwell on such speculations. Destitute, however, as we 
 
HEMORRHAGE. 165 
 
 may be, of any precise information on this point, it is still, per- 
 haps, not more obscure than many other parts of pathology. 
 The extreme vessels, in a healthy state, exercise the function of 
 secreting and throwing out a mucous, serous or some more 
 attenuated fluid, according to their respective offices. Becoming 
 diseased, this capacity is sometimes utterly lost, and blood which 
 enters them for the elaboration of these fluids, passes through 
 unaltered. As an illustration of this position, the case of menor- 
 rhagia is exceedingly striking. The uterine capillaries in health, 
 by a secretory action, convert the blood into a peculiar fluid, 
 denominated menses. In certain conditions, however, they are 
 deprived of this faculty, and pure blood escapes, constituting a 
 real haemorrhage. Lientery, also, affords an analogy which, 
 though remote, is still pertinent. Food received into the sto- 
 mach, in this affection, owing to a singularly irritable condition 
 of the alimentary canal, is hurried down, and evacuated without 
 any alteration from the digestive operations. 
 
 The hypothesis under view is further rendered probable by 
 the circumstance of the blood, in some cases being partially 
 changed, a sufficiency of it only remaining to colour the mucous 
 or other secreted fluid. We meet with such appearances in 
 haemoptysis, and still more frequently in dysentery. The evacu- 
 ations in this disease, which exhibit every variation from pure 
 mucus to nearly pure blood, surely can only be accounted for on 
 such a supposition. More explicitly stated, these various aspects 
 of the stools are owing either to gradations of diseased action 
 in the vessels of the same portion of the intestine, or while those 
 of one part may be secreting mucus, another is extravasating 
 blood, which, mixed together, present the complicated character 
 described. . 
 
 In a word, the doctrine I have endeavoured to expound sup- 
 poses that vital haemorrhage is an effusion from the exhalents 
 of some of the elementary tissues, and not at all occasioned by 
 rupture of the large vessels entering into the composition of 
 these or the substance of the organs. Even in cases where 
 blood is met with in the latter situations, as in cerebral and 
 pulmonary apoplexy, it is referable mostly to the same sort of 
 exhalation. 
 
 Of all the haemorrhages, those of the brain are most apt, it 
 is said, to be induced by rupture, which is attempted to be 
 
166 HEMORRHAGE. 
 
 explained as well by the peculiarity in the conformation and 
 arrangement of its vessels, as their greater liability to disease. 
 Granting this, still such events are comparatively rare. 
 
 To insist on the doctrine of exhalation, I have been led the 
 more strenuously, — for though now demonstrated to be true, 
 from long and general usage, a phraseology continues to be 
 employed by the profession and others that warrants a different 
 conclusion. As much almost as formerly do we hear of the rup- 
 ture, bursting or breaking of blood-vessels, in connection with the 
 occurrence of haemorrhage, which is inaccurate in itself, convey- 
 ing a mistaken pathological notion, and, among other evil con- 
 sequences, is well calculated to create unnecessary alarm. 
 
 Except, perhaps, the purely fibrous, every tissue is subject to 
 sanguineous effusion. 
 
 But in the mucous, in all its distributions, though especially in 
 the lining of the alimentary and pulmonary passages, it chiefly 
 takes place, and which may be accounted for as well from the 
 greater vascularity of this texture as by its freer exposure to 
 morbid agencies. Each one of the more common haemorrhages, 
 epistaxis, haemoptysis, haematemesis, haemorrhois, the vesical and 
 the uterine, in the unimpregnated state of the latter organ, belongs 
 to this tissue, and is thus induced. Those of the cellular mem- 
 brane are usually exhibited in the substance of organs into which 
 it enters as an interstitial tissue, though sometimes, in the sub- 
 cutaneous and other different portions of it, while the dermoid 
 mostly effuses in the shape of petechiae or vibices, or what is 
 called haemorrhea purpurea, from its greater extent, amounting 
 occasionally to real haemorrhage. Blood may, however, ooze 
 through the pores of the skin in place of the serous fluid in the 
 perspiratory process. 
 
 That haemorrhage is also incident to the serous membranes, 
 the arachnoid, the pleura, the pericardium and peritoneum, we 
 are assured, by extravasated blood having been found in their 
 respective cavities. 
 
 Formerly, haemorrhage was divided into active and passive, — 
 and on this pathological distinction, a controversy is now main- 
 tained, in which the latter state is utterly denied by one party. 
 This is really a dispute of definition, different meanings being 
 attached to the terms employed. The term passive, I am inclined 
 to believe, was adopted conventionally, to signify not an absolute 
 
HAEMORRHAGE. 167 
 
 want of action, as it strictly imports, but a weaker state, in con- 
 tra-distinction to that activity which belongs to febrile haemor- 
 rhage. Conceding that topical irritation and congestion may 
 exist with general weakness, and this is all which, perhaps, will 
 be demanded, I must still insist that extravasations of blood do 
 take place, though scarcely to be considered as genuine hemor- 
 rhage, in a state in which there is neither congestion nor action 
 in the vessels concerned. It is usually the result, as formerly 
 intimated, of the feebleness of vital power, affecting both the 
 vessels and the blood, the one being very relaxed, and the other 
 thin or wanting in consistency, — proofs of which are exhibited 
 in various diseases of exhaustion. As after death, where we 
 often meet with large livid patches on the surface, from sanguin- 
 eous exudations, as well as collections of blood within the cavi- 
 ties, which, as regards the former, we have ocular demonstration 
 that they did not pre-exist, so does it happen in the last expiring 
 efforts of life, under the circumstances stated. 
 
 The language of Andral, who is among the very highest 
 authorities, is very conclusive on this point. " The existence," 
 he says, " of vascular congestion is not essential to the production 
 of every species of haemorrhage. It is sufficient that the qualities 
 of the blood should be so modified, that its molecules lose their 
 natural form of cohesion, in which case the blood escapes from 
 its vessels with the greatest facility, and haemorrhages occur at the 
 same moment in different parts of the body, totally unconnected 
 with the presence of any irritative or inflammatory action. Ex- 
 amples of such haemorrhages are supplied in scurvy, in typhus, 
 and other diseases in which there is a certainty that the blood 
 has undergone such changes. How the vessels are modified, so 
 as to permit their contents to escape, is a mystery which we 
 cannot divine. But so much is ascertained, that the blood so far 
 from accumulating in them, constituting congestion, is permitted 
 to flow out as fast as it arrives." 
 
 As illustrating this principle, he adduces the analogies of the 
 profuse colliquative perspirations, in states of extreme weakness, 
 and also the cold sweats of death, to which he might have added 
 some instances of hydropic effusions. 
 
 To close, however, this controversy, let these different theoretic 
 views be subjected to practice, the fairest, and, indeed, the only 
 test of speculative truth. Do we, in any such case of feeble or 
 
168 HEMORRHAGE. 
 
 passive hemorrhage, resort to evacuant or depletory means? 
 But, on the contrary, are not ail our remedies of a tonic or even 
 stimulating character to restore tone and impart vigour to the 
 relaxed vessels and general system — and subsequently to such 
 means as are supposed to change and improve the character of 
 the blood itself? To an ordeal of this kind do I always bring 
 a theory. Before adopting it, I must see how it works in a sick 
 room. 
 
 An opinion at one time was very generally entertained, that 
 in early life, haemorrhage proceeds from the arteries, and after- 
 wards from the veins, plethora then being transferred to the 
 latter portion of the circulatory system. But some dissented 
 from it, and maintained that at every stage of existence, it is 
 mostly venous, when coming from the hepatic, splenetic, gastro- 
 enteric or hemorrhoidal vessels— while that from the nasal, pul- 
 monary and uterine, as uniformly to issue from the arteries. 
 Excepting maloena, and even this can scarcely be considered as 
 an exception, since the portal circulation is not strictly venous, 
 or admitting it to be such, it is still more probable that the 
 haemorrhage comes from the vessels of the alimentary tube, it 
 is quite certain, I think, that all genuine haemorrhages are of 
 an arterial nature. Distinct from other evidence to be here- 
 after cited when treating of the separate haemorrhages, such a 
 conclusion is to me irresistible, from the contemplation only 
 of the mode in which the effusion takes place, it being through 
 the capillaries performing the secretory and nutritive offices, 
 which are a part of the arterial and not of the venous system. 
 
 Coming to the practical portion of my subject, 1 am met, at 
 the very threshold, by the question, whether it is expedient, in 
 any case of haemorrhage, to interfere, or whether at all times it 
 should not be left to the uncontrolled efforts of nature ? 
 
 It was a doctrine, originally advanced by Stahl, in which he 
 was followed by his disciples, and some later authorities, that 
 these discharges are designed to remove a dangerous repletion 
 of system, which being sufficiently effected, they spontaneously 
 cease. That such a view, with certain limitations, is correct, 
 cannot be denied. Most haemorrhages of an active character are 
 undoubtedly salutary. It is also true, that the sudden checking 
 of the nasal and haemorrhoidal discharges is dangerous in a dis- 
 position to cerebral affection, as well as in fever, and many other 
 acute and chronic diseases. Nor can it be disputed that the 
 
HAEMORRHAGE. 169 
 
 flow of blood is often duly suppressed by the natural resources. 
 But admitting these postulates, it will still appear that we can- 
 not uniformly confide to nature the charge of such cases. Effi- 
 cient and wise, sometimes, in her endeavours, she is oftener the 
 reverse, and we are constrained, to prevent evil, to take the 
 management out of her hands. As an example, she frequently 
 neglects, or is not able, to give to these discharges a proper 
 direction, and instead of blood issuing from the nasal or rectal 
 vessels, it is poured into the cranial or some other occluded 
 cavity, from which it cannot escape or be removed. Not less is 
 her blindness or incompetency evinced in resorting, at all, to the 
 expedient, in enfeebled, or in permitting an excessive expenditure 
 of blood in other states of the system. The haemorrhage, too, 
 being copious, she cannot always, by syncope or by any other 
 means, afford relief. These, then, are the leading circumstances 
 demanding the interposition of art, and without which, indeed, in 
 numerous instances, the event must be inevitably fatal, 
 
 The leading indication, in all inordinately profuse haemor- 
 rhages, is to suppress the flow of blood, and when they are 
 active and febrile, it is done. 
 
 1st. By reducing the force of vascular action by evacuations, 
 and especially by bleeding, general and topical. 
 
 2d. By what are termed refrigerants, which may be external 
 or internal, the one consisting of cold applications and the other 
 of a set of medicines, so called, as nitrate of potash, &c. 
 
 3d. By the sedative articles, or such as are presumed to abate 
 the energies of the moving powers of the circulation without 
 any evacuation, as digitalis, Prussic acid, &c. 
 
 4th. By constringing the mouths of the vessels. Whether 
 there be a medicine with such a property is to me exceedingly 
 problematical, and, perhaps, does not exist. Yet it is supposed 
 that we are in possession of many, as certain preparations of lead, 
 of copper, of zinc, of alum, the mineral acids and kreosote, be- 
 sides several from the vegetable kingdom, as tannin or those 
 substances containing this principle. Directly applied to the 
 vessels, some of these are styptics — though acting through the 
 medium of the system, they probably have no such effect. 
 
 5th. Causing a revulsion in the circulating fluids, from the 
 affected part to one less interesting to the animal economy, is 
 another principle in the cure of haemorrhages, which occasionally 
 15 
 
170 HEMORRHAGE. 
 
 succeeds where the means are judiciously selected and well 
 timed. It is customary to recur to stimulating pediluvia, or sina- 
 pisms, or blisters to the extremities with this intention. 
 
 Excepting that evacuations, particularly by venesection, are to 
 be more limited, or sometimes entirely excluded, I am not aware 
 that there is any material difference in the means of meeting the 
 same indication in the less active hEemorrhages. Emetics, how- 
 ever, are here undoubtedly useful. 
 
 To prevent the recurrence of the affection, by guarding against 
 the exciting causes, and removing the pathological condition 
 which disposes to its production, is the second indication. The 
 latter may be found in some positive lesion of organs, requiring 
 a distinct mode of treatment, accommodated to the nature of the 
 case. But owing merely to the haemorrhagic diathesis or ten- 
 dency, the most effectual measure, perhaps, consists in such diet 
 as is the least calculated to fill the vessels with blood or excite 
 their movements. Care, at the same time, should be observed to 
 anticipate a repetition of the haemorrhage where it is menaced, 
 by a renewal of the means of direct reduction. 
 
 In the weaker state of the affection, we must endeavour to 
 invigorate the system and equalize the circulation, by the well- 
 regulated use of tonics, particularly the martial preparations, and 
 by a course of living co-operating to the same end, without, how- 
 ever, its having any heating or stimulating effect. Even in these 
 cases, local irritations or congestions must be watched and timely 
 removed by topical bleeding or vesication. 
 
 Much is to be expected from exercise as an auxiliary to diet, 
 in the prevention of each state of haemorrhage. Eminently has 
 it the power of promoting the secretions and excretions, of 
 renovating healthy action, and especially of re-establishing a just 
 equilibrium in the circulation, thereby obviating those local accu- 
 mulations which prove the proximate cause of the effusion. 
 Every thing else failing, an alterative course of mercury, very 
 cautiously conducted, has often succeeded in both forms of the 
 disease, acting as well by the restoration of healthy secretory 
 power, as removing visceral obstructions, constituting the remote 
 sources of the affection. 
 
 In regard to the purely passive haemorrhages, I have only to 
 say, that as incidents to a very low and depraved condition of 
 system, the treatment of them mainly consists in the correction of 
 
HEMORRHAGE. 171 
 
 the general vitiation from which they proceed. It may, however, 
 be added, that merely to check a flow of blood, the phosphorus, 
 the spirits of turpentine and kreosote, are thought to be singular- 
 ly well adapted, though it is with the turpentine only that I have 
 any experience. 
 
 As it usually appears, I think that too much importance is by 
 many attached, in the management of vital haemorrhage, to its 
 suppression. Great alarm is created by it in the individual him- 
 self, as well as in his friends, and from which the medical attend- 
 ant is not always entirely exempt. Every exertion is therefore 
 made to check it, and this being accomplished, the anxiety which 
 previously existed heedlessly subsides. Lulled into false security, 
 the patient is too often permitted to revert to his former habits, 
 without any permanent plan of treatment, till again awakened 
 to a sense of danger by a repetition of an attack, and in this way 
 he proceeds till the complaint is often irremediably fixed. Now, 
 the haemorrhage in itself is comparatively of little moment, for 
 the most part, indeed, beneficial, and the real object of attention 
 should be the correction of the condition giving rise to it, and 
 which by neglect, in numerous instances, leads to the most dis- 
 astrous consequences. 
 
 The general principles on which the treatment of haemorrhage 
 is to be conducted, having now been stated, it will be my next 
 duty to illustrate and enforce them in an application to each indi- 
 vidual case. 
 
 HAEMOPTYSIS, OR SPITTING OF BLOOD. 
 
 Taking this term in its literal acceptation, it is not at all signi- 
 ficant of the pathological state which it is designed to express. 
 As well might a catarrh be denominated an expectoration of 
 mucus or any other matter as this affection a spitting up of 
 blood. The act of sputation here is not always performed, the 
 blood, indeed, being more frequently ejected in other and very 
 different modes. Feeling the force of these objections, it has 
 been proposed to entitle this haemorrhage, pneumorrAdgia. But 
 this, as denoting merely a flow or discharge from the lungs, con- 
 veys scarcely a more precise or definite meaning. Far bettor are 
 the terms haemorrhagia pulmonum, hsemorrhoBa pulmonalis and 
 
172 HEMORRHAGE. 
 
 hsem : bronchia, which, indeed, are very expressive of the nature 
 and seat of the two forms of the effusion. 
 
 It is one of the most common of the modes of haemorrhage, 
 owing to the extent of the bronchial and vesicular surface, 
 through which the blood circulates, the exposure to the causes 
 of irritation, and the great liability of the lungs to congestion, as 
 well from their own lesions as those of other organs, and espe- 
 cially of the heart. 
 
 Numerous divisions of haemoptysis were formerly made, 
 founded on the difference of causes or the modes of production. 
 Discarding, however, these varieties as not belonging to vital 
 haemorrhage, recent pathologists have a distinction only in refer- 
 ence to the sources whence the blood issues, which are either the 
 mucous or parenchymatous tissues of the lungs. 
 
 Like all other haemorrhages, the one of which we are now 
 treating may be of an active character or the reverse,— and it 
 is the former that will claim our immediate attention. This is 
 usually ushered in by a sense of weight, sometimes of slight 
 pain or burning in the chest, particularly under the sternum — a 
 dry, hard cough — some shortness and difficulty of breathing — 
 tickling in the larynx, trachea or bronchi— a full, active pulse 
 and flushed face. But, on other occasions, the symptoms are far 
 more aggravated. Coming on with little premonition, for the 
 most part, though I have seen it preceded for some days by a 
 good deal of pectoral irritation, the attack is characterized by the 
 heaviest oppression, heaving of the chest— diaphragmatic or 
 abdominal breathing— tumid, purple or livid countenance — dis- 
 traction of mind — cold skin — dewy perspiration, particularly 
 about the face and neck— feeble, or a full, tumultuous circulation 
 — in the whole, presenting the aspect of the greatest distress and 
 most imminent danger. Death sometimes takes place in the 
 course of a few minutes, as I once witnessed myself, — and we 
 have heard of an individual who as suddenly died from it in our 
 theatre some short time ago. Thus characterized, it is probably 
 of the nature of pulmonary apoplexy, as it is called. 
 
 Cases, too, sometimes occur, introduced more decidedly as 
 fever. There is here a chill, with the pallid, constricted surface 
 — coldness of the extremities— pains in the back and loins — disor- 
 dered stomach — constipation and lassitude, followed, on reaction, 
 by a full, hard, bounding pulse, and much heat and excitement. 
 
HEMORRHAGE. 173 
 
 This may be continued, or betray more or less of an intermittent 
 type. The latter is not uncommon, of which I have seen some 
 instances, — the most remarkable of which was that of a lady, in 
 consultation with Dr, Mitchell, who, for eleven successive days, 
 had haemoptysis at nine o'clock precisely in the morning, always 
 preceded by a slight chill. Many, with the same type, are re- 
 corded, recurring daily, every other day, or fourth day, or week- 
 ly, or monthly ; thus conforming strictly to the law of periodicity 
 observed by intermittent fever or other diseases. 
 
 As an example of the quotidian form, Reil mentions the case 
 of a woman who had an attack of haemoptysis every morning 
 for two years, — and Thompson furnishes an instance of a tertian 
 that regularly returned for more than a year, — Burserius, one of 
 a quartan, that reverted with great exactness for a long time, — 
 and Richter saw another where the haemorrhage was repeated 
 monthly for twenty five-years. Tulpius, indeed, relates cases of 
 thirty and even forty years' continuance of this type. But here 
 the catamenia were suppressed. Lusitanus, Shenk, Meyer and 
 Mead, have reported similar facts, without, however, noticing 
 the state of the menstrual function, — and Blanchard had a case 
 reverting every three months, from an interruption of haemorrhois. 
 An attack of haemoptysis is very apt to be followed by others, 
 though comparatively seldom with any periodical precision. 
 
 In the mode, as well as in the quantity of blood discharged, 
 there is a difference. It sometimes comes up, attended by rat- 
 tling in the windpipe, as if the tube were stuffed with phlegm, 
 and by an irresistible propensity to cough, — which state of things 
 may terminate at once with a discharge of bloody sputa only, 
 or of a single mouthful of pure blood, or endure for a few days 
 or for a longer period. There are instances, probably, of pulmo- 
 nary apoplexy, in which it issues so copiously as to appear like 
 a stream from the mouth. Two quarts, at least, I once saw come 
 away in twenty or thirty minutes. Laennec says that he has 
 known thirty pounds lost in about fifteen days, — and, in another 
 case, ten pounds in forty-eight hours. To which may be added 
 the still more extraordinary instance given by Frank, of Vienna, 
 of one hundred and ninety-two ounces in twenty-four hours, 
 and that reported in one of the recent foreign journals of a larger 
 amount in a still shorter period, followed by ultimate recovery. 
 When so profuse, a sort of convulsive elevation of the diaphragm 
 
 15* 
 
174 HEMORRHAGE. 
 
 takes place, as in puking, which has probably led to the common 
 expression of vomiting of blood in this affection. 
 
 The causes, generally, of haemorrhage may occasion haemo- 
 ptysis,— though there are some which more particularly conduce 
 to this event. 
 
 1st. It is well ascertained that a predisposition to it is laid in a 
 certain conformation or structure. Thus, a narrow thorax and 
 prominent shoulders, a long neck, with a delicate make and san- 
 guine temperament, seem particularly to invite such attacks. 
 Connected, or otherwise, with such a configuration and tempera- 
 ment, this predisposition is often transmitted as an inheritance, 
 descending directly, or through intermediate generations, to the 
 whole, or greater part of a numerous family. On what it 
 depends is not always apparent, — though a strumous or tuber- 
 cular diathesis is mostly betrayed or may be suspected. 
 
 2d. The period of life is to be deemed a second cause of pre- 
 disposition. Haemoptysis rarely happens earlier than the twelfth, 
 and is not common after the thirty-fifth year,— chiefly prevailing 
 between the ages of fifteen and twenty-five, and especially at the 
 season of puberty. Cullen supposes this to be owing to a want 
 of due balance in the aortic and pulmonary circulations, from the 
 continuance of the growth and expansion of the thorax, after the 
 other portions of the body are completed, by which blood is 
 unequally determined to the lungs. 
 
 It may be, in part, at least, on this account, that females, in 
 whom the change is more conspicuous at the period of maturity, 
 are more liable to such attacks than males, though it appears 
 that at all times they have a much greater susceptibility to 
 this haemorrhage. The latter averment, I think, is sufficiently 
 established. With very few exceptions, this was the impression 
 from Galen till very modern times. Louis, whose authority 
 is high on such points, has stated the proportion very much 
 in conformity with my own observations, as three to two. 
 Frank, and some others, however, declare that men are more 
 liable to it than women, unless the catamenia be suppressed. 
 
 3d. That tubercles of the lungs predispose to haemoptysis is 
 indisputable. Nor, perhaps, is it less true that it is occasioned 
 by other derangements of these organs or of the heart, liver or 
 spleen, interrupting the freedom of circulation, as well, also, as 
 by gastric and intestinal irritation reflected on the lungs. 
 
HAEMORRHAGE. 175 
 
 4th. Certain classes of people are prone to haemoptysis from 
 their avocations or habits, among which are those who work in 
 a bent position, as tailors and shoemakers or clerks, constantly- 
 confined to their tables, as well as such as are exposed in their 
 operations to acrid or otherwise irritating inhalations. 
 
 The late Professor Rush tells us that those religious denomi- 
 nations who do not sing, and mostly worship silently, are very 
 subject to it, from weakness of lungs, owing to the want, in this 
 mode, of adequate exercise of these organs. My own experience, 
 however, does not confirm this observation. Living in the " city 
 of Friends/' I have seen no peculiar liability, in this description 
 of people, to be thus affected. Clergymen, on the contrary, are 
 exceedingly subject to haemoptysis, which has been ascribed, 
 though I think erroneously, to the performance of the services of 
 the pulpit. That it cannot be so, to the extent averred, is shown 
 by the comparative immunity of lawyers, legislators and lecturers, 
 each of whom harangue more constantly and loudly than preach- 
 ers. I have, in treating of phthisis, advanced a conjectural ex- 
 planation of this point. Be it as it may, the fact appears to me 
 unquestionable, that this haemorrhage is far more frequently to 
 be witnessed in connection with an undue exertion of the lungs 
 than the reverse, or the comparatively quiescent state, to which 
 an allusion has been made. 
 
 As regards public singers, especially those of the opera, where 
 the vocal powers are strained to the utmost, it is acknowledged 
 that they are singularly liable to haemoptysis, or if they escape 
 it, they soon begin to suffer from some pulmonary affection, 
 and either prematurely die or retire from their profession with 
 a shattered voice and infirm health. Three or four years, I was 
 informed by. one of them, are, perhaps, the average of the full 
 preservation of their powers. 
 
 5th. Nor are climate and particular localities without an in- 
 fluence in the production of this haemorrhage, it being most pre- 
 valent in the medium latitudes, where the weather is cool, damp 
 and austere, especially along the sea coast, and more in elevated 
 or mountainous than in flat districts of country. Yet, in the 
 absence of these and all other appreciable causes, an extraordi- 
 nary proclivity to the affection occasionally prevails, which, in 
 the present state of our knowledge, we must be content to re tor. 
 
176 HEMORRHAGE. 
 
 as heretofore, to the vague hypothesis of a hemorrhagic diathe* 
 sis in such cases. 
 
 Congenital or acquired predispositions are excited into action 
 by a variety of circumstances, or the latter may produce the 
 same effect without any such tendencies. Not the least common 
 of these, besides long or loud speaking or singing, already referred 
 to, are sudden bursts of laughter— paroxysms of anger or other 
 violent mental emotions — great exertions, especially raising heavy 
 weights — irregular habits of living — -the suppression of some 
 customary discharge, as haemorrhois, epistaxis or the catamenia 
 — the healing of old ulcers or the sudden cure or repulsion of 
 cutaneous eruptions — -the metastasis of gout or rheumatism — an 
 exposure to a heated and impure or very rarified atmosphere — 
 and, above all, the vicissitudes of weather, producing catarrhal 
 or other pectoral affections. I have frequently seen it proceeding 
 from the irritation of an elongated uvula, and sometimes, though 
 rarely, from enlarged tonsils. Cases, too, have been reported, 
 where an attack has followed the tying up of large arteries in 
 surgical operations, so as to throw on the lungs an oppressive 
 quantity of blood, and the loss of a limb, in the same way, more 
 constantly induces it. 
 
 Nevertheless, though haemoptysis is excited by the causes 
 enumerated, it is still true, however extraordinary it may appear, 
 that it occurs more frequently at night and in sleep, when, of 
 course, there is the least corporeal or mental agitation. Of this, 
 at least, I am persuaded that, of the cases I have seen, a majority 
 took place under the circumstances mentioned. 
 
 Whether it is to be imputed to an increased susceptibility, ac- 
 quired by the state of repose, as has been alleged, I shall not take 
 upon myself positively to determine. It is altogether a curious 
 fact, and has never, perhaps, been very satisfactorily elucidated 
 or explained. But I cannot help suspecting that it is referable to 
 the horizontal posture, and more particularly to the bending of 
 the lower extremities in sleep, which, unquestionably, have great 
 influence in determining blood to the lungs. 
 
 The mucous membrane, throughout its distribution in the 
 lungs, their appendages as well as in the fauces, being liable to 
 a sanguineous exhalation, it may be useful to distinguish the 
 immediate position of it. Generally, when the haemorrhage 
 proceeds from the latter structures, there is merely hawking 
 
HEMORRHAGE. 177 
 
 without any pulmonary oppression, cough or vascular excitement 
 — and, on examination of the throat, we may perceive that it 
 proceeds from that or adjacent parts. Coming, too, either from the 
 larynx or the fauces, &c., the amount, of blood is small — though 
 not always, as regards the latter structure especially. Examples 
 are numerously recorded, and some such I have witnessed, of 
 enormous and fatal losses of blood from the pharynx, the velum 
 pendulum palatai, the inside of the cheeks, the gums and the 
 tongue. But most of these cases were the result of acts of vio- 
 lence or of general depravity of system, or of the haemorrhagic 
 diathesis. 
 
 As to haemoptysis proper, it is, perhaps, impossible always to 
 discriminate accurately, by symptoms only, its two forms — that 
 of the mucous membrane, and of the tissue of the lungs. Being, 
 however, a pulmonary case, by which I mean an affection of 
 the lung itself, it is usually designated by all those characteristics 
 1 have mentioned as belonging to the most violent attacks of the 
 affection, coming on more suddenly, and with such intense op- 
 pression as even to threaten suffocation. 
 
 Nor can we uniformly rely on the external means of explora- 
 tion — though, by carefully weighing the respective indications, 
 much may be learned. In haemorrhage of the mucous mem- 
 brane, the chest, on percussion, is perfectly sonorous, and the 
 stethoscope betrays a mucous rattle, proportionate to the quantity 
 of blood retained in the bronchi. The former of these means in 
 the pulmonary engorgement, when it is considerable, elicits a dull 
 sound over the affected part — and the latter shows a want of the 
 respiratory murmur in it, and the crepitous instead of the mucous 
 rattle. Cases, however, are to be met with of great ambiguity, 
 and where these resources fail, as when the two affections are 
 united, or the engorgement is slight, or is seated in a portion of the 
 lung beyond the reach of percussion. Taken in any view, the 
 decision of the point is rather a matter of curiosity than practical 
 utility. But very different is it in regard to the chronic lesions, 
 tubercles, hepatization, &c, of which the effusion may be the effect, 
 and, happily, as it is important, so is it comparatively easy. He 
 who is skilled in the application of these means is enabled, at 
 once, to pronounce with tolerable certainty on the nature of the 
 affection, and to institute the practice best fitted for its removal. 
 
 It may be affirmed, as a general proposition, that the inactive 
 
178 HAEMORRHAGE. 
 
 is far more intractable than the active hemoptysis. There are, 
 however, other considerations by which the case is to be estimated 
 in this respect. The degree of danger is influenced by the posi- 
 tion whence the haemorrhage proceeds, and still more so by the 
 pathological condition with which it may be associated. Coming 
 from the larynx, it has been deemed the least alarming, and 
 which may be generally so, though sometimes of the most seri- 
 ous import. Being precursory to consumption, as it is apt to be, 
 probably the lungs are previously affected, the morbid action 
 ascending upward, or, as may be, the reverse, it descending till 
 the whole pulmonary system becomes engaged. Located in the 
 mucous membrane, copious as the effusions may be, little is 
 directly to be apprehended. Emanating, on the contrary, from 
 the substance of the lung itself, haemorrhage is almost uniformly 
 and speedily fatal : such, however, is happily of rare occurrence. 
 
 Caused by tubercles, or any other serious lesion of the lungs 
 or other organs, particularly the heart, an unfavourable result is 
 sooner or later to be anticipated, more, however, from the ante- 
 cedent lesion than the consequent effusion. Death, indeed, from 
 haemoptysis, as an immediate effect, is infinitely more rare than is 
 usually supposed. 
 
 Heberden informs us that, in a practice of sixty years, he never 
 lost a patient by it — and my own experience, which extends to 
 two-thirds of this period, supplies me with very few instances — 
 and none of these, I have reason to believe, were of the mucous 
 membrane. Three of the four fatal cases which I have seen 
 were, indeed, by a post-mortem examination, shown not to be so. 
 
 For the most part, haemoptysis ought to carry with it little 
 further terror than that excited by a suspicion, too often well- 
 founded, that it is an outward sign or expression of disease of the 
 lungs, and especially a tubercular state of these organs. Exempt 
 from such lesions, they seem, in some instances, to suffer no more 
 from haemorrhage than other parts — in proof of which 1 have 
 several very striking facts supplied by my own observations. 
 Cases have come under my care where the haemorrhage had been 
 repeated again and again for a series of years, which ultimately 
 did well — and there is no reason to doubt that a very distin- 
 guished person of this city, who died in his ninetieth year, was 
 subject to very frequent recurrences of it for nearly two-thirds of 
 his life. It was probably of a habitual nature, which is rather 
 
HEMORRHAGE. 179 
 
 salutary than pernicious. Yet, though the lungs may escape 
 from any serious injury, it were prudent, in most cases, to effect 
 a cure. The event itself shows an undue irritation in these 
 organs — for, without it, the afflux of the blood leading to the 
 effusion would not take place— and it is obvious that this is the 
 very state of things which, by continuance, is so apt to lay the 
 foundation of irreparable mischief. 
 
 Considering the diversity of condition on which haemoptysis 
 depends, the post-mortem appearances must, of course, be ex- 
 pected to vary. From the infrequency of death in that of the 
 mucous membrane, the phenomena are not precisely determined. 
 But we are not without some intelligence regarding them, and 
 the following has been reported. In the most simple cases, 
 caused merely by turgescency of the vessels of the tissue, little 
 is observable, excepting the surface covered more or less with 
 blood, which, being washed away, may present even a preter- 
 natural, pale or blanched appearance. But, sometimes, where 
 the effusion has not been sufficient to empty the capillaries, the 
 engorgement is continued. Connected with actual phlogosis, the 
 ordinary evidence of such a state in the mucous lining is exhibited 
 — and, being a chronic case, there are some changes of structure, 
 thickened and either softer or more indurated or condensed than 
 natural, with, occasionally, fibrinous concretions in the form of 
 polypi. 
 
 Extravasations taking place in the parenchyma, which, as I 
 said, is a very rare event, the appearances resemble very much 
 those in cerebral apoplexy. Looking at the lung thus affected, 
 we shall discover such portions of it circumscribed, from one to 
 two or three inches, of a very deep dark red colour, and of a 
 density equal to the completest hepatization. Cutting into these 
 portions, they are found to consist of concrete blood — the sur- 
 rounding tissue being crepitant and of the usual colour, or red- 
 dish, as if tinged with blood. More commonly than those masses 
 of clotted blood embedded in cells, is a general infiltration of it 
 into the alveolar and vesicular tissues, to the obstruction of respi- 
 ration and the causation of the sudden extinguishment of life. 
 
 These are the phenomena in the simplest states of haemoptysis. 
 But, in the more complicated forms of it, there are discoverable, 
 in different instances, besides tubercles in their several stages of 
 development, all those organic lesions to which the lungs are 
 
180 HAEMORRHAGE. 
 
 exposed. Extending, too, our researches further, we may find 
 the heart, the liver, spleen or other of the viscera variously dis- 
 eased, while the lungs shall sometimes escape — the irritation caus- 
 ing the effusion of blood being entirely of a derivative nature in 
 such cases. These are the prominent phenomena exhibited in 
 the solids. But the blood, also, may differ from that of health, 
 and seldom, indeed, is entirely normal. I have already alluded 
 to some of these changes as influencing the production of haemor- 
 rhage. But, while I believe they are mostly the antecedents of 
 the affection, I am equally persuaded of their secondary nature, 
 the direct consequence of an altered condition of the heart and 
 vessels from the haemorrhagic action. Frequently have I seen 
 blood which, at first, seemed perfectly natural, soon to become 
 otherwise in its aspect, its crasis and other respects. These 
 changes are best determined by an inspection of the fluid taken 
 away by venesection. Early in an attack of active haemorrhage, 
 it is very much such as in the plethora of the sanguine tempera- 
 ment. Not long afterwards, and especially if fever be set up, it 
 resembles that of the phlegmasia — henceforward becoming more 
 fluid and dark, with evidently a vast diminution of its fibrine, 
 and a corresponding increase of serum. The same changes in 
 kind, though less in degree, are observable in the weaker haemor- 
 rhages. Bleeding in the passive form of the disease not being 
 practised, we are debarred the opportunity of thus tracing the 
 changes in the blood. (Probably it undergoes none, or, at all 
 events, very slight, judging from that effused; and such blood, 
 never primary, is the invariable result of a persistent distempera- 
 ture of body.) What is its character has been so recently told as 
 not to require to be repeated. 
 
 Enough, perhaps, has been said in the preceding discussions, 
 to convey my views of the pathology of haemoptysis. Essen- 
 tially is it the same as that of haemorrhage generally, and as to its 
 trivial peculiarities, these need scarcely detain us. The mucous 
 membrane of the lungs is the seat of much the larger proportion 
 of cases, — and it might be added, of the whole of genuine spon- 
 taneous haemorrhage, with the exception of those of the cellular 
 tissue of the pulmonary structure, which latter are so exceedingly 
 rare, that I have seen only three, or, perhaps, four instances 
 of it. Even those proceeding from tubercles, or other organic 
 lesions of the lungs themselves, seem thus to be located — these 
 
HAEMORRHAGE. 181 
 
 lesions serving so to irritate the mucous membrane as to cause 
 the effusion. 
 
 In support of this doctrine, it were easy to extend the author- 
 ities on the subject, were it required. The language of Laen- 
 nec, however, is so emphatic that I cannot forbear to cite it. 
 " Haemoptysis," says he, "is now very generally considered as 
 depending on some functional derangement of the bronchial mem- 
 brane, which causes it to exhale blood, in place of its ordinary 
 mucous secretion/' — and speaking of the other form of it, he 
 remarks, that "it is evidently an effusion of blood into the paren- 
 chyma of the lungs, or, in other words, into the air-cells. From 
 its exact resemblance to the effusion which takes place in cere- 
 bral apoplexy, I have thought the name pulmonary apoplexy 
 very applicable to it.* Commonly the effusion is into the air- 
 cells, and may pass out through the bronchi, communicating 
 with the cells, though, occasionally, there is a rupture of the 
 substance of the lung, and the blood escapes into the cavity of 
 the pleura, of which Corvisart gives an example." 
 
 It is not, however, to be understood that the doctrine I am 
 sustaining, goes to the denial of haemoptysis in other modes. 
 That it may be induced by rupture from mechanical violence, 
 or by an aneurism of the pulmonary arteries or varicose state of 
 the veins, is certain, and, perhaps, scarcely less so occasionally, 
 when it attends the tubercular excavation or ulceration of the 
 lungs. But such cases seldom occur, and cannot be considered 
 as spontaneous or vital haemorrhage. 
 
 From the exhibition I have presented of the tendencies of 
 haemoptysis, it follows, that with the exception of the apoplectic 
 species of it, which always requires the most prompt relief, it 
 were of no great consequence to suppress it, unless the effusion 
 be excessive or occur in a debilitated system. Generally, it will 
 be found salutary, when moderate, producing very much the 
 same effect as the artificial detraction of blood, and often super- 
 
 * In passing on, I will merely remark, that this term is not original with 
 Laennec, as he seems to suppose. It was, I know, employed forty years ago, 
 by the late Professor Rush, to express those heavy congestions to which the 
 lungs are liable, in contra-distinction to pneumonia, an inflammation of the same 
 texture, and in this sense, has ever since been retained among us. Laennec, 
 however, I believe, was the first, to apply it to pulmonary hemorrhage, lie hav- 
 ing, too, the much higher credit of the original detection of this particular lesion. 
 16 
 
182 HEMORRHAGE. 
 
 sedes the necessity for it. Determined, however, from any con- 
 sideration to check the haemorrhage, the indication in the active 
 form of it is plainly to reduce vascular force or remove local 
 congestion or phlogosis, for which purposes venesection appears 
 peculiarly appropriate, and has the sanction of long and concur- 
 rent authority. Yet. some have objected to it,— and among others 
 the celebrated Heberden. Gravely is it put by him as a ques- 
 tion to be solved by medical ingenuity, how the opening of a 
 second vessel can check the flow from the one already ruptured? 
 Not to advert particularly to the erroneous predication of this 
 haemorrhage being dependent on rhexis or rupture, I shall re- 
 mark that this is a sophism unworthy of that candid physician. 
 Whatever might be the difficulty of explanation, he well knew 
 that the efficacy of bleeding had been amply demonstrated. 
 Really, it seems to me that the case involves no dark enigma. 
 Distinct from other modes in which it operates, such as the 
 reduction of the amount of blood and the force of the circulation, 
 by opeuing a vein in another part of the body, the flow of blood 
 is invited to it, and thus, on the principle of revulsion, contributes 
 largely to check the haemorrhage. The solution of the problem, 
 however, is immaterial. Bleeding is sufficiently admitted to be 
 useful, and with this, we may at present be satisfied. 
 
 To meet the more violent attacks, it is indispensably necessary 
 that the detraction of blood be large. Boerhaave says, "that 
 haemoptysis is cured by copious bleeding every third day, for 
 four times, or till the inflammatory crust disappears from the 
 blood." The latter clause of the aphorism is sound, and conveys 
 excellent practical advice, — though why this ternary recurrence 
 to the remedy? More, however, to be condemned are the small 
 and repeated bleedings advised by some practitioners. They 
 harass and weaken, without at all contributing to the cure. Did 
 this require any enforcement, it might be had in the history of 
 numerous cases on record, where such practice was pursued 
 ineffectually for a length of time, among which I have read an 
 account of one in a late number of an English journal, where 
 three hundred and fifty-seven ounces of blood were drawn away 
 in seventeen days. Now, a large bleeding would, probably, at 
 once have proved decisive, and all this time and exhaustion 
 spared. It is my practice, when called to a bad case of haemo- 
 ptysis, in which I think it expedient promptly to effect relief, to 
 
HEMORRHAGE. 183 
 
 take away directly so much blood as to make a decided impres- 
 sion, or, in other words, to attain the end for which it is designed. 
 Nothing short of this will be effectual in such haemorrhages. 
 
 By some of the authorities, it is recommended to restrict the 
 use of the lancet to cases only that are marked by fulness and 
 activity of the circulation, with vigour of constitution. But, 
 though here more urgently required, were the practice encum- 
 bered by such a limitation, the consequence would be eminently 
 pernicious. It so happens, indeed, that a large proportion of the 
 cases of haemorrhage, and of active haemorrhage, too, is attended 
 not so much by redundancy of blood, as an unequal distribution 
 of it, and this in individuals very far from being robust. Driven 
 into the lungs in this undue quantity, which they are unable at 
 once to return, and still more pushed on by the vis a tergo, 
 which this congestion increases, the blood must force itself out, and 
 continue to flow while such a condition of things endures. To 
 remove this topical accumulation, as well as to restore an equili- 
 brium in the circulation, venesection is the appropriate remedy. 
 We see it most strikingly evinced in cerebral apoplexy and in 
 many other analogous cases. 
 
 Nor, in another view, is the loss of blood less important. The 
 lungs, in active haemoptysis, are inflamed, or highly disposed to 
 take on inflammation. Cases are exceedingly familiar, which, 
 in the commencement exciting little solicitude, have, from a 
 neglect of this sort of depletion, run on to the establishment of 
 inveterate and even fatal lesions. Whether with a view, there- 
 fore, to immediate relief from the pressing evil, or as a measure 
 of prevention against more serious mischiefs, depletion in the 
 way and to the extent I have advised is imperatively demanded. 
 
 As a substitute for the lancet in less urgent cases, or on con- 
 siderable reduction by it of vascular force, leeches or cups to the 
 chest may be usefully employed. 
 
 Of the late writers, some seem to prefer the detraction of blood 
 from the remote parts, as the vulva or anus, on the principle of 
 derivation. Excepting, however, in those instances occasioned 
 by a suppression of the catamenia or haemorrhois, (and here. 
 probably, answering better, it should be adopted,) I think an 
 application over the seat of the affection is more certain and 
 advantageous. But it is maintained, and by very high authority, 
 that both topical and general bleeding, instead of proving reme- 
 
184 HEMORRHAGE. 
 
 dial, serve, on the contrary, sometimes to excite haemorrhage. 
 "I have noticed/' says Laennec, "a return of the menses, and 
 an increase of the menorrhagia during an application of leeches 
 to the epigastrium. General bleedings, more particularly those 
 of small extent, appear occasionally to have a similar effect on 
 haemoptysis." Clarke, one of the most respectable of the late 
 writers, also states, that in a plethoric person, threatened with 
 apoplexy of the brain or pulmonary haemorrhage, the use of 
 leeches may, and, he believes, frequently does decide the occur- 
 rence of the very disease it was intended to prevent, in proof of 
 which, cases are given by him. Creditably as the position is 
 sustained, I still doubt exceedingly the accuracy of the fact, and 
 am disposed to consider such occurrences as rather coincidences 
 than effects. They are, at least, contradictory to the tenour of 
 observation and experience. But while thus vindicating the 
 utility, and even absolute necessity of bleeding, I am no less 
 sensible that there are limits beyond which it ought not to be 
 carried. As in profuse or repeated haemorrhage itself, any great 
 excess in the operation is followed by the febrile movement, 
 unequal distribution in the circulation, with a tendency to further 
 effusions, or even, sometimes, to a general vitiation or cachexy 
 of system. Counter-irritation, by a vesicatory to the chest, will 
 supersede the necessity of any undue loss of blood, and, in every 
 view, is so important that it should not be neglected. 
 
 Cold applications to the thorax, and particularly under the 
 arm-pits, have been proposed as further means of suppressing 
 the haemorrhage. No part is more susceptible than the axilla, 
 and such applications are said to prove very effectual. The 
 origin of the practice may be traced to an Italian writer early in 
 the last century, who directs the naked breast to be covered with 
 sponges dipped in cold water. It has indeed been recommended 
 on very urgent occasions, to wrap the whole body in a sheet wet 
 with cold vinegar or water, or even to resort to immersion. The 
 late Dr. Thomas Bond, of this city, a distinguished, though an 
 eccentric, physician, is said to have pursued this course success- 
 fully. Bennet, on the contrary, tells us that the cold bath is 
 perilous. Two objections have been raised against the use of 
 cold in any way: that it is calculated to repel the blood from the 
 periphery to the centre, and thereby aggravate the haemorrhage, 
 and subsequently to induce catarrh or pneumonic inflammation, 
 
HEMORRHAGE. 185 
 
 the lungs at all times being exceedingly intolerant of cold, in 
 whatever manner applied, and the more so in a predisposed 
 state to disease. Nevertheless, such an impression on the skin 
 may, through the medium of sympathy, possibly constringe or 
 otherwise close the bleeding vessels, and thus operate bene- 
 ficially. An effect of this kind is conspicuously displayed in 
 uterine floodings, and it should also be recollected, that cold 
 applications to the surface are unquestionably sometimes of the 
 greatest service in the phlogosis of the contents of the other cavi- 
 ties of the body, which, on the same principle of driving the 
 blood inwardly, would, were it not for the lessons of experience, 
 be equally contra-indicated. The cold bath, however, I should 
 still very reluctantly try, except in the extremest emergencies, 
 and where other measures had utterly failed. 
 
 Greater authority have we for the use of cold drinks, which 
 seem to have been employed from the earliest down to the pre- 
 sent times. No one, perhaps, has borne such strong testimony 
 in their behalf as Martin Ghisi, he who first described croup. 
 Cases of the most profuse haemorrhage are reported by him, 
 which were very speedily checked by a repetition of a cup of 
 iced water every fifteen minutes. My own experience confirms 
 this statement to some extent. The swallowing of small pieces 
 of ice I have found, I think, still more effectual. 
 
 It was an early, and, for a very long time, an established prac- 
 tice, to apply ligatures to the legs, thighs and arms, promptly to 
 suppress the haemorrhage. "By this," says Van Swieten, "a 
 considerable part of the blood is retained in the limbs, and a 
 less quantity returns to the heart." Erasistratus probably intro- 
 duced the remedy, which has been commended by Moreton, 
 Lieutaud, B.urserius, &c.* Being abandoned, I presume it was 
 ultimately found not to answer the end, or came to be supplanted 
 by other means of superior efficacy. Of these, among the more 
 prominent, is the muriate of soda, a teaspoonful or more every 
 five, ten or fifteen minutes, in substance. Dissolved in the mouth, 
 and gradually swallowed, it is supposed to create a stronger im- 
 pression on the parts with which the vessels of the lungs have 
 the most intimate sympathy. 
 
 Few articles, perhaps, are more popular in haemoptysis than 
 the nitrate of potash. It is one of the most common of the do- 
 
 * Vid. Celsus. 
 16* 
 
186 HAEMORRHAGE. 
 
 mestic remedies in this city, and there is abundance of profes- 
 sional authority among the foreign writers in favour of it. From 
 its general properties, we should presume that it has no direct 
 control over a flow of blood. The quality of astringency it cer- 
 tainly does not possess. Yet it is often prescribed under such a 
 conviction and in a large quantity. As much as an ounce of it 
 has been given in the day. Thus freely exhibited, its utility 
 being confirmed, the explanation of its modus operandi must be 
 sought, I think, in the irritation caused in the stomach, by which 
 action is diverted from the pulmonary vessels. 
 
 Even better established, perhaps, is the reputation of the ace- 
 tate of lead. The mode of giving it is in the dose of a grain or 
 two, with a small portion of opium, at short intervals. Conform- 
 ably to our general notions, a large dose of the article ought, to 
 accomplish much more, and certainly it might be taken with 
 safety. Yet, on one occasion, I directed twenty grains of it with- 
 out any good effect. As in the case of mercury, may not the 
 action of the lead be influenced by the quantity? The former is 
 a salivant or purgative, according to the dose — and the latter 
 may prove astringent or otherwise, in the same way. More am 
 I inclined to think so, from having observed, in several instances, 
 where very large amounts of it had been taken through mistake, 
 that it operated altogether as a purge. There was, particularly, 
 the case of an Irish woman, which I saw, with a sore leg, who 
 had been directed to take an ounce of Glauber's salts, and to wash 
 the ulcer with a solution of two drachms of sugar of lead in a 
 quart of water. Endowed with the Hibernian propensity to 
 blunder, she reversed the matter, swallowing the lead and making 
 an application of the salts to the sore. Even this immense quan- 
 tity of the article had no other effect than to bring away a num- 
 ber of watery stools with some griping. 
 
 To the utility of one of the preparations of zinc, namely, the 
 vitriolic solution, a compound of the sulphate of zinc and the 
 sulphate of alumine, in this haemorrhage, we have the evidence 
 of Mosely, and of the late Professor Barton, strongly and unre- 
 servedly expressed. Of my own knowledge I can say nothing 
 in its favour, and on the same footing would I place the prepa- 
 rations of copper, so highly praised at one period. 
 
 By some practitioners the efficacy of another class of remedies, 
 the narcotics, is fully accredited. No benefit, I presume, would 
 
HAEMORRHAGE. 187 
 
 result from the henbane and hemlock, though commended. But 
 opiates promise more. It has been alleged against them, I am 
 aware, that they are stimulant, and hence improper in this case. 
 But, while granting this property to them, let it be recollected 
 that they have the effect of assuaging pain and doing away irri- 
 tation, by which excitement is so tempered that they may do 
 good, where, influenced by general principles, they would be 
 prohibited. Nevertheless, for a long period I was not prepared, 
 by my own experience, to vindicate to the full extent the pro- 
 priety of this practice. Whenever I directed it in the early stage 
 of haemoptysis, there was great irritation, attended with cough, 
 and here I thought the call for it indisputable. But, for some 
 years past, I have made a more general application of it, and, I 
 think, very successfully, to this and other haemorrhages. The 
 mode of operation of opiates has been partly explained in regard 
 to certain cases. Further must we look, however, to embrace the 
 whole of their beneficial effects. These are, probably, referable to 
 their peculiar action on the nervous system. It has already been 
 shown that haemorrhage is immediately dependent on an altered 
 condition of the capillaries, without which, indeed, blood could 
 not escape, ascribed to some defect of innervation. Now, by the 
 supply or rectification of this, it is presumable that opiates restore 
 the extreme vessels to their normal state, and arrest sanguineous 
 effusions. 
 
 Digitalis, from its influence over the circulation, has been ex- 
 tolled in active haemorrhages of every description. But as a 
 substitute for the lancet, for which it is proposed, I know it is 
 totally ineffectual, and ought never to be trusted. Even where 
 vascular action is reduced by direct depletion, it has appeared to 
 me very precarious, and decidedly inferior to many other reme- 
 dies. In the ordinary dose, much time elapses before the pulse 
 feels its influence, and, if it be increased largely, there is such 
 general prostration, with relaxation of the vessels, that a more 
 copious effusion may be apprehended. An egregious error has 
 been committed in the various applications of this medicine to 
 haemoptysis. The case to which alone it is suited will hereafter 
 be indicated. 
 
 Emetics have been employed in haemoptysis with great suc- 
 cess. My experience in regard to them is, however, chiefly 
 confined to less active ha3morrhage, to which I believe them sin- 
 
188 HEMORRHAGE. 
 
 gularly well adapted, and what I have further to say in regard 
 to them I shall postpone until I reach that part of the subject. 
 
 Doubting, as the generality of practitioners do, the propriety 
 of emetics in active haemoptysis, there is almost an undivided 
 opinion as to their utility in small doses. The whole of this set 
 of medicines may, perhaps, be applicable. Tartarized antimony 
 is much employed, particularly in highly febrile states.* 
 
 Generally speaking, however, ipecacuanha is preferable to any 
 of the antimonials. Distinct from the power which it in common 
 possesses with these preparations, of depressing vascular action, 
 it seems, also, to exercise a positive control over the haemorrhagic 
 disposition. Combined with the acetate of lead and opium, it 
 sometimes proves more efficient than either article separately. 
 
 Nothing has hitherto been said of purging, which, however, 
 whether we have regard to the reduction of vascular force, or the 
 removal of local congestion, or the irritation induced by consti- 
 pation, is not to be omitted. By Sydenham, who urged it to a 
 considerable extent, and with the very active articles, its value is 
 strongly insisted on. Laennec also affirms that a drastic cathartic 
 or enema frequently checks the haemorrhagic molimen, especially 
 if productive of faintness, and altogether highly commends the 
 practice. Castor oil, however, if the stomach be in a state retent- 
 ive of it, answers well. Magnesia, which is sometimes selected, 
 is apt, on account of its huskiness, by tickling the fauces, to excite 
 coughing, should be avoided, or very carefully comminuted and 
 mixed in the preparation. Much testimony might be collected, 
 in this country, in favour of the sulphate of soda in ounce doses, 
 as well to arrest promptly the flow of blood as to effect complete 
 cures. But hitherto its use has been restricted mainly to cuta- 
 neous haemorrhage, arising seemingly from some idiosyncrasy, 
 under which head I shall more fully speak of it. 
 
 The remedies mentioned, or some of them, at least, are those 
 of the highest repute, with the design chiefly of suppressing the 
 flow of blood. It is obvious, however, that, on the accomplish- 
 ment of this end, some further treatment may be demanded. The 
 system, for the most part, is left febrile, or, at least, too highly 
 
 * The exorbitant use of this article, after the mode of Razori, was tried by 
 Laennec, who reports that, though it appeared to lessen the discharge, it did not 
 produce the same admirable results as in the case of pneumonia and some other 
 purely inflammatory diseases. 
 
HAEMORRHAGE. 189 
 
 excited, and to do away this state, an important consideration, a 
 recurrence may be had. to the mild febrifuge remedies, among 
 which the antimonials are the best, alone, or with the nitrate of 
 potash. This is the occasion where I have principally used these 
 articles, and to which I deem them exceedingly appropriate. 
 Exciting diaphoresis or diuresis, especially, they hardly ever fail 
 of producing the most unequivocal advantage. To appease the 
 cough or pectoral irritation, opiates and demulcents may be re- 
 quired. 
 
 Meeting with considerable depravation of the primse viae, indi- 
 cated by the furred tongue, morbid secretions, habitual constipa- 
 tion, &c. , which is not uncommon, the proper treatment is by 
 three or four grains of the blue pill at night, worked off the next 
 morning by a laxative. 
 
 In place, however, of the active haemorrhage of which I have 
 now disposed, cases are to be encountered in a very opposite 
 condition of system. They are chiefly found among the valetu- 
 dinary, and especially those of scrofulous or tubercular tendencies. 
 Manifestations of incipient or more advanced consumption exist 
 in many instances. Together with a dry, diminutive cough, 
 hurried respiration and more or less pain or uneasiness of chest, 
 we have a quick, irritated or very feeble pulse, occasional hectic 
 flushes, much prostration of strength and a pallid or sallow skin, 
 with softness, flaccidity and bloatedness. The discharge of blood 
 may be small, in sufficient quantity merely to streak the sputa, 
 or perhaps a mouthful or two of it, and then ceasing for a time. 
 Extreme laxity of the exhalents existing, or proceeding from 
 congestion of the lung, it is copious, pouring in a stream, so that 
 a pint or more escapes. 
 
 In the cure there are mainly the same objects to be attained 
 as in the preceding form of the disease. The first is to check the 
 bleeding when profuse, and to which end the means before 
 enumerated, except the evacuant or otherwise depressing, may 
 be employed. Even these, however, are not totally to be ex- 
 cluded under certain circumstances. It may, indeed, become 
 indispensably necessary, where there is very heavy oppression, 
 to take away a small portion of blood generally or topically. 
 Dry cupping, however, in less emergencies, is sometimes very 
 advantageously substituted. 
 
 As an additional remedy, the spirits of turpentine should be 
 
190 HAEMORRHAGE. 
 
 mentioned, given in the dose of ten, fifteen or twenty drops, very 
 frequently repeated. The powdered capsicum, in four or five 
 grains, repeated in the same way, has also been recommended, 
 though its propriety seems to me very doubtful. From a scruple 
 to half a drachm of the nitrate of potash in an ounce of brandy 
 is very effectual, according to some recent reports. Without the 
 brandy, which is here proposed in rather a staggering dose, nitre 
 has long been prescribed, and with repeated success. Neither of 
 these two last remedies have I tried. Cullen praises alum, which 
 I have not found of service, — and the same remark applies to 
 certain vegetable astringents, as kino, catechu, &c. Greater 
 advantage may be derived from the elixir vitriol, ten or fifteen 
 drops at a time, adequately diluted in sweetened water, and much 
 has recently been said of the kreosote. 
 
 Frequently the most decisive of all measures is an emetic, the 
 modus operandi of which is not obscure, and the practice may 
 be vindicated h priori, independently of any evidence of facts in 
 support of the deduction of reasoning. 
 
 In haemorrhage there is a want of equilibrium in the circu- 
 lation, occasioning irregular determinations of blood, some one 
 organ being surcharged at the expense of other portions of the 
 system. The impression of the emetic, in conformity with an 
 old aphorism, " ubi irritatio, ibi afiluxus," probably invites pri- 
 marily a current to the stomach as a centre of fluxion, and 
 thereby immediately tends to exonerate the previously affected 
 organ from its oppressive congestion, — and secondarily by filling 
 the cutaneous vessels especially, re-distribates the blood, and 
 hence restores that just balance which had been subverted. 
 Effects like these from puking are very observable in the con- 
 gestive forms of fever and other acute diseases. In our late 
 typhoid epidemics, both of the winter and summer, how effec- 
 tual this process proved in relieving engorgements of the great 
 viscera is sufficiently known. Numerous were the instances 
 which I saw myself of its extraordinary success where the liver, 
 or the spleen, or the lungs, or even the brain was unduly 
 loaded. 
 
 But more than I have indicated is to be ascribed to emetics in 
 restraining haemorrhage. Nausea itself represses the force of the 
 circulation, and in some cases must be useful, — though it is to the 
 controlling influence over the whole of the capillaries, changing 
 
HAEMORRHAGE. 191 
 
 that condition which admits of sanguineous exhalation, that 
 their efficacy is mainly owing. As colliquative perspiration, 
 watery diarrhoea and hydropic effusion are sometimes arrested 
 by vomiting, so does it operate in haemorrhage. The exhalents 
 in all these cases, under certain circumstances, become morbidly 
 changed,— and a sanguineous or serous discharge ensues, accord- 
 ing to the peculiar modification of condition which may exist at 
 the time. 
 
 It remains only to detail some of the results of my experience, 
 in confirmation of the efficacy of the practice which has been 
 suggested, to be illustrated by a few examples. 
 
 In 1807, 1 was called to a young man of consumptive tenden- 
 cies, who, for several months, had suffered occasionally from 
 haemoptysis, and was treated by another physician in part by 
 digitalis. Being suddenly attacked with a copious effusion of 
 blood, he took before my visit an exorbitant dose of the medi- 
 cine which excited vomiting; the haemorrhage ceased, he became 
 convalescent, and ultimately recovered. Effects so decided I 
 did not then impute altogether to the act of puking. As often 
 happens from digitalis, an extremely distressing nausea con- 
 tinued for several days, to which I thought it probable the per- 
 manent benefit was in a considerable degree owing. 
 
 Encouraged, however, by the cure, and influenced, perhaps, 
 still more by theoretical notions of the nature of haemorrhage, 
 and of the applicability of the remedy to it, I resolved to subject 
 the practice to a further and fairer trial. 
 
 It was not long before I had an opportunity of doing so, in the 
 instance of a young man from the country, whom I had been 
 attending for several weeks, for pulmonary consumption. Three 
 years previously to my seeing him, he was compelled to abandon 
 the study of the law on account of the frequent recurrence of 
 spitting of blood — and when he came under my care was far 
 advanced in phthisis. One night he was aroused from sleep by 
 a repetition of the haemorrhage, and on my arrival had lost more 
 than a pint of blood without any diminution of the flow. Com- 
 mon salt, sugar of lead, and such like articles were used in vain, 
 — and bleeding, generally or locally, seemed inadmissible, from 
 the debilitated state of the system, and of the pulse especially. 
 Excepting an emetic I was nearly destitute of resource in this 
 emergency, — and accordingly twenty grains of ipecacuanha were 
 
192 HEMORRHAGE. 
 
 administered, which soon bringing on vomiting, the effusion was 
 suppressed. On several subsequent occasions the same means 
 proved equally effectual, though ultimately he died of the main 
 disease. 
 
 I had within a month a third case, which afforded me a further 
 opportunity of pursuing the practice, and of confirming my con- 
 fidence in its efficacy. It was that of a young woman, who a 
 considerable time before having suppressed her menses by an 
 exposure to cold, had ever since, at irregular periods, suffered 
 from haemoptysis. When I saw her, which was in consultation, 
 the haemorrhage had already existed for forty-eight hours, the loss 
 of blood very considerable, and she much exhausted. As the 
 usual remedies had been unavailing, I induced Dr. Stewart, with 
 whom I was attending, to try an emetic of ipecacuanha, which 
 put an end to the haemorrhage, and by proper management, 
 subsequently menstruation returned, and with it a restoration of 
 health. 
 
 More than thirty years have since elapsed, during which 
 lengthened period I have pursued this treatment, and with such 
 success as to have inspired great confidence in it. Like all other 
 means, it will sometimes fail, as might be expected from the 
 diversified nature of the causes and states of the haemorrhage. 
 But I am persuaded, when properly applied, it will be found to 
 do more than any thing else, and certainly from my own obser- 
 vations, it never produced mischief in the vital or spontaneous 
 extravasations. The emetic I have preferred, and, indeed, only 
 prescribed in these cases is ipecacuanha. 
 
 To treat haemoptysis in this mode is not a practice resting on 
 my authority exclusively. 
 
 Towards the middle of the last century it was strenously 
 recommended by Dr. Bryan Robinson, of Dublin, whose publica- 
 tion on the subject attracted great attention. To his evidence in 
 favour of it, might be added the attestations of several other 
 respectable writers. Cullen, however, having tried the practice 
 unhappily in a single case, probably from rupture, did much 
 towards its condemnation, from the great weight of his authority. 
 Neglected, it was not, however, entirely abandoned. We find, 
 on the contrary, it receiving the support of Maryatt, Stoll, Bur- 
 serius, Mosely, &c. Willis, too, so celebrated for his skill in the 
 treatment of mania, especially for the cure of George III. of 
 
HEMORRHAGE. 193 
 
 England, resorted to it freely, and declared that ample experience 
 had taught him to confide in it above all other means, as well on 
 account of its safety as efficacy. In this latter opinion, however, 
 I do not entirely concur. Cases of hsemoptysis occasionally arise 
 from rupture, by ulceration of vessels or mechanical violence, 
 to which it is not at ail adapted, and where, indeed, it might 
 prove aggravatory or even fatal, and such are not always readily 
 discriminated. 
 
 The second indication in this weak form of hsemoptysis is to 
 invigorate the system, and through it to impart tone to the re- 
 laxed or patulous vessels, and to rectify the state of the blood 
 itself. To attain this end, the various astringents and tonics are 
 usually called into requisition. Before prescribing any of them, 
 it were well, however, to be assured by a careful perquisition, 
 that no congestion or inflammation, or more serious lesions pre- 
 vail. The state of haemorrhage to which they are almost exclu- 
 sively adapted, is where the process of haematosis is badly 
 performed, or the system is rendered nearly exsanguineous by 
 previous losses of blood from haemorrhage or in any other mode, 
 that remaining being thin, pallid and impoverished, oozing out 
 chiefly from its own tenuity. Great disorder or pravity of system, 
 with the chlorotic or cachectic aspect, and extreme debility, are 
 here observable. 
 
 The Peruvian bark was formerly among the first of the articles 
 to attract attention. Many of the older writers confess its utility, 
 and there are some who extravagantly praise it. But I seldom 
 employ it, except in cases distinctly periodical in their nature, 
 and here the sulphate of quinine is much to be preferred. It 
 may be given alone, though its powers are sometimes improved 
 by a combination with the chalybeates, of the efficacy of which 
 much is asserted, and undoubtedly with justice. Eminently 
 calculated are they to improve the constitution of the blood itself, 
 and hence their utility in that species of haemorrhage, owing to 
 this condition chiefly. There is, however, a choice among the 
 martial preparations. The muriated tincture is said to be best, 
 though the carbonate, the sulphate or phosphate of iron answers 
 very well, and especially the last. Lately, the hydriodate, lactate 
 and citrate of iron have been also much praised. 
 
 Of the management of the idiopathic and more regular forms 
 of haemoptysis, I have now disposed. But it has anomalies 
 17 
 
194 HEMORRHAGE. 
 
 originating in some peculiarity of cause, which ought not entirely 
 to escape notice. Most of such cases are of a secondary nature, 
 and were pointed out in tracing the etiology of haemoptysis. 
 Emanating from the irritation of a tubercular or any other 
 essential pulmonary lesion, or derangement of the heart, or of the 
 abdominal viscera, the effusion of blood, incidental only, must be 
 subordinate to the pre-existing pathological condition, in every 
 rational or efficient scheme of cure. But the consideration of 
 these primary affections were alien to my present purpose, it 
 being reserved for the future. Nor can I, with propriety, do 
 more in this place than summarily to state that when haemoptysis 
 is owing to a suppression of the hemorrhoidal, catamenial or 
 other discharge, or the repercussion of cutaneous eruptions, or 
 the metastasis of gout or rheumatism, the endeavour should be 
 to re-establish these several affections in their original positions, 
 and then to aim at their eradication, — or excited by an elongation 
 of the uvula, or enlarged tonsils, or any affection removable by 
 a surgical operation, this is at once to be performed. 
 
 By prosecuting a course such as I have laid down, correctly 
 shaping it to the peculiarities of each case, we shall frequently 
 succeed in accomplishing a cure. Yet in some instances, and 
 especially when it is connected with constitutional or local im- 
 perfection, haemoptysis leaves behind it a liability to relapse on 
 the slightest provocation. To guard against these repetitions of 
 attack, a system of prophylactic instructions should be carefully 
 suggested and undeviatingly observed. 
 
 1st. The exciting causes of the haemorrhage must be pointed 
 out and avoided. Taking cold is the most common of these, 
 and at the same time is very apt to entail serious consequences. 
 But there are others scarcely less to be apprehended, and among 
 which are inordinate exertions of the voice. Let those espe- 
 cially, who are necessitated to pursue a profession dependent on 
 public speaking, be impressed with the importance of moderating 
 its tone. As one of many examples of the utility of this advice, 
 we learn that Atticus, the friend of Cicero, having acquired the 
 habit of vociferation, and suffering consequently from haemo- 
 ptysis, repaired to Athens, to be taught a more tempered and 
 graceful elocution, in which succeeding, he had an exemption 
 afterwards from the affection. 
 
 2d. In regard to regimen, some distinction is to be made, and 
 
HEMORRHAGE. 195 
 
 first as to diet. To the active form of the haemorrhage, vegeta- 
 ble matter, particularly the mucilaginous or farinaceous, is best 
 suited,— and to the other, light animal nutriment, as milk and 
 eggs, — and I have known malt liquors in moderation sometimes 
 to prove very serviceable. Exercise, in each instance, is of 
 importance, provided it be cautiously used, and the system pro- 
 perly prepared for it. On this point great errors are committed. 
 Not unusually, patients are ordered on horseback, or even sent 
 on a journey, with activity of pulse and febrile excitement. 
 From such mal-practice, a recurrence of the haemorrhage, with 
 aggravation, must inevitably result. 
 
 3d. To watch the state of the pulse and respiration. Either 
 thoracic pain or oppression, or any considerably increased force 
 of the circulation is a sufficient ground of apprehension, and must 
 be removed without delay. To effect the purpose, small bleed- 
 ings, general or topical, a still lower diet, a state of rest for the 
 time, some laxative or perhaps febrifuge medicine, and, in short, 
 the whole antiphlogistic plan in all its parts, may be demanded. 
 Where a slight haemoptysis is attended by a quick and irritated 
 pulse, and considerable mobility and weakness, digitalis has been 
 found useful. No longer admissible is the loss of blood, and 
 that article may be resorted to as a substitute, so administered 
 as just to affect the circulation, and keep it within its natural 
 standard. This is the case that I formerly promised to point 
 out, to which digitalis is, perhaps, only and certainly best suited. 
 
 4th. Great good has been experienced from a succession of blis- 
 ters, and these, where there is considerable pulmonary affection, 
 are to be applied to the chest: under other circumstances, they 
 will do very well on the extremities, acting as divellents. It is 
 to be borne in mind, that even in less active haemoptysis, though 
 there be general debility, local congestion, with sometimes in- 
 flammation, may exist, — and as the removal of these states is 
 of primary importance, the appropriate remedies, though deple- 
 tory ■, are not to be timidly withheld. 
 
 5th. In some very obstinate cases, a slight mercurial impres- 
 sion should be tried. The effect thus induced in the mouth 
 serves, it has been said, as a diverticulum to the diseased action 
 of the lungs. But more probably, by the general and revolu- 
 tionary operation of mercury on the system, it supplants the 
 disease, substituting its own peculiar action in place of it. To 
 
196 HEMORRHAGE. 
 
 those cases in any degree connected with obstruction of the chy- 
 lopoietic viscera, it is particularly adapted. An exception to 
 this practice is to be found in a tubercular state of the lungs, or 
 vitiation of the blood, formerly described, with which the use of 
 mercury is utterly incompatible. 
 
 6th. Emetics, occasionally repeated, are entitled to confidence. 
 They operate, by breaking up the habits and associations which 
 continue the predisposition, and are, also, well calculated to 
 emulge loaded vessels, and to distribute the blood equally 
 throughout the circulation. 
 
 Conduct, however, the treatment as we may, haemoptysis 
 sometimes presents itself, of a nature so stubborn, that it will resist 
 all these endeavours. Consulted, in such cases, we should advise, 
 as the very last resource, a removal to a temperate climate, and 
 by a voyage, when practicable. This has very often protracted 
 life, and even effected permanent relief, where every thing else 
 had failed, and under circumstances the least promising. 
 
 Of the treatment of haemoptysis, I have only a few words 
 more to say, and these regard the conduct of the case during 
 and immediately following the flow of blood. 
 
 1st. The moment we are called to it, a state of rest in bed is 
 to be enjoined, with the shoulders elevated and the lower ex- 
 tremities extended, for reasons before stated. 
 
 2d. The chamber is to be kept cool and well ventilated. 
 
 3d. Company should be excluded, and the patient not per- 
 mitted to talk. 
 
 4th. Diet to consist of small portions of demulcent drinks, acid- 
 ulated and drank cold. It is right that the stomach be not 
 loaded, as through it the lungs become oppressed. 
 
 5th. The bowels to be kept in a soluble state. 
 
 Not the least of the errors committed in the management of 
 this disease, is an attention too exclusive to the mere suppression 
 of the bleeding. The fact is, as previously stated, that such 
 haemorrhages are, for the most part, the efforts of nature to ex- 
 onerate the lungs of oppressive accumulations of blood, or to 
 reduce phlogosis, and, if not excessive, are probably as salutary 
 as epistaxis in the affections of the brain. They may, it is true, 
 leave some coagula or clots in the bronchial or cellular structure, 
 which sometimes do harm, and this seems to me to be the main 
 objection to permitting the effusion to continue. These remarks 
 
HEMORRHAGE. 197 
 
 obviously apply to haemorrhage of the mucous membrane only, 
 It is very different with respect to the other form of the disease, 
 where the consequences are so serious that it should be arrested 
 as speedily as possible. Cases, however, of this kind are so rare 
 that the principle is scarcely affected. No sound practitioner 
 doubts that, the haemorrhage of itself is comparatively of little 
 moment, the real object of attention being the correction more 
 especially of the morbid state of the pulmonary organs giving 
 rise to it, and which, if not timely arrested, results too frequently 
 in the full establishment of phthisis, or some other fatal lesion of 
 the lungs. 
 
 Contemplated in another light, the ordinary treatment of this 
 affection seems to me to be amenable to criticism. Governed by 
 no principle, pathological or therapeutic, it is empirical, or at 
 least tentative, every sort of nostrum or specific being tried to 
 suppress the effusion of blood. Genuine haemorrhage may be 
 mostly resolved into one or tv/o conditions, either inflammatory or 
 congestive, and to be managed accordingly, whatever removing 
 these states being best calculated to put an end to the effusion, 
 which is merely an effect. Guided by this view, and having 
 little confidence in those articles usually deemed peculiarly ap- 
 propriate, such as astringents, I seldom resort to them, preferring 
 to conduct the cure on common principles, and by common 
 remedies. 
 
 HEMORRHAGIA NARIUM, OR HEMORRHAGE 
 FROM THE NOSE. 
 
 This title should be adopted, as precisely expressive of what is 
 desired to be conveyed, to the exclusion of epistaxis, which really 
 has no meaning in its application to this affection. The latter, 
 however, having been conferred by Vogel, the nosologist, and 
 approved by Cullen, has ever since pretty generally prevailed, 
 and is the only one employed by the profession in Britain and 
 this country. Habit, I fear, has too strongly confirmed it to 
 admit of its being superseded. 
 
 Bleedings from the nose may be, as the other haemorrhages, 
 either active or otherwise. The first state is often preceded by 
 evidence of undue determination of blood to the head, as a sense 
 
 17* 
 
198 HAEMORRHAGE. 
 
 of fulness or tensive pain, vertigo, tinnitus aurium or other noises, 
 flashes of light before the eyes, which latter are sometimes in- 
 jected and red, a flushed, tumid countenance, heat and itching in 
 the nostrils, with even a slight degree of swelling, attended by 
 throbbing of the carotid and temporal arteries and activity of 
 pulse. It sometimes puts on a more distinct febrile character, 
 and here, previously to an attack, there is a cold fit, succeeded 
 by fever, or only alternate chills and flushes, observing, in the 
 return of the paroxysms, with more or less precision, the order 
 of regular intermittents, — while, in other instances, it comes on 
 without any premonition whatever, a gush of blood following 
 the slightest exertion or any excitement. The discharge may be 
 from one or both nostrils, though rarely from both, and, when 
 it does happen, is much larger from the one than the other. 
 
 As the vessels spread over the Schneiderian membrane are 
 exceedingly numerous, forming a complete reticulated texture, 
 with a thin and delicate covering and very much exposed, we 
 are, at all times, peculiarly liable to this haemorrhage, but it is 
 most common at an early age, again towards maturity and 
 on the decline of life. Menstruation occurring, a new train of 
 action is established, and it is comparatively seldom met with in 
 women where this function is uninterruptedly performed. 
 
 Distinct from the period of life, which certainly has an influ- 
 ence, the predisposition to epistaxis chiefly consists in a certain 
 conformation, — the short neck and large head, by which blood is 
 disproportionately invited to the part. It takes place, however, 
 under very different circumstances. Generally to be met with 
 in the full or plethoric, the opposite condition is not exempt from 
 its occurrences, provided there are irregularities in the circulation, 
 with special directions of blood to the head. Numerous circum- 
 stances conduce to the latter effect, among which are violent 
 exercises, certain efforts in a bent position, straining at stool, also 
 loud speaking or singing, or sneezing or coughing, playing on 
 wind instruments, exposure to intense heat or the reverse, cold, 
 and especially cold feet, stimulating ingesta, constipated bowels, 
 tight lacing or cravat. From loud sounds, as a clap of thunder 
 or the explosion of cannon, it has suddenly gushed forth, and, 
 sometimes, from very slight jarring noises. Blanchard says he 
 has seen it to occur by the ringing of bells. I had a friend at 
 Edinburgh who assured me that he was never exposed to the 
 
HEMORRHAGE. 199 
 
 screechings of the Scotch bagpipes without fulness of the head, 
 often leading to an effusion of blood, — and I have somewhere 
 read of an individual in whom the discords of music operated 
 as a sternutatory, beginning with sneezing and ending in the 
 escape of blood. 
 
 It is sometimes, too, excited by acrid fumes, and may be by 
 pungent or the blandest odours. I once knew an individual who 
 could bring it on by smelling cheese for only a few minutes, and 
 have heard of another in whom rotten apples had a similar effect, 
 Bruyerin, indeed, gives an instance where the soundest apple 
 induced it — and Rhodius tells us that it has followed the smell- 
 ing of a rose. Moreover, it is occasioned by mental emotions, 
 rage or terror, or a very excited imagination, or intense study, 
 or anxiety with insomnolency. 
 
 Caused by blows or falls, or other acts of violence by which 
 vessels are ruptured, so frequent a mode of its production, it does 
 not come within the definition of vital haemorrhage, and hence is 
 excluded from our present consideration. 
 
 But, in common with other haemorrhages, it is sometimes of a 
 secondary nature, induced by all those pre-existing lesions of 
 organs or structures heretofore enumerated. Especially, how- 
 ever, does it result from cerebral fever of high excitement — or 
 the reverse, the low typhoid conditions, and, above all, perhaps, 
 obstructions of the abdominal viscera, the liver, spleen, &c. It 
 may be added, that it is often consequent on the suppression of 
 the catamenial and hemorrhoidal discharges. 
 
 Mainly in these modes is epistaxis, in its several grades of 
 activity, produced, and, when purely passive, to which state I 
 think it more liable than any haemorrhage, it must be usually 
 assigned to changes in the blood itself, wrought by those circum- 
 stances formerly enumerated, by which the vital powers are 
 impaired and it rendered more fluid. But what I have said has 
 reference only to the etiology of epistaxis in its common present- 
 ations. Like other haemorrhages, it sometimes prevails so gene- 
 rally as to amount to an epidemic, and to this character I am 
 inclined to believe it is particularly disposed. The most remark- 
 able instance, perhaps, of such an occurrence, is to be found in 
 Morgagni, who states that, from its wide pervadence, a great 
 mortality took place from it in Tuscany and other parts of Italy. 
 
200 HEMORRHAGE. 
 
 During the year 1823, haemorrhage of every description, though 
 mostly from the nose, was observed among us, extremely copious 
 and difficult of suppression. No satisfactory explanation can be 
 given of these occasional wide-spread prevalences of haemor- 
 rhage. Certainly they are not owing to the excesses or variations 
 of temperature, or the usual states of the atmosphere. But the 
 latter may undergo some other change at the period, and, from 
 the well-known influence of its rarefaction in this respect, such 
 may be that change. 
 
 Epistaxis cannot be confounded with any other affection, and 
 the only concern as to the diagnosis refers to the discrimination 
 of its own varieties, having regard, in the first place, to the mode 
 of its production — and next, to its precise character and the state 
 of system with which it is associated. These are particulars so 
 easily learned by an investigation of the case, that the subject 
 may be dismissed without further remark. 
 
 Not in excess, the active form of this haemorrhage is to be 
 deemed salutary, whether it occurs in a general plethoric condi- 
 tion or in special determinations — and hence the relief from it, in 
 the excitement of fevers, and, perhaps, in every acute, inflamma- 
 tory or active congestive disease. No one who has not witnessed 
 it can well appreciate the effect of the loss of even a few ounces 
 of blood from this source, in the cerebral affections particularly. 
 An explanation, however, of the fact is afforded in the arrange- 
 ment of the vessels of the nasal lining. These are supplied 
 chiefly from the internal maxillary artery, which, inosculating 
 freely with some of the ramifications of the internal carotid, 
 blood is diverted from the brain, and its oppression mitigated or 
 relieved. But the consequence of this haemorrhage is very much 
 the reverse when of a less active, and, still more, of a passive 
 nature, or it is postponed to the advanced stage of these affec- 
 tions, having then only a tendency to increase exhaustion, and 
 is, indeed, mostly to be considered of fearful import. 
 
 Being active and original to the part whence the effusion takes 
 place, it is of easy management — and difficult or troublesome, 
 and even dangerous, under opposite circumstances, and the more 
 so if derived from obstructions or other organic lesions of the 
 thoracic or abdominal viscera. 
 
 Confirmed into a habit, it is uniformly to be dreaded. Hip- 
 pocrates remarks that, thus subjected, young persons are apt to 
 
HEMORRHAGE. 201 
 
 incur disease of the chest, as pleuritis, pneumonitis, haemoptysis 
 and consumption, probably owing to a metastasis of the nasal 
 irritation to the lungs. But such not taking place, it is held to 
 have a contrary effect, or preventive of pulmonary lesions. 
 
 By the long continuance of it the system becomes exceedingly 
 deranged and health impaired in various ways. Even the more 
 recent attacks of it sometimes present the most formidable aspect, 
 proving exceedingly intractable or utterly unmanageable. No 
 haemorrhage is occasionally more profuse, or in which larger 
 quantities of blood are lost, and, among other instances which 
 might be cited to this purport, Bartholin mentions a case of 
 forty-eight pounds within a period not given — Rhodius, another 
 of eighteen pounds within thirty-six hours — and a respectable 
 writer in the Leipsic Acta Erudita, a third, of not less than 
 seventy-five pounds within ten days. The Ephemera of Natural 
 Curiosities contains a case where the quantity is not stated, from 
 the difficulty of taking an account of it, which continued, without 
 cessation, for six weeks.* 
 
 In 1820 I attended an elderly gentleman who, during a night, 
 must have lost several quarts. He frequently fainted, on which 
 there was uniformly a suspension of the flow, recurring, how- 
 ever, on his revival. 
 
 Nearly about the same time one of our most distinguished 
 citizens died of this haemorrhage, after three weeks' continuance, 
 which the best skill could not control. As well from his general 
 aspect as that of the blood, which was thin and nearly colourless, 
 he must have become almost exsanguineous. More recently I 
 was consulted in the progress of such an attack, in the vicinity of 
 this city, which ended fatally. Cases of this kind usually occur 
 in persons advanced in life, and of very vitiated habits, having 
 their viscera, the liver or spleen, much disordered. They often 
 prove fatal. 
 
 Of the morbid phenomena, on dissection, in epistaxis, I have 
 no knowledge, so far as regards the immediate seat of it, the case 
 not being of sufficient importance to have attracted attention. 
 They may, however, be presumed, from analogy, to be such as 
 are presented in other haemorrhages of the mucous membrane. 
 Extraneous formations, as polypi, fungoid and other growths. 
 
 * Good. 
 
202 HEMORRHAGE. 
 
 or a varicose state of the vessels, which has also been observed, 
 occasionally productive of bleedings, are not properly incidents 
 to spontaneous or vital haemorrhage. In the secondary forms of 
 the affection we often discover great disorder of the thoracic and 
 abdominal viscera, the lungs, the heart, the alimentary tube, the 
 liver and spleen especially. 
 
 Nothing, perhaps, need be said of the pathology of epistaxis, 
 it being, also, in this respect, analogous to the haemorrhages of 
 other mucous surfaces, and hence I shall dismiss it with merely 
 suggesting the resemblances between it, in its active form espe- 
 cially, to apoplexy, in the causes and prelusive symptoms, the 
 direction of the extravasation of blood from the nostrils or brain 
 being determined, as it were, accidentally. This is one of the 
 most interesting views in which the affection can be contemplated. 
 
 Epistaxis exacts some difference in the treatment. 
 
 Connected with a state of vascular force or cerebral determina- 
 tion, the blood should be permitted to flow as an effort of nature 
 to afford relief, and when demanded, we have to call to her aid 
 venesection or local bleeding, and successively, the evacuant and 
 antiphlogistic measures of nearly every description. 
 
 To obviate a recurrence of this state of things, the same course 
 may be required to be pursued for a length of time, consisting in 
 occasional bleeding, purging, the liberal use of the nitrate of 
 potash, low vegetable diet, moderate exercise, and in the careful 
 avoidance of the exciting causes. 
 
 It has, indeed, been questioned, how far it is proper, under 
 such circumstances, to interfere at all with a haemorrhage usually 
 so beneficial. The fact is, that our exertions are intended for the 
 removal of the condition producing it, and which, if allowed to 
 remain, instead of this safe discharge from the nostrils, may occa- 
 sion a cerebral or some other effusion, where the consequences 
 become alarming or even fatal. 
 
 Epistaxis, however, is, also, of a less active nature, and is then 
 marked by no repletion of the circulation. The pulse is without 
 augmentation of volume or force, or may be considerably below 
 the natural degree in these respects, or small, quick and irritated, 
 denoting a debilitated system, and which is further manifested 
 by the pallid or sallow skin, cold feet, soft and flabby integu- 
 ments and loss of muscular power. The blood which escapes 
 is of a light colour and very thin, as if diluted with water, — yet 
 
HEMORRHAGE. 203 
 
 local congestion may here, sometimes, be detected. Cases of 
 this sort are exceedingly troublesome, the flow of blood being 
 often alarmingly copious and difficult to be restrained. 
 
 In the absence of all fulness or excitement, we are called at 
 once to suppress the haemorrhage, as any further expenditure 
 of blood is not allowable, and to effect which a variety of expe- 
 dients, regular or domestic, has been proposed. The patient 
 is to be placed sitting, in a cool situation, even in a draft of air, 
 with the head inclined backwards and the feet immersed in a 
 stimulating warm bath. Cold applications, as a cake of ice, or 
 cloths rung out of the coldest water, are next to be made to the 
 nostrils, or back of the neck, or to the genital organs, which last, 
 having great sensibility, such applications to them prove very 
 effective. Let, at the same time, the sides of the nose be pinched 
 by the fingers till a coagulum is formed. These means not 
 availing, dossils of lint, dipped into a solution of the sulphate of 
 alumine or the acetate of lead, or the sulphate of zinc, or cop- 
 per, or the muriate or sulphate of iron, or the infusion or tinc- 
 ture of galls, or kino, or the catechu, or the gallic acid, or the 
 kreosote or some other styptic, that of Ruspini particularly, which 
 I believe has much efficacy, should be pushed up the nostril. 
 Blowing some pulverulent matter through a tube into the nostril, 
 flour, or starch, or chalk, or Armenian bole, or charcoal, some- 
 times answers even better. The coal of a burnt cork, pulver- 
 ized, is particularly recommended by Sims, of London; — the dust 
 forming a coat over the surface of the membrane, chokes up the 
 mouths of the patulous vessels. 
 
 In very intractable cases the head may be dipped in cold 
 water, rendered intensely so by the addition of ice, which is said 
 to be decisive by Darwin and other authorities. 
 
 An immersion of the whole body in a cold bath has been ad- 
 vised, and we are not without evidence of its complete success.* 
 The patient, however, should continue in it for some time, so as 
 to attain the sedative effect, or otherwise the object would be 
 defeated by the powerful reaction excited by the sudden impres- 
 sion of the remedy. Yet it is the more common, in such emer- 
 gencies, to endeavour to effect compression, by introducing a 
 piece of sponge, properly shaped, into the nostril. This may be 
 
 * Philadelphia Journal of the Medical Sciences, vol. ii. 
 
204 HEMORRHAGE. 
 
 pushed in by a probe, or, where the bleeding proceeds from 
 vessels very high up, it is suggested to tie a piece of catgut to 
 the sponge, carry it through the posterior nares by a probe, and 
 out of the mouth, by which the sponge can be completely drawn 
 up. But though this is generally recommended, it will, I appre- 
 hend, be found exceedingly difficult in execution, from the ex- 
 treme irritation induced in the muscles of the pharynx, and is 
 altogether so uncomfortable, that it will seldom be submitted to 
 long enough to be of any service. I recollect that it was a 
 remark of Mr. Abernethy, in one of his lectures, that though he 
 had often tried to do it, he had been uniformly baffled in the 
 attempts. But, at the same time, he told us, that he had not 
 seen a case in which he did not succeed in suppressing the 
 haemorrhage, by a plug exactly shaped to the cavity of the nos- 
 tril, made of lint, first wetted and wound round a probe, which 
 may be withdrawn on the introduction of the lint, keeping the 
 latter in for several days. 
 
 But, perhaps, the simplest of all means of arresting the bleed- 
 ing has lately been suggested. It consists in merely closing 
 with the opposite hand the nostril from which the blood flows, 
 while the arm of the same side is raised perpendicularly above 
 the head. Neguier, of France, from whom the proposition comes, 
 declares that he has never failed with it, in a practice of three 
 years. To what credit he is entitled I know not. But the expe- 
 riment may be easily made, though 1 confess I have no con- 
 fidence in this expedient. Through the medium of the imagina- 
 tion, haemorrhages are often checked, especially the nasal, even 
 by charms, amulets or other impositions, and in the same cate- 
 gory am I disposed to place this remedy. 
 
 An emetic, except it be positively contra-indicated by great 
 exhaustion, I think ought to be tried in an emergency. It is 
 only in a single case, that of an aged and infirm man, that I 
 have ventured on the practice, — and though it did not succeed, 
 it was productive of no mischief. Emetics, however, on the 
 authority of Stoll, have been used advantageously. They some- 
 times prove very decisive in diverting blood from the head, — 
 and their control over the capillary system is not less established, 
 on which views we should be warranted in resorting to them, 
 independently of the positive testimony I have cited, or any 
 analogical conclusion from their efficacy in other haemorrhages. 
 
HEMORRHAGE. 205 
 
 To evacuations of the bowels, unless constipation exists, no 
 importance has been attached. But on every account, it seems 
 to me, that a strong impression by an active, even drastic cathar- 
 tic, promises well. The acetate of lead, and similar articles, 
 alleged to be so useful in most other haemorrhages, I do not think 
 exercise here any power. But I am strongly inclined to suspect 
 that opiates are of great value. For the last few years, I have 
 occasionally directed them with success. Lately, I witnessed 
 signal advantage from a dose of the Dover's powder, in a case 
 that previously had very obstinately resisted the customary 
 means, to which I was called in consultation with Dr. Jack- 
 son. The Dover's powder I have found to be incomparably the 
 best of the opiate preparations. How it operates, I pretend not 
 to determine with any precision. It may be by producing a 
 change in the nervous system, certain conditions of which must 
 undoubtedly influence haemorrhage, — though something, I think, 
 is also ascribable to the emetic substance entering into the com- 
 position of the remedy, as without it, neither opium nor its 
 simple preparations have an equally beneficial effect, — and this 
 conjecture is rendered the more probable, from the reputation 
 ipecacuanha, in small portions, has long had in the heemorrhagic 
 affections. 
 
 Having arrested the bleeding, the patient may be permitted 
 to repose in bed, with the head and shoulders elevated. But in 
 children, care ought to be observed that the blood is not flowing 
 through the posterior nares, as it occasionally does, when appa- 
 rently checked, producing much inconvenience. I have known 
 it to enter the trachea, and still oftener the oesophagus, and sub- 
 sequently coughed or puked up in considerable quantities. 
 
 To do away the disposition to a recurrence, which, in some 
 instances, is exceedingly inveterate, it is required to pursue a 
 course of prophylactic measures. As a leading part of the plan, 
 an endeavour is to be made to equalize the circulation, the 
 balance in which is often subverted by a tendency to the head, 
 and at the same time cautiously to recruit ihe tone and energies 
 of the system. The first of these purposes, provided there be 
 not too great debility, is met by purging, which is useful in the 
 affections of the head generally, and particularly so in this, from 
 torpor of the bowels usually attending it. Counter-irritation is 
 likewise serviceable^ and a. blister to. the nape of the neck has 
 18 
 
206 HEMORRHAGE. 
 
 of itself very frequently accomplished a cure. The application, 
 however, of vesicatories may sometimes be made to the lower 
 extremities, acting as divellents. 
 
 As a dernier resource, mercury, urged to a slight salivation, is 
 said to have been appealed to with advantage, in singularly 
 obstinate classes, though it is not to be indiscriminately employed. 
 Certainly, it would prove injurious in the cachectic condition, 
 dependent especially on a scorbutic or tubercular diathesis, and, 
 perhaps, is most or only appropriate when the attack proceeds 
 from lesions of the abdominal viscera. 
 
 During the progress of this treatment, it may be found, though 
 the general circulation be weak, there are manifestations of cere- 
 bral determinations, to relieve which cups or leeches may be 
 applied. 
 
 Thus having prepared the system, tonics, as the sulphate of 
 quinine, alone, or with the chalybeates or the mineral acids ? 
 and a nourishing, though temperate diet, with regulated exercise, 
 are to be directed. 
 
 Of the idiopathic shape of the disease, 1 have nothing more 
 to say. But it is also met with of a secondary nature, proceed- 
 ing from metastasis, or is the effect of diseased viscera, the liver, 
 or spleen, &c. It is plain, in the management of such cases, 
 having suppressed the flow, attention is to be called to the pri- 
 mary affection, to re-establish the hemorrhoidal or catamenial 
 discharge, or to remove the morbid condition of the viscus affect- 
 ed, as the one or the other may be the remote cause of the 
 haemorrhage. But I shall decline now pointing out the remedies, 
 as I should have to repeat what has previously been the subject 
 of ample discussion. 
 
 H^MATEMESIS, OR VOMITING OF BLOOD. 
 
 It were better to call it hsemorrhoea ventriculi. Even this 
 term, however, is wanting in precision, since the effusion of blood 
 sometimes remains in the stomach, even unto death, and on other 
 occasions is discharged upwards and downwards, resembling 
 more cholera, or by purging only. 
 
 For a long time it was supposed that the discharge here came 
 uniformly from the stomach. But it being ascertained that simi- 
 
HEMORRHAGE. 207 
 
 lar extravasations also take place from the intestines, the liver 
 and spleen, and are occasionally ejected by puking, the whole 
 of these cases have been comprehended under the same head by 
 Pinel, Good and some other of the modern writers. Even thus 
 extended in its meaning, the term haematemesis is still a very bad 
 one, expressive only of a symptom, and of that imperfectly. 
 
 Comparatively seldom is this haemorrhage an acute affection, 
 and when it does so appear, is, for the most part, the consequence 
 of some mechanical injury, and may be deemed of a traumatic 
 nature. Certain fevers, it is true, are attended by vomitings of 
 dark fluids, and which, though probably consisting of altered 
 blood, the case still differs in every material feature from haema- 
 temesis proper, and cannot fitly be brought into the same cate- 
 gory. 
 
 An attack of hasmatemesis sometimes comes on without any 
 premonition, the ejection of blood being the very first occurrence. 
 But oftener it is preceded by the ordinary signs of vomiting. 
 Nor is it unusual for those phenomena to pre-exist which belong 
 to the condition vaguely denominated dyspepsia. Except, indeed, 
 in the most acute seizures, we shall find anorexia or the reverse, 
 a voracious or an irregular appetite, oppression after eating, 
 sometimes tenderness of the epigastrium, furred tongue, in the 
 centre and at the root, with florid edges and tip, constipated 
 bowels, &c. Cases more inveterate are marked, also, by car- 
 dialgia, flatulence, sour, foetid eructations, palpitations of the 
 heart, dry skin, pale, or sallow and doughy, depressed spirits, 
 muscular weakness, and a feeble or small and corded pulse. 
 Mostly, under all circumstances, the attack is anticipated by 
 alternate chilliness and flushes, a sense of tension of the stomach, 
 and by burning or pricking in it, with weight and anxiety about 
 the praecordia, — nausea and confusion of the senses, — a dispo- 
 sition to syncope, and much jactitation, and depression of spirits. 
 
 Not a few of these latter symptoms, however, are referable to 
 oppression of the stomach from a mass of blood in it, collected 
 previously to vomiting, and it may be remarked in confirmation 
 of the conjecture, that on its being thrown up, the greatest relief 
 is for a time afforded. But unless the haemorrhage is checked, 
 the same train of affections recurs, till finally absolute exhaus- 
 tion takes place. The ejected blood varies, as well in quantity 
 as quality, — small, or extremely copious, dark or florid — the 
 
208 HEMORRHAGE. 
 
 latter not common — sometimes resembling tar in colour and con- 
 sistence, and, in other instances, like coffee grounds, or the sedi- 
 ment of port-wine. 
 
 But those instances excepted, proceeding from rupture of vessels 
 or a phlogistic action, it is almost uniformly black, grumous or 
 clotted. Fever is not common at this stage or subsequently, — the 
 pulse being slow, soft and compressible, or exceedingly feeble, 
 with cold, dewy skin, and lank, haggard countenance. Evidently 
 are the recuperative powers heavily oppressed — it is difficult to 
 raise any excitement, and still more to produce a complete reaction. 
 
 As suggested, however, the effusion in haematemesis may pro- 
 ceed from other of the abdominal viscera, or be vicarious to the 
 suppression of the sanguineous discharge in some remoter or less 
 connected organ. The upper portion of the intestinal tube being 
 concerned, the symptoms are nearly the same as in gastric haemor- 
 rhage, and issuing out of the lower bowels, mere is a sense of 
 weight and oppression, very characteristic in the hypogastric 
 and pelvic regions. 
 
 Emanating from the liver, it is entitled melaena or morbus 
 niger. Hippocrates considered the fluid as consisting of black 
 bile or grumous blood, and the same notion was long entertained. 
 The modern authorities, however, restrict these terms to haemor- 
 rhage only, including under them such as proceed from any of 
 the abdominal contents, by the mouth or anus, provided the 
 fluid be dark. 
 
 When the liver or spleen is the seat of the effusion, with a 
 loaded feeling, sometimes an obvious distension in the right or 
 left hypochondrium is observable, according as the one or the 
 other organ may be implicated, accompanied, in some instances, 
 by vomiting or purging, headache, sallowness of complexion, 
 particularly if the liver be concerned, some fever or entire absence 
 of it, a low and feeble pulse, a heated or cold surface, and occa- 
 sionally oedema of the face or of the lower extremities, or ascites, 
 or all. Yet I have known sueh haemorrhages independently of 
 any apparent disorder or vitiation of system, breaking out unex- 
 pectedly, owing, perhaps, to sudden engorgements of the portal 
 circulation. As to the phenomena of the vicarious discharges, 
 they require no special recital. An attack of these is usually 
 sudden, indicative of an afflux of blood to the stomach, produc- 
 
HAEMORRHAGE. 209 
 
 tive of the symptoms of the primary affection of that viscus, 
 with, at the same time, a suppression of the original discharge. 
 
 From whichever of the preceding sources it may come, the 
 quantity of blood evacuated is, on some occasions, enormous. 
 Cases of ordinary gastric hemorrhage frequently occur where 
 several pints are voided, and I have previously mentioned others 
 connected with ulceration of the stomach, in which the amount 
 was gallons in a few days. These latter, however, are, perhaps, 
 not vital hemorrhages. 
 
 Nor may it be less from the other structures. Examples are 
 recorded of immense discharges of blood under such circum- 
 stances, one of the most remarkable of which is that by Miche- 
 lotti in the Transactions of the Royal Society, for 1731, where a 
 young man with enlargement of spleen, threw up in two hours 
 more than twelve pounds of blood, and finally recovered. 
 
 In IS 13, 1 was called to a man from the country, for supposed 
 dropsy, whose abdomen was immensely distended and his lower 
 limbs oedemata us, and with general cachexy. The case being 
 equivocal, Dr. Hewson was brought into consultation, and very 
 soon after we saw him, an evacuation took place upwards and 
 downwards, particularly from the bowels, at first so copious and 
 incessant, that a succession of chamber pots was filled. The 
 evacuations continued for two weeks, though not as largely, till 
 finally about eight gallons were voided. The abdominal intu- 
 mescence progressively subsided, and in the course of a month 
 he returned home apparently doing well. Whether the liver or 
 spleen was concerned in this case could not be accurately deter- 
 mined, though the latter was suspected. 
 
 Nearly about the same time, I had under my care a mariner, 
 lately from India, whose case presented very much the same 
 appearance as the preceding, with, however, more unequivocal 
 evidence of hepatic affection. During my attendance on him 
 he was suddenly seized with vomiting of black, dissolved blood, 
 which scarcely intermitted for three days, when he expired, hav- 
 ing previously thrown up eight quarts, as nearly as could be 
 ascertained. 
 
 Not long afterwards I attended a case in the Almshouse In- 
 firmary, of chronic hepatitis, in which the discharge of the same 
 sort of blood, chiefly from the bowels, averaged a pint daily for 
 more than a fortnight, and which ultimately did well. 
 
 IS* 
 
210 HEMORRHAGE. 
 
 During the summer of 1829, 1 visited, with Dr. Rhea Barton, 
 an aged gentleman having jaundice, who, in twenty-four hours 
 evacuated probably three or four gallons of this grumous fluid. 
 He expired with it flowing from his bowels ; — and subsequently 
 I saw, with Drs. Parrish and Sharpless, a young man who, appa- 
 rently in good health, was suddenly and without any premoni- 
 tion, seized while walking in the street, with the same kind of 
 discharge, where the quantity could not have been less, in half 
 the period. Nothing which we attempted was of any avail and 
 he sank completely exsanguineous. It seemed highly probable 
 that the haemorrhage came from the liver. 
 
 In 1835, 1 had a case, with Dr. Morton, very analogous to the 
 foregoing one, in a young lady, who, in previous good health, 
 was awakened out of her sleep by a purging of blood so profuse 
 that, on my arrival, I found the bed filled with it. Continuing in 
 this way for the greater part of the night, till a prodigious, though 
 uncertain quantity escaped, it gradually ceased the next day, and 
 she recovered. There was here every manifestation of intestinal 
 haemorrhage. 
 
 Lately, I attended, with Dr. Pancoast, a distinguished member 
 of the bar of this city, who, for some time previously having 
 laboured under some slight symptoms of dyspepsia, was, without 
 any direct premonition, attacked with vomiting and purging of 
 dark, grumous blood, so copious that, in despite of our efforts, he 
 died from exhaustion on the third day, though the haemorrhage 
 was early checked. 
 
 Further instances might be adduced to illustrate the extent, 
 the danger, and even fatality of this haemorrhage. To account 
 for such immense losses of blood is difficult, — and were they not 
 so well attested, would be incredible. Yet they are not wholly 
 inexplicable. We are aware of the copiousness of the effusion 
 sometimes, from very limited external surfaces, of which we 
 have ocular proof, — and it is not improbable, that in the vis- 
 ceral cases, by chronic congestion of an atonic nature, an enor- 
 mous amount of blood previously accumulates in the affected 
 organ in a stagnant state, ultimately poured into the alimentary 
 canal. Every practitioner of experience has seen the whole 
 abdomen distended by such a condition of the liver and spleen 
 especially, — and there is an instance reported of the latter viscus 
 having weighed ninety-three pounds, and many of prodigious 
 
HEMORRHAGE. 211 
 
 dimensions. An escape of blood under these circumstances is 
 very different in its effects from the loss of it directly out of the 
 circulation, and resembles more the exhaustion induced by the 
 sudden abstraction of the extravasated fluid in ascites. 
 
 Diversified in its sources, many causes produce vomiting of 
 blood, from which, however, are to be excluded acts of violence 
 and all others by which vessels are ruptured— such not apper- 
 taining to vital haemorrhage. Even this differs in several parti- 
 culars which, perhaps, may deserve to be noticed. Females are 
 most liable to it from the commencement to the termination of 
 menstruation, and males at a more advanced period of life. The 
 former have it chiefly as an acute and the latter as a chronic 
 affection. Connected in the one with a plethoric condition and 
 florid aspect, it is exactly the reverse as to the other — the appear- 
 ances of leucophlegmasia, with a shattered constitution, being 
 presented. Exceptions, however, are common to each of these 
 general rules. 
 
 Gastric hsematemesis, when of an acute and primary character, 
 is excited by circumstances acting directly or indirectly on the 
 stomach; — among the former are certain acrid, harsh or stimu- 
 lating, poisonous ingesta — and of the latter, the influence of cold 
 and other circumstances of a general nature concentrating their 
 force on that organ and constituting it a centre of fluxion. Being 
 chronic, its production is referable mainly to those agencies to 
 which gastritis or dyspepsia is assigned. These I shall not now 
 recite, having done it in detail, on a former occasion, when treat- 
 ing of these subjects. 
 
 Of the other varieties it may be remarked that the enteric is 
 induced very much in the same way as the gastric, though more 
 particularly by harsh purging or constipation — those of the liver 
 and spleen, by whatever causes congestion or more permanent 
 obstructions of these viscera — and the vicarious, by a metastasis 
 from the hemorrhoidal or uterine vessels, or those of some other 
 organ, by which the hemorrhagic irritation is transferred. 
 
 From the history I have given it may be inferred that it is not 
 always easy to discriminate between the several localities of this 
 haemorrhage. Careful attention, however, to the more charac- 
 teristic symptoms of each will usually conduct us to a correct 
 decision. More readily may it be distinguished from haemoptysis, 
 which it sometimes resembles. It is seldom preceded or attended 
 
212 HEMORRHAGE. 
 
 by any pulmonary affection. No cough, dyspnoea or thoracic 
 pain exists, and the blood is often mixed with the ingesta of the 
 stomach and is brought up by vomiting. Nearly always it is, 
 also, of a dark colour — while that in haemoptysis of the mucous 
 membrane is so only in those rare instances where, owing to 
 excessive bronchial secretions, an imperfect decarbonization of 
 the blood takes place, from the atmosphere inspired not fully 
 reaching the air-cells. 
 
 Greater ambiguity will be experienced in the haemorrhage 
 incident to pulmonary apoplexy, from the darkness of the blood 
 and its being ejected, in many instances, by a sort of convulsive 
 effort somewhat imitative of vomiting. But here, among other 
 peculiarities, there is extreme thoracic distress, which is very dis- 
 tinctive. 
 
 In its ordinary result, vomiting or purging of blood, when 
 copious, is of serious import, as well from the immediate exhaus- 
 tion induced by it, as from its denoting certain organic lesions or 
 a general state of system not very manageable. There are, how- 
 ever, degrees of danger in these several occurrences. Caused 
 merely by a turgescency of vessels, the gastric haemorrhage is 
 alarming— and still more so if connected with any organic lesion 
 of the stomach. Not less applicable are these remarks to that of 
 the bowels. An effusion from the liver or spleen, as being most- 
 ly dependent on great derangement, is very apt to prove fatal. 
 Chiefly are recoveries from simple sanguineous congestion of 
 these organs. Effusions of florid may be held far more favour- 
 able than that of dark blood — the one arising from an active 
 condition and small in quantity, and the other the reverse in each 
 respect. 
 
 Examinations, post-mortem, we are told, show, in the very 
 active, acute, gastric and enteritic haemorrhage, the mucous mem- 
 brane of the stomach or bowels, or sometimes both, with diffused 
 floridness, or streaked, or stellated, or its vessels only injected. 
 But such appearances have been seldom noticed, and probably 
 are of very rare occurrence. An infiltration which is, sometimes, 
 so thorough that no washing removes the discoloration, may be 
 mistaken, too, for the redness of phlogosis. Much more com- 
 monly it presents a darkish hue, from venous congestion, with 
 patches of ecchymosis, though frequently otherwise, or of nearly 
 its natural complexion, the vessels being emptied by the escape 
 
HEMORRHAGE. 213 
 
 of the blood. Lesions of a chronic character are also to be met 
 with, sometimes a varicose state of the veins — or engorgement, or 
 inflammation in every stage of its progress— softening or indura- 
 tion of texture, thickening or the reverse— common ulceration or 
 scirrhosity and open cancer. But some of these phenomena can 
 hardly be considered as belonging to vital haemorrhage. The 
 liver and spleen, when they are the seat of the haemorrhage, are 
 found in every variety of condition, either mere engorgement or 
 the several grades of disorganization of structure, to the extremest 
 extent. 
 
 Of the pathology of this haemorrhage it is to be observed, in 
 the first place, that its occurrences, when very profuse, are gene- 
 rally of an inactive nature. The blood, in the gastric and ente- 
 ritic cases, comes from the exhalents of the mucous membrane — 
 and, in the hepatic and splenetic, it is supposed to proceed from 
 those of the interstitial tissue, passing out, in the former instance, 
 through the ductus choledochus, and, in the latter, from the ex- 
 tremities of the vasa brevia into the stomach— neither of which 
 is probable. Granting, however, that such may be the occasional 
 modes of its escape, it appears to me very clearly that the effu- 
 sion generally issues out of the mucous membrane of the ali- 
 mentary canal, caused by an irritation derived from the diseased 
 organs, exactly as they influence the production of serous and 
 cellular dropsies. More distinctly expressed, I mean that, when- 
 ever these great viscera are obstructed by engorgement or other- 
 wise, the capillary circulation of the neighbouring tissues becomes 
 also impeded, and, as a result of this condition, there is from the 
 exhalents either sanguineous or serous eliminations. Bichat has 
 advanced very much the same view, or that, "in consequence of 
 the impeded circulation through the portal vessels, the blood is 
 more strongly determined to the extreme arterial capillaries or 
 exhalents of the intestines, causing distension and effusions from 
 these capillaries.' 7 Dissection has, to a certain extent, demon- 
 strated the fact, so far at least as that, on many occasions, the 
 whole haemorrhage had proceeded from the enteric mucous sur- 
 face, where the reverse had been suspected, and no less indis- 
 putable is it that dropsy is occasioned, in like manner, by the 
 extreme vessels of the peritoneum being affected. To the adop- 
 tion of this hypothesis I am the more inclined, as affording the 
 only satisfactory explanation of the entire problem. For, though 
 
214 HEMORRHAGE. 
 
 blood may sometimes come from the liver through its ducts, how 
 can it get out of the spleen except by rupture of the viscus, and 
 then into the peritoneal cavity and not into the bowels? The 
 allegation of its transmigration by the vasa brevia really seems 
 to me very feebly sustained. 
 
 Commencing the treatment of hasmatemesis with that of the 
 stomach, I shall subsequently indicate the modifications of it 
 required by the other varieties of the disease. Called to a case, 
 however induced, with any activity of pulse or warmth of sur- 
 face, venesection becomes proper, to be followed or substituted, 
 according to the severity of the attack, by cups or leeches and a 
 sinapism or blister to the epigastrium. Consulted in time, these 
 remedies, with low diet and rest, will very often prevent the 
 haemorrhage. To check the flow of blood, the swallowing of the 
 coldest water, or of ice itself, and cold applications over the sto- 
 mach, are useful. To the same end various astringents are em- 
 ployed, as a solution of common salt or alum, or sugar of lead, 
 or white vitriol, or the muriated tincture of iron, or the sulphuric 
 or gallic acid, or the kreosote, or the spirit of turpentine. Ex- 
 cepting the last, which is undoubtedly serviceable, all the rest 
 are, in my opinion, very equivocal medicines. Even the turpen- 
 tine should not be prescribed when any height of inflammation 
 is suspected. 
 
 Emetics, in the absence of phlogosis, are entitled to the largest 
 share of confidence, and have been prescribed by me with signal 
 advantage. To the use of them I was led by the views I enter- 
 tained of the pathology of haemorrhage, and particularly of their 
 influence over the capillaries. More than any other process does 
 vomiting, from ipecacuanha especially, change that condition 
 of the exhalents which favours sanguineous effusions — though, 
 in this case, not a little also is to be ascribed to its removal of 
 large clots of blood by which the stomach is oppressed. Nor 
 should we be unduly intimidated or discouraged from a resort to 
 an emetic by the state of the pulse or general feebleness. This 
 is a condition commonly to be expected — and, so far as I have 
 seen, the recuperative energies are revived by the operation of 
 the remedy, and especially when a large amount of blood is 
 voided. 
 
 Two cases, out of a number in my possession, I shall select, 
 to exemplify the safety and utility of this practice. 
 
HEMORRHAGE. 215 
 
 In 1818, I had under my care a girl of eighteen years of age, 
 of a leucophlegmatic temperament, exceedingly distressed by the 
 train of dyspeptic symptoms already enumerated, who, while 
 under the common treatment for such affections, was in the night 
 attacked with a vomiting of blood. On my visiting her I learned 
 that, in less than an hour, she had thrown up about three pints, 
 and the haemorrhage continued, after I saw her, till nearly one 
 pint more was discharged. The usual astringent remedies were 
 unavailingly tried —and, as the exhaustion had become so ex- 
 treme as to menace speedy dissolution, I resolved on the use of 
 an emetic, encouraged by my experience of its success in some 
 former cases of less violence, and ipecacuanha was accordingly 
 exhibited very freely. Ejecting a large quantity of dark, grumous 
 blood, she soon after became composed — her pulse rose — the skin 
 resumed its warmth — and, before morning, I left her doing well 
 in every respect. No return of the haemorrhage took place on 
 this occasion — and in a few weeks she went into the country, 
 where I understood she completely recovered. 
 
 By a lady, who consulted me in 1827, 1 was informed that, 
 from the cessation of her menses, some six months previously, 
 she had been much afflicted by headache, burning sensations in 
 the stomach, praecordial uneasiness, tension and tumidity of the 
 epigastrium, nausea and periodical vomitings of small portions of 
 blood. 
 
 Her appearance, at this time, was valetudinary— and, on the 
 investigation of the case, I was confirmed in the suspicion I at 
 once adopted, that, if not arrested, it must inevitably lead to a 
 serious attack of hsematemesis. But she was prepared to take a 
 short journey — and, perhaps, confiding more in exercise and fresh 
 air than in medical prescriptions, it was agreed that they should 
 be postponed till her return to the city. Ten days afterwards my 
 prediction was verified, for, in getting out of a carriage, she was 
 seized with a vomiting of blood, repeated at short intervals, till 
 the whole amounted to several pints. Her pulse being active, 
 the skin tolerably warm, and some sensibility of the epigastrium 
 existing, the treatment was commenced by leeches, followed by 
 cold applications over the stomach and small portions of cold 
 acidulated drinks. No advantage resulted from these measures, 
 and, debility becoming alarming, she at length consented to take 
 an emetic, which evacuated some considerable masses of blood, 
 
216 HEMORRHAGE. 
 
 and, for several hours, she was greatly relieved. The vomiting, 
 however, again recurring, I had to repeat the emetic, which 
 proved very effectual. Convalescence henceforward took place, 
 and, by a properly regulated regimen chiefly, her health was 
 pretty well re-established. 
 
 Not much is to be found of this practice in haematemesis. 
 Excepting, indeed, some cases very analogous to those I have 
 related, which were successfully treated in precisely the same 
 way by Dr. Sheridan, contained in a late volume of the Dublin 
 College of Physicians, I have been unable to discover any notices 
 of it. 
 
 Concerning the other varieties of this haemorrhage, I have to 
 state that the treatment in the early stage of each is essentially 
 the same, adapted to the condition of the system and to the part 
 affected. Thus, in sudden and active congestions or phlogosis of 
 the bowels, liver or spleen, we resort to venesection or leech, or 
 cup and blister the centre or the right or left side of the abdomen, 
 according to the indication. Cold applications, even of ice, are 
 here also sometimes very beneficial. 
 
 Cases, however, of any activity of condition, and particularly 
 those of the viscera of the hypochondriac regions, are seldom 
 met with, and the detraction of blood, generally or locally, is 
 hence inadmissible. Cold appliances, too, seem to do harm, by 
 increasing the torpor of the venous circulation and thereby 
 aggravating the already existing congestion. Blisters and sina- 
 pisms I have found nugatory. The effect of an emetic, under 
 such circumstances, I cannot say, having no experience with it. 
 From its known properties, and its decided utility in analogous 
 instances, might it not be ventured in an emergency, and more 
 especially as our resources are so limited and precarious ? 
 
 On the whole, I have derived the most constant and unequi- 
 vocal advantage in all these cases, including the active states of 
 the haemorrhage, on a proper reduction by depletion, from the 
 liberal employment of the spirits of turpentine. More than thirty 
 years have I prescribed it, and am prepared to affirm that it is 
 deserving of greater confidence than any other known to me. 
 The same favourable opinion is entertained of it by many of my 
 medical friends, — and I have learned that Dr. Brooke, of Dub- 
 lin, a very distinguished practitioner, has lately reported several 
 cases of melasna treated successfully by it. My mode of giving 
 
HEMORRHAGE. 217 
 
 it, is the dose of from twenty drops to a drachm, repeated more 
 or less frequently, according to the exigency. 
 
 Being loaded and distended, it is urgently required to evacuate 
 the bowels. This condition is nearly always productive of ex- 
 treme depression of the vital powers, evinced by feeble circula- 
 tion, cold skin, heavy anxious breathing, and nausea or vomiting, 
 — all which may probably be relieved by the removal of large 
 quantities of grumous blood. Castor oil, with a portion of the 
 spirits of turpentine added to it, I deem to be best adapted to the 
 purpose. Even should no such accumulation exist, purging is 
 useful, and cannot be safely pretermitted, where constipation or 
 a tendency to it prevails. It is, indeed, said by the celebrated 
 Hamilton, that a species of hsematemesis, occurring in females in 
 early life, is promptly cured by it only. That this particular 
 haemorrhage, which is proved to have no connection with any 
 structural injury of the stomach, is a discharge vicarious to the 
 menses, has long been maintained, — and such is still my opinion, 
 since, among other reasons sustaining it, I have remarked in the 
 cases coming under my notice, either a retention or suppression 
 of the menses. 
 
 Transiently, it may be mentioned, that effusions of blood from 
 some part are very apt to occur on a sudden suppression of the 
 catamenia, — of which a case is related by Hufeland, of a woman 
 who, having the discharge checked by taking cold, fell sick the 
 same evening, and the next morning died. On inspection, three 
 pints of blood were found in the peritoneal cavity, without, how- 
 ever, any inflammation or other lesions in any portion of the 
 body.* 
 
 An instance very similar happened in my own practice, — that 
 of a girl, who, having imprudently gone into a cold bath while 
 menstruating, had the discharge stopped, and soon after was 
 seized with raving delirium, of which she died the next day, — 
 and on opening the cranium, large quantities of extravasated 
 blood were observed in several portions of the brain. 
 
 Hamilton, however, contends, that the heematemesis he alludes 
 to, proceeds from, or at least is mainly dependent on, a consti- 
 pated state of the bowels, the fseces brought off being always 
 copious and of an unnatural colour, consistence and smell. 
 
 The success of this, compared with the former mode of treat- 
 
 * Philadelphia Journal, vol. vii. p. 182. 
 19 
 
218 HEMORRHAGE. 
 
 ment, I will not take on myself positively to pronounce on, — 
 though I am inclined to believe that purgatives have been too 
 sparingly used in such cases. Certain it is, that in chlorosis, so 
 intimately associated with the haemorrhage before us, they are 
 among our most efficacious remedies. Governed, however, by 
 the view which I have expressed of the pathology of the case, it 
 being essentially vicarious, it has been managed by me accord- 
 ingly, having, as a principal object, the establishment or restora- 
 tion of the uterine function. 
 
 As to diet in these haemorrhages, some discrimination is de- 
 manded. During the flow of blood in the active form of them, 
 cold, mucilaginous drinks acidulated, or ice water, or ice itself, 
 in small portions, should only be allowed. But in an opposite 
 state, and especially under circumstances of exhaustion, which 
 often happen, more cordial and stimulating beverages become 
 proper, such as wine, or even ardent spirits diluted. On the 
 admission of food, care must be observed that it be of the mildest 
 kind, and very little taken at a time. This precept, of general 
 excellence, is especially so, as regards the affections of the stomach 
 and upper bowels. 
 
 To check, merely, however, this or any other haemorrhage, is 
 partially to perform our duty. It remains, still, to guard against 
 recurrences, which demands the ascertainment of the condition 
 giving rise to it, and the institution of an appropriate treatment for 
 its removal. Considering how often are the abdominal haemor- 
 rhages inseparable from the most serious lesions of the viscera, 
 such a course seems to be imperatively dictated. 
 
 HEMATURIA, OR VOIDING OF BLOODY URINE. 
 
 These are wretched appellations, not at all conveying a just 
 notion of the affection, which is really a haemorrhage that may 
 arise from the kidney, the ureter, bladder or urethra, and should 
 be designated accordingly, hsemorrhagium renum, hsemorrhagia 
 vesicae, &c. From its derivation, haematuria strictly means mix- 
 ture of blood, though the English phrase I have given is com- 
 monly adopted as its equivalent. The term hsematuria is dif- 
 ferently applied by the authorities, some using it to denote a 
 bleeding from the kidney only, calling that of the bladder cystir- 
 
HEMORRHAGE. 219 
 
 rhagia, while others embrace under it the sanguineous effusions 
 of the whole of the urinary apparatus, and in this extended 
 sense, it is now mostly employed and, for the present, will be 
 retained by me. 
 
 Coming from different sources, and occasioned by a diversity 
 of causes, the symptoms of this haemorrhage must necessarily be 
 exceedingly modified. Generally, however, it is characterized 
 by obtuse pain and sense of weight in the loins, sometimes 
 extending down the thigh, with, perhaps, retraction of the tes- 
 ticle, the urine at first high-coloured only, then of a darkish red, 
 owing to the dissolved blood, or tolerably clear with small clots 
 floating in it, or the discharge may consist of pure blood, black 
 and grumous, or be entirely suppressed from the urethra being 
 choked up by coagula. This occurring, the bladder sometimes 
 fills to a painful distension. Distinct, however, from such a con- 
 dition, there may be great uneasiness in that viscus, dull, heavy 
 or burning, or pricking sensations, and those of swelling in the 
 perineum, with frequent erections of the penis and spasm resem- 
 bling chordee, attended by tenesmus and strangury, or mictu- 
 rition. 
 
 Concomitantly with these local affections, some constitutional 
 disturbance generally exists, evinced by fever or at least an irre- 
 gular circulation and especially by headache and nausea, and 
 retchings. The symptoms, however, as I have said, are ex- 
 tremely diversified. On some occasions there is apparently no 
 affection whatever, except the discharge of blood, which passes 
 away without any suffering. 
 
 Like every other haemorrhage, this may proceed from general 
 or local causes, though of the former, instances are of rare occur- 
 rence. But it has been seen by myself and by others occa- 
 sionally to appear, consequent on a plethoric condition, with 
 undue determinations of blood to the parts. No doubt whatever 
 can be entertained of its connection with both inflammatory and 
 congestive fevers, as well as other acute affections, in which 
 some portion of the urinary organs has become involved. Cer- 
 tain articles, too, operating through the system, though from a 
 sort of specific affinity, concentrating their force more imme- 
 diately on the source of the haemorrhage, lead to its production, 
 — among which are phosphorus and cantharides, and in regard 
 
220 HEMORRHAGE. 
 
 to the latter, whether applied to the skin as a vesicatory or taken 
 internally. 
 
 As a further illustration of the sympathetic production of haema- 
 turia, it may be mentioned that it has been noticed as concomitant 
 on painful dentition in children, and excited by the irritation of 
 worms in the alimentary canal. More frequently, however, it 
 is met with from metastasis of the catamenial or haemorrhoidal 
 flux especially, or vicariously to these discharges. As incident 
 to intermittent fever, it has been occasionally remarked recurring 
 with the paroxysm and leaving in the apyrexia. Excessive 
 venery is a further cause of it, and instances are mentioned 
 where it was induced by vehement passions or emotions. 
 
 Nevertheless, haematuria is mostly to be traced to causes ope- 
 rating directly on the part, some violence done to the kidney by 
 blows or falls, or from lifting heavy weights, or leaping, or hard 
 riding. By the irritation of a calculus in the kidney or the ureter, 
 or bladder, it is also induced, and there is a case recorded of its 
 having been brought on by a worm in the second of these posi- 
 tions. Besides which, it is the effect of many organic lesions of 
 these structures, arising from the numerous diseases to which 
 they are exposed. 
 
 Every period of life is liable to this haemorrhage, from child- 
 hood to extreme age, though it is more constantly seen among 
 the old and infirm, broken down by gout or intemperate or 
 debauched habits. 
 
 Especially have I found the habitual use, in excess, of old 
 bottled Madeira wine conduce to this effect. Those, indeed, 
 who have long practised such indulgence seldom escape lesions 
 of the kidney. From new cask wine of the same kind, much 
 less, and very often no similar injury results. Even when the 
 affection existed, I have, in several instances, known it to cease 
 by the substitution of the one for the other wine. Differently 
 in these two states do they operate in several respects. The old 
 seems to be retained, and uniformly distresses the nervous system 
 severely, while the new goes off by the excretories in the form of 
 perspiration, urination or alvine evacuations. 
 
 It may happen where the amount of blood is small and tho- 
 roughly commingled, or it has undergone some change in its 
 constitution, thereby rendered more pallid, or the urine becomes 
 of a more reddish or darker hue from an excess of its saline 
 
HAEMORRHAGE. 221 
 
 ingredients, or of lithic acid, a case is presented of some difficulty 
 of discrimination on a superficial examination. But here, we 
 are supplied with a test of great certainty. Dipping a piece of 
 linen into the fluid, however minute the quantity of blood, it is 
 stained of a reddish tinge, which does not take place otherwise. 
 
 Not so easy is it at ail times, to determine the precise part of 
 the urinary apparatus whence the blood escapes. As a general 
 rule, however, it will be found in the renal and uretral cases, 
 that, with much more lumbar affection, the blood is usually inti- 
 mately mixed with the urine so as to give to it one uniform red 
 appearance, whereas, in the vesical haemorrhage it comes away 
 in clots or flocculi, floating in the urine, and is accompanied by 
 pain, a sense of fulness and tenderness of the pubic region, and 
 those other indications of an affection of the bladder. No per- 
 plexity can exist with regard to that of the urethra, for inde- 
 pendently of the absence of the symptoms appertaining to the 
 other cases, the blood is emitted without mixture with urine, or 
 any effort to its evacuation. It were fortunate could we come to 
 any satisfactory conclusion concerning the several pathological 
 conditions giving rise to this haemorrhage. But sometimes it 
 cannot be done, though much, in other instances, may be accom- 
 plished by a diligent investigation of the history of the case and 
 comparison of symptoms, as well as by a careful inspection of 
 the urine, which, containing mucus or pus or gravelly deposits, 
 considerable light is shed on the subject. 
 
 Excepting in those acute cases, in a sound and vigorous con- 
 stitution, owing to a general redundancy of blood, or local accu- 
 mulations of it, or its occurring metastically or vicariously, and 
 here, if not salutary, it does little or no injury, haematuria is to 
 be deprecated, not so much from any danger in itself, as its indi- 
 cating some serious derangements of the organs whence the 
 haemorrhage proceeds. Nevertheless, it may be immediately 
 alarming in appearance, from an immense loss of blood. 
 
 In the winter of 1831, I attended an elderly gentleman of a 
 very full, plethoric habit, who voided, on an average, about three 
 quarts of nearly pure blood in the twenty-four hours for three 
 successive returns of this period, and which continued in a dimi- 
 nished quantity till he became nearly exhausted. 
 
 Not many months afterwards he had a repetition of the attack, 
 in which he lost, in the aggregate, perhaps an equal amount of 
 
 19* 
 
222 HEMORRHAGE. 
 
 blood, though not in so short a time. Many recurrences of it 
 had he subsequently, on each occasion profusely, till he died, 
 which was not, however, of the haemorrhage. Death, indeed, 
 from it very seldom happens. The register of the Vienna Hos- 
 pital shows only a solitary instance out of thirteen thousand six 
 hundred and forty-seven cases of the affection. 
 
 Effusions from the kidneys and bladder are of course the most 
 copious. Being, however, of a vital character, they either spon- 
 taneously cease or are readily checked, and seldom prove detri- 
 mental. But it is very different with the physical, or those 
 dependent on organic derangements. The cause here enduring 
 permanently, so must the effect, or if the latter be removed, it 
 is temporarily, reverting again at no distant interval. The most 
 ominous occurrence, however, of hematuria, is in the advanced 
 stages of low fevers and other diseases of extreme exhaustion. 
 But this happening, it is purely passive, a mere leakage of blood 
 from the impairment or still feebler exertion of vital power, and 
 can scarcely be deemed a genuine haemorrhage. On the whole, 
 our prognosis must be derived from the estimate formed of the 
 condition of the parts and the system generally with which the 
 haemorrhage may be associated. 
 
 Of the autopsic phenomena in the acute and vital form of 
 hematuria, I have no precise information. They may, however, 
 be conjectured from the history of the disease, varied by the seat 
 and cause of it. The kidney itself probably presents similar 
 appearances to those in other parenchymatous haemorrhages and 
 the ureters, bladder and urethra, such as are observed in the 
 mucous membranes generally. But in chronic cases, every va- 
 riety of disorganization of structure of the kidney and bladder 
 especially, has been reported. 
 
 Equally may its pathology be deduced from analogy, and I 
 shall, therefore, occupy little time on a point, the discussion of 
 which were merely a recapitulation of what has been, on pre- 
 ceding occasions, amply expounded. Excepting the cases caused 
 by acts of violence or organic changes, every other may be 
 referred to the mode in which I have shown vital haemorrhage 
 to take place. Like the rest, it comes from the mucous mem- 
 brane of one of the several parts of the urinary apparatus and 
 by exhalation. That from the kidney is not always an excep- 
 tion. Though it does proceed from the parenchymatous struc- 
 
HEMORRHAGE. 223 
 
 ture, it is equally certain that the mucous lining of its pelvis is, 
 and, perhaps, oftener, the source of the discharge. 
 
 In the treatment of this we are to be guided by the same gene- 
 ral principles as in other haemorrhages, having special regard to 
 the existing pathological condition. The case exhibiting local 
 phlogosis or active congestion, or febrile excitement, we resort 
 to venesection, cupping or leeching over the lumbar region, slight 
 purging, demulcents, and especially an infusion of peach leaves, 
 or of the petals of the red rose. The two latter articles, though 
 apparently very simple, are the most efficacious with which I 
 am conversant. 
 
 Many instances I have seen, that, resisting more energetic 
 means, were relieved by these mild remedies. It is customary, I 
 am aware, to rely here mainly on those astringents which are sup- 
 posed so efficacious in the kindred affections. But really I have 
 witnessed no decisive advantage from them, and certainly they 
 are more appropriate to another state of the haemorrhage, pre- 
 sently to be noticed. As usual is it to administer largely the 
 diuretics, the nitrate of potash particularly, with the beverages 
 promotive of its operation, to which I entirely object, provided 
 the kidney be the seat of the effusion and already unduly excited. 
 The reverse, indeed, is the indication under such circumstances 
 rather to allay than provoke any increase of action, by forcing it 
 to greater secretory efforts. 
 
 In a case of less activity, if admissible at all, venesection must 
 be comparatively moderate and topical bleeding chiefly used. 
 Blistering over the lumbar region is entitled to great confidence. 
 That it has been strenuously opposed is not unknown to me, 
 though on false grounds. From experience I have learned that 
 it may be as safely and efficaciously adopted as in any of its 
 ordinary employments. But the blister should be permitted to 
 remain on long enough only to produce simply a rubescence of 
 the skin, by which its beneficial effect is amply attained and the 
 danger of strangury prevented. 
 
 This is the conjuncture to which I alluded, when the ace- 
 tate of lead, the sulphate of alumine, the muriated tincture of 
 iron, the gallic acid, the elixir of vitriol, the kreosote, and alike 
 articles, may be tried with a fairer prospect of success. Yet 1 
 confess that I have found them, even here, of very doubtful 
 utility. As to the uva ursi, so commended by some, it lias totally 
 
224 HEMORRHAGE. 
 
 disappointed my expectations. But the tincture, in combination 
 with gallic acid, is, of late, very favourably spoken of, which I 
 have not used. The best article known to me is the spirit of 
 turpentine. 
 
 Emetics had formerly great reputation, and I believe de- 
 servedly, though I have never had recourse to them, — finding, 
 on all occasions to which I deemed them appropriate, measures 
 less disagreeable to answer. 
 
 Much of this treatment is equally suited to haemorrhage of 
 the bladder. The topical applications are usually made to the 
 pubes or the sacrum, as nearer the seat of the affection. Yet 
 leeches to the groins and perineum are more effectual It has 
 also been proposed to inject into the bladder cold mucilages or 
 astringent fluids, according to the indication. 
 
 Great suffering, I have said, is sometimes felt by a retention of 
 blood from an occlusion of the urethra. This is removed, at 
 once, by the introduction of a bougie or catheter. 
 
 It is obvious that the management of these cases requires to 
 be further accommodated to their peculiarities. Excited, for 
 instance, by calculi, and especially when a small one is lodged 
 in the ureter, though the haemorrhage may be slight, the agony 
 is extreme. Disregarding the effusion, our attention must be 
 directed to the mitigation of pain and to the passage of the cal- 
 culus through the tube, by which complete relief is only afforded. 
 Fortunately the means are the same with both intentions, con- 
 sisting of general and local bleeding to a great extent, the warm 
 bath and opiates chiefly as an enemata. Caused by any material 
 structural lesions, it is better, in an inflammatory condition of the 
 parts, to allow the haemorrhage to continue, as serviceable, unless 
 it be inordinately profuse. Then, or in a case of original debility, 
 the balsams or terebinthinates are to be preferred, in reference to 
 a suppression of the effusion, and with a view to the alleviation 
 of the pain, commonly an attendant, the opiates. 
 
 In the arrestation of this haemorrhage, when active, from what- 
 ever source it may emanate, or the cause occasioning it, much 
 will depend on the adoption of a course of living, to the total 
 exclusion of every article, whether of food or drink, of a heating 
 or stimulating kind, and, scarcely less, on the strictest observance 
 of a state of rest during and for some time after the effusion. No 
 less does the latter clause of this precept apply to the opposite 
 
HEMORRHAGE. 225 
 
 state of the affection, — but the diet should be more nutritious, 
 though still bland, or without any irritating qualities. 
 
 Need it be added, that before dismissing the case, the patho- 
 logical condition to which the effusion is owing, is carefully to 
 be ascertained, with a view to its rectification or entire removal? 
 
 H^EMORRHAGIA UTERINA, OR UTERINE HEMOR- 
 RHAGE. 
 
 An opinion having been formerly entertained that the whole 
 of the extravasations of a sanguineous aspect from the womb 
 were of a menstrual nature, the term menorrhagia, which means 
 an undue flow of the menses, was applied to this affection. 
 Elsewhere,* I trust, I have shown that the catamenia, instead of 
 blood, are a peculiar fluid, the product of a secretory action of the 
 uterus. Nor is it true, as many suppose, that all of the periodi- 
 cal discharges from this source are menstrual. On the contrary, 
 I have found, in every instance in which such were copious, pure 
 coagulable blood to be emitted. Even where, in the commence- 
 ment, the fluid seemed to be partially menstrual, it lost that cha- 
 racter and became blood. 
 
 Granting, then, the correctness of this view, the impropriety of 
 the term menorrhagia is obvious. Convinced of this, some have 
 proposed the substitution of metrorrhagia. But, as it means only 
 a discharge from the womb, it is vague and unsatisfactory. No- 
 thing can more precisely express the affection than hsemorrhagia 
 uterina, and hence it should be adopted to the exclusion of all 
 other titles. 
 
 This haemorrhage may take place in the unimpregnated or 
 impregnated state of the organ, and precede or succeed delivery. 
 The latter, or such as is incident to the gravid uterus, is occa- 
 sioned in a mode, namely, by the rupture of vessels, which 
 removes it from my consideration, and will be resigned to the 
 department of midwifery. To me it belongs to treat only of the 
 former, as properly vital or spontaneous haemorrhage. This may 
 recur monthly, with considerable exactness, or more irregularly, 
 at shorter or longer intervals, or continue almost uninterruptedly. 
 
 * Elements of Therapeutics and Materia Medica. 
 
226 HEMORRHAGE. 
 
 But the law of periodicity is observed by it with greater uni- 
 formity than by any of its allied affections. 
 
 An attack of an active uterine haemorrhage may be ushered 
 in without any, or a very slight premonition, though generally 
 by a train of precursory symptoms, lassitude and weariness of the 
 limbs especially — sometimes chilliness, followed by fever, or, at 
 least, by increased force or acceleration of pulse, headache, flushed 
 face, embarrassed respiration, a sense of fulness in the uterus, 
 pain, acute or dull, in the lumbar region or groins, with sensa- 
 tions of dragging or bearing down, attended by a frequent desire 
 to urinate and occasionally by tenesmus. These phenomena are 
 often connected with much of that sort of feeling expressed by 
 the vague term nervousness. The discharge appearing, not a 
 little relief is afforded unless it be very profuse, when the ante- 
 cedent suffering is exchanged for the wretchedness of exhaustion, 
 sometimes with nausea or vomiting, coldness and shivering, dis- 
 position to syncope, &c. &c. 
 
 Among the remote causes of uterine haemorrhage, the most 
 conspicuous is the period of life. Never is it met with previously 
 to the season of puberty, — is very apt to occur slightly, in an- 
 ticipation of the complete establishment of the menses, — again, 
 when they are about to cease and, sometimes, very copiously. 
 No period, however, between these extreme points is exempt 
 from attacks, and the liability to it may be continued much longer. 
 
 The predisposition is also dependent on certain constitutional 
 states, and the character of the haemorrhage modified accord- 
 ingly, — the active variety being chiefly found in the sanguineous, 
 the florid and robust, — and the less active, or passive, in the 
 enervated, relaxed and phlegmatic. 
 
 More particularly is blood directed to the womb by the habits 
 of sitting or luxurious indolence, or such employments or amuse- 
 ments as spinning or dancing, or equitation, or walking rapidly, in 
 which the lower extremities are exerted, or by excess of venery 
 or the reverse, abstinence from it where the desire is urgent, or by 
 numerous labours or repeated abortions, or by the prevalence of 
 leucorrhoea, and by constipation or frequent purging, with articles 
 operating mainly on the rectum and through it on the uterus, — 
 certain emmenagogues, an undue use of the warm bath, or of 
 foot stoves, &c. 
 
 Besides these ordinary agencies, haemorrhage is sometimes 
 
HEMORRHAGE. 227 
 
 the consequence of a series of organic lesions of the uterus, — 
 induration or softening of texture, common ulceration, scirrhosity 
 or open cancer, polypi and various tumours, — fungoid, or other 
 morbid growths of diverse sorts. Connected, however, with 
 such states, the effusion, I suspect, proceeds mostly from rupture 
 of vessels, and hence does not strictly appertain to the present in- 
 quiry. Yet it may be otherwise, these lesions sometimes operating 
 to the disorder of the capillaries of the mucous surface. This 
 haemorrhage, I think, is seldom to be traced to cardiac or other 
 remote influences. Nor is it often vicarious or succedaneous in 
 its character so far as I have observed. 
 
 No difficulty can exist in distinguishing the uterine from other 
 haemorrhages. Menorrhagia is most apt to be confounded with 
 it. An inspection of the discharge will, however, at once remove 
 all doubts, it being in the one pure coagulable blood, and in the 
 other a thin, dark fluid, of a peculiar odour. Between the blood, 
 in some of the less active haemorrhages, and the menses there 
 is a closer resemblance, and great attention will be required in 
 the discrimination. Embarrassment, too, may be experienced 
 in this respect, as relates to the haemorrhage dependent on those 
 structural derangements of the womb just mentioned, though 
 here the obscurity is cleared away by an examination per vagi- 
 nam. 
 
 It seldom happens that there is any immediate danger in the 
 active form of this haemorrhage, provided it be spontaneous, to 
 whatever extent it proceeds. Death, at least, rarely or perhaps 
 never suddenly ensues from it. Much, however, is to be appre- 
 hended in the ulterior consequences where it is frequently re- 
 peated or long continued, by the constitutional disturbance and 
 general derangement of health of which it is productive. But 
 it is otherwise in the less active or passive states of the disease, 
 the loss of blood here being sometimes most copious and the 
 effects truly alarming. I have met with some instances and 
 many are reported, where pints of blood have escaped in an 
 inconceivably short time, — and though never within my own 
 observation ending fatally, such events have undoubtedly taken 
 place. Yet it would seem that from no part of the body is 
 excessive haemorrhage better borne than the uterus, or the pre- 
 servation of life more frequent, under apparently desperate cir- 
 cumstances. 
 
228 HEMORRHAGE. 
 
 Commonly the active haemorrhage is easy of cure. The cases 
 which prove intractable are of long standing, to be found, for 
 the most part, in women somewhat advanced in life, very often 
 about the season of the cessation of the menses, with some 
 organic lesion of the uterus, or of a lymphatic temperament and 
 general bad condition of system. 
 
 The rareness of a fatal termination in either state of this affec- 
 tion has prevented the acquisition of any precise knowledge of 
 its anatomical characters. No doubt, however, they are the 
 same as in haemorrhages of other mucous surfaces, and which 
 have been sufficiently detailed under some preceding heads. The 
 organic lesions, I have said, seldom bear a relation to vital 
 haemorrhage, and hence need not be again enumerated or more 
 minutely described. 
 
 With those who confess the peculiar obscurity in which the 
 pathology of uterine haemorrhage is involved, I can not unite. 
 To me it is as plain as that of any of its affiliated affections. 
 Lined as the womb is with a mucous membrane, why should 
 it not be subject to haemorrhage? But the chief difficulty com- 
 plained of seems to relate to those cases where pure blood peri- 
 odically escapes instead of real menses, or in which the two 
 fluids are mixed. Every haemorrhage displays such a tendency 
 occasionally, — and that it should be more strikingly manifested 
 in the uterine, is readily to be conceived from the natural func- 
 tions of the organ. The uterine vessels, I have said on a former 
 occasion, when in a healthy state, by virtue of their secretory 
 office periodically exercised, convert the blood into a peculiar 
 fluid. Disordered, however, they lose this capacity, and blood 
 is exhaled more or less unchanged. But it is asked whether 
 different sets of vessels are not engaged in these operations? 
 Recurring to what was delivered on the general pathology of 
 haemorrhage, an explanation of this phenomenon will be acquired. 
 No more of that discussion shall I now recapitulate, than merely 
 the remark, that the secretory vessels of a part may be so dif- 
 ferently influenced at the time, that while one portion of them is 
 adequately performing its duty, another shall allow blood to pass 
 through them, little or not at all affected. There is not the 
 slightest necessity to suppose a double set of vessels to solve the 
 problem. 
 
 In a well-marked case of the active state of this haemorrhage 
 
HEMORRHAGE. 229 
 
 we have to contend with a plethoric, and perhaps an inflamma- 
 tory condition, local or general. Excepting from the inconve- 
 nience of it, I am not aware of any objection to permitting it to 
 continue as an effort of nature, in most instances at least, to get 
 clear of a morbid irritation or redundant blood. Deeming it, 
 however, expedient on any account to interfere, we can have 
 little doubt as to the remedies. To a considerable extent, vene- 
 section becomes necessary, — the bowels, when constipated, should 
 be opened by a mild laxative, and the nitrate of potash, with a 
 modicum of tartarized antimony subsequently directed. The 
 latter is undoubtedly among the most suitable of our remedies 
 at this time. 
 
 Digitalis has been proposed here, even as a substitute for vene- 
 section, — and it will be found most strenuously urged with this 
 view, especially by Currie, Ferriar and Drake. No substitute 
 for it, however, have we in this or in any other instance, of a ple- 
 thoric or active circulation. Digitalis, in this case, is to be placed 
 on nearly the same footing with some other sedatives. The pulse 
 being without force or volume, though quick and irritated, it 
 may be recurred to, provided the haemorrhage be not copious, 
 since it is apt to induce a relaxed or patulous state of the vessels, 
 and hence to increase the flow of blood. Nevertheless, under 
 such circumstances or where venesection is no longer admissible, 
 the most appropriate means usually is cupping the lumbar region, 
 or an application of a blister to the same part, or both, in suc- 
 cession. 
 
 Certain astringents are next resorted to, and, properly directed, 
 may be serviceable, though I have some doubts of their efficacy. 
 Nothing, however, is better established, than that these articles 
 ought to be preceded by depletion. Let this be omitted or too 
 timidly employed, and these and all other means will prove 
 inefficient and sometimes positively detrimental. 
 
 Of the class of astringents, the acetate of lead stands probably 
 first in repute, and is, indeed, represented as sometimes display- 
 ing extraordinary powers. Many, as well of Europe as this 
 country, who have used it largely, concur in this estimate of its 
 value. Heberden says, "if ever there was a specific in any 
 disease, it is surely the lead in uterine haemorrhage." The late 
 Professor Barton was equally lavish of his commendations of it. 
 My own experience will not allow me to go so far, and I even 
 20 
 
230 HEMORRHAGE. 
 
 suspect that the accounts of its efficacy are great exaggerations. 
 It is prescribed in the dose of two or three grains with a quarter 
 of a grain or less of opium, to be repeated at shorter or longer 
 intervals, according to the emergency. 
 
 As the other articles of this description are more employed in 
 the less active state of this haemorrhage, I shall postpone my 
 animadversions on them till I come to that portion of the subject, 
 and now turn to the consideration of a very different set of medi- 
 cines. The first which attracts notice is ipecacuanha. 
 
 No inconsiderable testimony might be adduced to its powers, 
 which, in my opinion, are superior to those of the acetate of lead. 
 The mode of giving it is in minute doses, with a small portion 
 
 opium, so as scarcely to distress the stomach, under an appre- 
 hension of exciting vomiting. What would be the effect of this 
 process induced by an emetic, I cannot say from any knowledge 
 of my own in active uterine haemorrhage. Cases of it, however, 
 
 1 have seen to cease on the coming on of spontaneous vomiting, 
 — and I can discern no objection to the use of emetics, provided 
 there has been previously a reduction of vascular action. But 
 of this again presently. 
 
 More effectual than either of these articles is the ergot, accord- 
 ing to recent declarations of some practitioners. That it con- 
 trolled the floodings preceding, and following delivery, had been 
 long known, — and it was presumed that it would here prove 
 still more decisive. Not positively denying its utility, for I have 
 very slight experience with it, I do still think that the analogical 
 reasoning which led to the extension of this application of it, is 
 incorrect. The haemorrhage in the two cases is produced very 
 differently, and seems to require remedies equally dissimilar, — 
 in the first, by the rupture of vessels, to be compressed by uterine 
 contractions, and in the second by a mere exhalation of blood, 
 which is checked by an alteration in the state of the capillaries. 
 It has been said, I am aware, in defence of its efficacy, that it has 
 the quality of imparting tone to the capillaries, inducing con- 
 traction, by which the patulous mouths of the exhalents are 
 closed, and further effusions obviated. But this conjecture is 
 contradicted by facts. Ergot is shown, by the well-conducted 
 experiments of Dr. Charles Byrd, to have no remedial effect 
 except on the gravid uterus. Given under other circumstances 
 it appeared to be utterly inert, even in relation to the system of 
 
HEMORRHAGE. 231 
 
 the female, the womb included. Were it, too, endowed with the 
 power ascribed to it, should it not be displayed in regard to 
 haemorrhages generally? That in epistaxis, haemoptysis and 
 haematemesis it has none I am persuaded from all my observa- 
 tions. We are told by some that the tincture of ergot answers 
 far better than the powder. The dose is thirty or forty drops, 
 occasionally repeated. 
 
 Evidence of a very respectable character might be collected 
 of the utility of opium, and under various circumstances of this 
 haemorrhage. Yet 1 cannot help thinking that it has been abused 
 by a too general and indiscriminate application of it. Thus it 
 appears to me, that prescribed in a full dose in the early stage 
 of active haemorrhage, under ordinary circumstances, its effects 
 would be injurious. We, however, meet with such cases attended 
 by pain, irritation and spasm of the uterus, by which irregular 
 movements, the effusion of blood is excited or kept up. Here, 
 after sufficient bleeding, opium signalizes its utility, acting on a 
 principle too plain to require any explication. Nor am I pre- 
 pared to limit its application exclusively to this condition. The 
 more I prescribe it, the stronger is my conviction that it exercises 
 a very general power over haemorrhage, provided adequate de- 
 pletion has been practised, and which I think it does by its ope- 
 ration on the nervous system, as formerly explained. Commonly, 
 it, or some one of its preparations, is given alone, — but the Dover's 
 powder often answers better, — and in some instances, a union 
 of opium, ipecacuanha and camphor, is still more to be preferred. 
 
 The most prominent of the general remedies with which we 
 endeavour to arrest uterine haemorrhage of the species under 
 review have been mentioned. There are, however, some topical 
 expedients,— ^among which is an application of cloths wrung 
 out of cold water, or vinegar, or ice itself to the pudendum and 
 belly, or to pour down water from a height in a small stream on 
 the latter. 
 
 An advantage may also be gained by injecting into the vagina 
 a solution of alum, sugar of lead, white vitriol or other astringent 
 fluids. The rectum is resorted to by some as a medium of ad- 
 ministration of these articles, it being affirmed that they thus act 
 with greater efficacy. Whether it be so, I am unable to state 
 from any trials of my own. Yet where much irritation and 
 spasmodic action of the uterus prevailed, I have sometimes de- 
 
232 HEMORRHAGE, 
 
 rived great benefit from opiate enemata. More, however, to be 
 trusted than any of the means I have suggested, is plugging up 
 the vagina, so as to allow a coagulum of blood to form, — and 
 the best substance for the purpose is sponge, though tow, flax, 
 cotton or even soft rag may be substituted. This is the tapon of 
 the French. 
 
 Connected as this haemorrhage is, with an active and, perhaps, 
 sometimes an inflammatory condition, it is often circumstanced 
 differently. We have, in the latter cases, proofs of a debilitated 
 and sometimes a vitiated state of the system. The pulse is feeble 
 and quick, the respiration hurried on the slightest exertion, the 
 skin damp and cold, pallid or sallow and doughy, with, in pro- 
 tracted instances, oedema of the lower extremities, and particu- 
 larly of the feet, in the evening. That, however, which dis- 
 tresses most, is a constant pain in the lumbar region, sometimes 
 acute, though more frequently dull, with a sense of weakness in 
 the back, which may be so great as even to prevent the erect 
 position. Effusions are occasionally very profuse, the blood thin 
 or watery, and inasmuch, from the existing debility, any further 
 expenditure of it must be detrimental, it is to be checked as 
 speedily as possible. 
 
 General bleeding here can rarely be practised. But in those in- 
 stances, where there is much local congestion, though the system 
 may be weak, cupping over the lumbar region is allowable, — 
 and, at all events, dry cupping or a blister, or both, in the same 
 position, may be applied. Excepting the nitrate of potash and 
 tart, antimony, all the other medicines, in the active, are adapted 
 to this haemorrhage, and especially the topical means before enu- 
 merated. There are, moreover, some other articles given inter- 
 nally, and among these is alum. That it has been found useful, 
 it is hard to doubt. The earliest appropriation of it, indeed, was 
 to uterine haemorrhage, by Van Helmont, who acquired immense 
 fame by the cures effected by it. The dose is from three to five 
 grains, with a portion of opium, to be repeated according to the 
 emergency. Though it is usual to combine it with kino or catechu, 
 no advantage is gained, and it were better to give these articles 
 separately. They are not, however, in any mode of adminis- 
 tration, highly appreciated by me. The tincture of rhatany has, 
 perhaps, stronger claims to attention, and the elixir of vitriol is 
 undoubtedly sometimes serviceable. Neither of the gallic acid 
 
HEMORRHAGE. 233 
 
 nor kreosote, lately so strongly praised, have I any personal 
 experience in this application of them. 
 
 It is now proper that I should deliver some account of the 
 use of emetics, and particularly, as the practice is not without 
 claims to originality. This inactive haemorrhage may be alarm- 
 ing in its immediate tendency, — it is always seriously injurious 
 to health, and often proves intractable to the customary mode of 
 treatment. Embarrassed by a case of the kind, which had re- 
 sisted the best efforts of some other practitioners, I determined 
 to venture on the experiment with emetics. To this conclusion 
 I was led by the reflection that there is no peculiarity in uterine 
 haemorrhage not reconcilable to the common principle on which 
 I had conducted the cure of other forms of the disease. It struck 
 me, that by the revulsion of vomiting, distinct from the second- 
 ary effects of the process, the flow of blood might be checked, 
 and that in the interval of its recurrences, by occasional repeti- 
 tions of the remedy, the uterus reinstated in its secretory func- 
 tions. Emetics, I was also aware, are among the most active 
 and certain of the emmenagogues, by which 1 mean an imme- 
 diate power to arouse the energies, or otherwise to reinvest the 
 uterus with the faculty of secretion, when suspended or per- 
 verted. Having seen their salutary agency in this respect, as 
 well in amenorrhoea as fluor albus, I indulged the hope that if 
 in these cases they can revive a natural action, or rectify a de- 
 praved one, so they might be serviceable in the same way in 
 haemorrhage. 
 
 The case to which I have referred occurred at the close of 
 1827. It was that of a lady in the prime of life, from a distant 
 part of the country, who came to consult me. Her appearance 
 was sickly, and she told me that from her marriage, a year and 
 a half before, she had been subject to haemorrhage, at first in- 
 considerable and monthly, progressively, however, increasing in 
 quantity, and renewed at shorter intervals, till it had become so 
 copious on some occasions as to endanger her existence. This 
 distressing situation was greatly aggravated by her sterility. 
 
 The ordinary routine of remedies having been ineffectually 
 exhausted, I suggested a trial of a course of treatment in con- 
 formity to the views just presented. With this advice she 
 returned home, promising strictly to adhere to it. Two months 
 afterwards I received a letter from her, in which she informed 
 
 20* 
 
234 HEMORRHAGE. 
 
 me that on her journey she had a comparatively slight haemor- 
 rhage, — though, under an apprehension of its increasing, recourse 
 was had to an emetic, which promptly suppressed it ; — that, by 
 this favourable result fresh confidence was inspired in the pro- 
 posed practice, and she had accordingly taken six emetics at the 
 intervals of eight days each, when regular menstruation return- 
 ing, her general health was sensibly improved. Encouraged by 
 this communication, I have since pursued the practice to some 
 extent, and though not uniformly successful, it has proved suffi- 
 ciently so to claim, in my opinion, great respect. 
 
 With two additional examples of its efficacy I must be satis- 
 fied. Not long before his death, I was urgently called by Dr. 
 Physick to meet him in a case of a lady, at one of our hotels, 
 who was suffering from uterine haemorrhage to a very alarming 
 extent. As he had experienced great difficulty in restraining it, 
 and she had become somewhat exhausted, an emetic was directed, 
 which proved promptly successful. The next day, on inquiring 
 more thoroughly into her situation, I ascertained that her general 
 health was much impaired by recurrences of this haemorrhage 
 periodically, in place of menstruation, which had long been sup- 
 pressed. On her leaving us soon afterwards, we strenuously 
 recommended a trial of a course of emetics as in the preceding 
 case, with what advantage, however, I do not know, never hav- 
 ing heard from her. 
 
 Three years ago I was consulted by a lady who came hither 
 for the purpose, from the interior of the State of New York, by 
 whom I was informed, that in consequence of the repetitions of 
 this haemorrhage, her health was inconceivably wretched, and 
 her aspect fully justified the statement. Much having been pre- 
 viously done for her without avail, I proposed the emetic prac- 
 tice, and had the happiness to learn from her that she had entirely 
 recovered, and had since given birth to a fine robust child. 
 
 It were easy to adduce further cases of a similar kind, though 
 perhaps not so striking. 
 
 To excite vomiting I have uniformly employed ipecacuanha, 
 and perhaps no other article is so well adapted to the case. It 
 affords me pleasure to find, from a late publication, that the emetic 
 practice, as well as the preference of this article, is fully sanc- 
 tioned by two very eminent practitioners of Europe. Coffin, of 
 Paris, declares this as the result of ample experience, — and which 
 
HAEMORRHAGE. 235 
 
 is abundantly confirmed by Osborne, of Dublin, who states that 
 a scruple of ipecacuanha, taken in the evening, and followed by 
 an acidulated saline purgative in the morning, stops the discharge 
 very speedily, and when it returns, the emetic repeated once or 
 twice, never fails to complete the cure. Tartarized antimony 
 had no such effect. As to the applicability of the practice, he 
 perceived no difference, whether the haemorrhage was decidedly 
 active or the reverse, it being alike successful. 
 
 Checked in any manner, the next consideration is to prevent 
 the recurrence of the haemorrhage, or, in other words, to effect 
 a thorough cure. Before commencing the treatment, the patho- 
 logical condition on which this disposition to effusion depends, 
 must be ascertained. Either of a phlogistic or active congestive 
 nature, the loss of blood, generally or locally, from time to time, 
 with the other means of reduction, including low diet, are, per- 
 haps, only demanded. But in an opposite state, or one of enerva- 
 tion or relaxation, an essentially different course becomes proper. 
 
 Of the utility of emetics, as well to arrest the flow as to obviate 
 its recurrence, I have already spoken. Cathartics which act on 
 the lower portion of the bowels and indirectly on the uterus, 
 have also been employed. The aloetic preparations are of this 
 description, and among the very best of them are the hiera 
 picra and elixir proprietatis. These articles are designed to 
 operate not so much as evacuants, as by an impression on the 
 vessels of the uterus, supposed to be promotive of the menstrual 
 function. Governed by the same principle, emmenagogues of a 
 more decisive character have been directed. But whatever may 
 be the merit of these, of which I am exceedingly distrustful, the 
 tonics are less equivocal and more commonly employed. Great 
 reliance was once placed on the Peruvian bark and its ordinary 
 preparations, now superseded by the sulphate of quinine. 
 
 But, above all, should our trust be reposed in the chalybeates. 
 Excellent in every variety of this enfeebled state of the system, 
 it is when exsanguineous or cachectic that they are best adapted. 
 The phosphate of iron is the most valuable alone, or with the 
 quinine, though the muriated tincture, the subcarbonate, the 
 sulphate, the tartrate, the prussiate, hydriodate, the lactate and 
 citrate, are all in repute. To aid this plan of corroboration, 
 nutritious, though not a heating or stimulating diet, may be sug- 
 
336 HAEMORRHAGE. 
 
 gested, with the use of the cold bath, moderate exercise, and 
 whatever else is calculated to renew or improve health. 
 
 Not, however, succeeding, some radical derangement of the 
 uterus is to be suspected, and without much investigation of the 
 nature of the lesion, mercury has been directed with a view to 
 its reparation. Cautiously administered, there are states in which 
 it might be serviceable, as those in which it is beneficially resorted 
 to in the lesions of other secretory organs. Even under the sup- 
 position of such uterine depravations, an indiscriminate applica- 
 tion of it could not, however, fail of producing infinite mischief. 
 With these very states there is, in many instances, a pervading 
 bad habit of body, both of the solids and blood, the latter espe- 
 cially being thin and impoverished by the loss of its fibrin and red 
 globules — and here, mercury would prove the most pernicious of 
 articles ! Employed at all, it must be reserved for cases where 
 the integrity of the constitution has not materially suffered. 
 
 In the management of this hasmorrhage, the principal design 
 should be to replace the system in a healthy state, on the accom- 
 plishment of which, menstruation usually returns, and with it, 
 the hasmorrhagic tendency ceases. Never ought it be forgotten, 
 that the latter, existing during the period of life when the former 
 should be performed, it is seldom completely overcome, except 
 by the restoration of the natural function. 
 
 Nor as a prophylactic of the utmost importance, must it escape 
 notice, that on the hasmorrhage observing the law of periodicity 
 with any degree of exactness, reverting, for instance, monthly, 
 or at any stated interval, it may often be averted, by enjoining 
 for a few days, in anticipation of an attack, a state of entire rest, 
 — and where local uneasiness, or other signs of a congestive 
 or phlogistic state prevails, by the loss of blood, generally or 
 locally, a reduction of diet, and, perhaps, occasionally an opiate. 
 Examples, indeed, occur in which the tendency to effusion is so 
 continued, that the recumbent position is absolutely required for 
 weeks or months together, to prevent its reappearance. 
 
 It remains to make a few remarks on a peculiar state of the 
 disease. An irregularity in the discharges of the uterus may 
 be expected to a greater or less extent at the season of the 
 cessation of the menses. The secretory office of this organ 
 being about to terminate, it is imperfectly performed, and, conse- 
 quently, we have some anormal secretion, or oftener pure blood, 
 
HAEMORRHAGE. 237 
 
 in the place of the catamenia, or a mixture of these fluids, and 
 which is thrown out with no uniformity as to time or quantity. 
 It happens, too, at this, or a later period, that we meet with 
 cases where there is a small, though nearly constant oozing of 
 blood, quaintly denominated by the late Professor Rush "a 
 hemoptoe of the uterus/' It may be suspected, under such cir- 
 cumstances, particularly the latter, that there is something wrong 
 in the condition of the womb, either chronic congestion, or phlo- 
 gosis, and which being neglected leads to the formation of some 
 more formidable lesion. 
 
 Cases of this nature are to be usually recognized by a sense of 
 heat and pain in the uterus, the latter extending to the lumbar 
 region and lower extremities, — by the smallness of the discharge, 
 — and, in a more advanced stage, by an aggravation of the 
 preceding symptoms, with depraved and offensive discharges. 
 Doubts, however, existing, these may be removed by an exa- 
 mination per vaginam, when, in the commencement, the os 
 tineas, and, perhaps, the neck of the womb will usually be found 
 thickened, betraying increased sensibility to the touch, and sub- 
 sequently still more disease. Desirous of absolute certainty as 
 to the nature and degree of the affection, this is attainable by the 
 introduction of a speculum, lately contrived for the purpose, into 
 the vagina, which brings the parts distinctly into view. 
 
 It is, however, with reluctance that I even allude to these last 
 resources. Designed only for the extremest emergencies, they 
 have become of too common application among some regular 
 practitioners, and are now actually one of the most profitable 
 expedients of the vilest of the quacks. The extent is hardly to 
 be credited, — though undoubtedly true, to which these charlatans 
 are patronized in this and other respects,— wholly revolting, as 
 might be supposed, to female sensibility. There are now men 
 in all our large cities, low, vulgar and illiterate, who, professing 
 through the medium of the speculum, or some equally indelicate 
 mode, to determine and cure with certainty the physical suffer- 
 ings of the sex, receiving a degree of employment utterly inex- 
 plicable, — prone as we know the human mind is to every sort of 
 illusion and imposture. 
 
 The mere suppression of the sanguineous discharge in the 
 state just noticed, is, however, a subordinate consideration. Not 
 excessive, it is even salutary and must not be checked. The 
 
238 HAEMORRHAGE. 
 
 great object is to arrest the progress, or entirely relieve that con- 
 dition from which it emanates. To this end, the most approved 
 means are general and topical bleedings. The latter are usually 
 made from the groins and vulva, though it is now sometimes 
 effected by leeches to the uterus itself, as more effectual, applied 
 by means of the speculum mentioned, which, however, I think 
 questionable. As well on the general principle, that it is pre- 
 ferable to draw blood from the vicinity than directly from the 
 affected part, I have actually seen instances of uterine irritation 
 by the bites of the leeches. Further, the treatment consists in 
 an alterative use of mercury, low diet, principally of milk, with 
 an avoidance of all exasperating causes. 
 
 In a later stage, when scirrhus and other serious organic de- 
 generations have taken place, our chief reliance has been on arse- 
 nic and the free exhibition of the narcotics, hemlock, stramonium, 
 henbane, opium, &c. Little is to be anticipated from these reme- 
 dies, — and such cases are now usually resigned to the resources 
 of surgery, from which, however, I apprehend scarcely more is 
 derived. Notwithstanding all the vauntings of Lisfranc and 
 others, of the extraordinary success of their operations on the 
 uterus, for the removal of diseased portions of it, great reason 
 exists to distrust the integrity of these statements. As regards 
 those of Lisfranc especially, there has been lately published the 
 solemn declaration of the resident surgeon of the hospital in 
 which they occurred, that nearly the whole of the cases reported 
 as cured ended fatally. We have here a very striking illustra- 
 tion of the common and highly censurable conduct of certain 
 surgeons, who, to acquire the eclat of a daring operation, pro- 
 claim at once the performance of it, and conceal the ultimate 
 result, however ineffectual or disastrous it may be. It is a cus- 
 tom, to say the least of it, far " more honourable in the breach, 
 than the observance," and from which, every one who is sensible 
 of what is due to himself, or of the obligations to the profession, 
 will turn with loathing and disgust. 
 
 HEMORRHOIS, OR HEMORRHOIDS. 
 
 These terms, strictly meaning a flow of blood, are now applied 
 exclusively to such as come from the vessels of the rectum. By 
 
HEMORRHAGE. 239 
 
 the phrase proposed to be substituted for them, Hsemorrhcea 
 Vasorum Hasmorrhoidalium, the affection is clearly expressed. 
 — though with too little conciseness for familiar use, and hence, 
 probably, the old titles, inadequate as they are, will not be super- 
 seded by it. This haemorrhage, in common language, is denomi- 
 nated piles, — the plural of pile, to coacervate or heap on, — the 
 tumours incident to it exhibiting such an appearance in some 
 instances. Generally, indeed, it is to be met with in the form 
 of tumours, which are designated according to their position, 
 external or internal to the anus, and these may be with or with- 
 out a discharge of blood, the first called bleeding, the second 
 blind piles. But haemorrhage sometimes takes place independ- 
 ently of any such formations, and it is the effusion under what- 
 ever circumstances existing, that can now properly claim my 
 attention. Cases complicated with tumours, are, from the force 
 of prescription, still surrendered to surgery. 
 
 An attack of active haemorrhois is usually preceded, and may 
 be attended, for a time, by a sense of weight and fulness in the 
 epigastrium, belly and loins, — constipation, tormina and tenes- 
 mus, — scanty and high-coloured urine, sometimes strangury or 
 entire suppression of the discharge, — uneasiness in the perineum, 
 florid countenance, giddiness or headache, nausea or vomiting, 
 and, in some rare instances, by inordinate venereal impulses, with 
 itching of the glans penis, slight swelling of the prepuce and 
 testicles, — occasional erections, — a blennorrhagic discharge from 
 the urethra, and seminal emissions.* 
 
 Cases, too, occur, introduced by chills or horripilations, fol- 
 lowed by fever, — and almost uniformly the circulation is more 
 or less disturbed, either by an increase of force and acceleration, 
 or by becoming fuller and more sluggish. Tumours having 
 formed, much aggravation of distress ensues. They may be 
 exquisitely tender, with a burning sensation, or throbbing, pul- 
 satory pain in them, — especially when forced down and incar- 
 cerated by the sphincter ani. Going to stool, the agony is so 
 extreme as scarcely to be endured,— occasionally giving rise to 
 such intensity of inflammation as to produce sloughing, — though 
 oftener to a sort of muco-purulent secretion. By an effusion of 
 blood, great and immediate relief is commonly afforded to these 
 
 * Richter. 
 
240 HEMORRHAGE. 
 
 affections. Even without this occurrence, the phlogosis, the ten- 
 sion and pain slowly abate, — the tumours correspondent^ dimi- 
 nish, and may entirely disappear, — mostly, however, to revert 
 again at some uncertain period. 
 
 Consequent on repetitions of attacks, changes are induced in 
 their structure, which render them permanent, they then becom- 
 ing, sometimes, a perpetual source of irritation, and when exa- 
 cerbated, of suffering. Disorder of system may ultimately ensue 
 whether there be haemorrhage or not,— though aggravated by 
 excessive losses of blood, — manifested by dyspepsia or vertigo, 
 confusion of mind, sometimes excruciating neuralgia of the head, 
 panting and oppressed respiration, foetid breath, palpitations of 
 the heart, — an intermittent or otherwise irregular pulse, mus- 
 cular weakness, — pallor so great as to resemble white wax, with 
 soft, doughy integuments, and sometimes dropsy. These are the 
 most prominent of the general effects to which might be sub- 
 joined a variety of local affections that sometimes complicate the 
 case and enhance the difficulty of its treatment. But though such 
 are the ordinary results of haemorrhoids, it very often is infinitely 
 milder in its earlier and subsequent stages, and, indeed, I have 
 known it to endure for years, with little or no suffering, locally 
 or generally. 
 
 Looking to the remote or predisponent causes of the disease, 
 it will be found that the period of life has considerable influence 
 in this respect. Belonging to every age, except, perhaps, that of 
 infancy,* it is of more frequent occurrence somewhat beyond the 
 meridian of existence, and in the plethoric and robust, — incident, 
 however, to an opposite state, or the enfeebled, attenuated or 
 depraved. 
 
 Distinct from this, there is, at all times, a peculiar susceptibility 
 to it from the conformation of parts. 
 
 The rectum is one of the most dependent portions of the body, 
 and its veins being lax, without valves, and little sustained by 
 the loose, surrounding cellular membrane, readily become sur- 
 charged with blood, which leads to this result. 
 
 Many families are so liable to haemorrhois, that it has been 
 supposed to be hereditary. The temperaments most favourable 
 
 * I once saw it in a boy four years old, and it has been observed by others 
 in children still younger. 
 
HEMORRHAGE. 241 
 
 to its production are the sanguineous, or rather, perhaps, the 
 sanguino-bilious or melancholic. Not at all, however, confined 
 to this, I have seen it not unfrequently in every one of the simple 
 or combined of these original constitutional conditions. 
 
 That males are more affected with it than females was the 
 doctrine of Stahl and his disciples, who paid great attention to 
 haemorrhage. Cullen and other high authorities, however, enter- 
 tained an opposite opinion, in which I am inclined to concur. 
 Certain it is, that women are exposed to three peculiar causes, 
 amenorrhoea, pregnancy and parturition, — and probably, also, 
 have greater delicacy of vessels. Yet while the menstrual func- 
 tion is duly performed, it exerting a counter-agency, they, per- 
 haps, are comparatively exempt. 
 
 Climate and seasons seem to dispose to its production. It is 
 far more prevalent in the hot, damp and miasmatic, than in the 
 temperate, or cold and dry. Examples we have where, under 
 the former circumstances, it became so general as to have some 
 claims to be an epidemic, and surely, there is more of it in the 
 extreme southern than the northern portions of our country. 
 
 Further may be stated all those causes producing local deter- 
 mination or fulness in the vessels of the rectum, among which is 
 disorder of the chylopoietic viscera, and hence the greater pro- 
 clivity of the sedentary, the voluptuous and debauched, to the 
 affection. More immediately tending to the event is whatever 
 irritates the part, as ascarides in the rectum, or lodgment there of 
 indurated faeces, or purging with the aloetic preparations. Cos- 
 tiveness, especially, is represented to be so influential in this 
 respect, that it is assigned as the main reason of the wider pre- 
 valence of it in the higher classes of society, where those habits 
 predominate, to which I have just alluded. In imputing hasmor- 
 rhois to the aloetics, I am led by authority, and not my own 
 experience. No effect of the kind have I witnessed, and am, 
 indeed, inclined to suspect that the ascription of it to those purga- 
 tives has arisen from their being so constantly resorted to in con- 
 stipation, the real occasion of the haemorrhoidal lesion. 
 
 Not the least curious fact belonging to the subject is the prone- 
 ness of haemorrhois occasionally to observe the law of periodicity. 
 I have seen it return with regularity, at stated intervals, in men, 
 though oftener in women, sometimes in the latter alternating with 
 the menses, and particularly where the secretory function of the 
 21 
 
242 HEMORRHAGE. 
 
 uterus has not been well established. Examples, too, are not 
 uncommon, less equivocally vicarious, as well in relation to the 
 catamenia as the real haemorrhages. But while haemorrhois is 
 thus induced, it is, perhaps, scarcely less so by certain morbid 
 conditions of the abdominal viscera, as specified on some pre- 
 ceding occasions, with an explanation of their mode of operation 
 in effecting haemorrhage. 
 
 To distinguish this from all other effusions of blood is so easy, 
 on account of its being, for the most part, exposed to view, that I 
 shall forbear to point out minutely its discriminating signs. Chief- 
 ly it resembles some of the discharges of blood from an upper 
 portion of the alimentary canal, or, as may be, those of the liver 
 or spleen. But the symptoms are altogether so different that any 
 mistake may be avoided. 
 
 Enough will it be to state that, independently of the general 
 characteristics of haemorrhois, the blood in it is fluid and florid, — 
 sometimes accompanying, though never mixed with the faecal 
 contents of the bowels. In the other instances it is usually 
 blended with mucus or other extraneous matters, or is dark, 
 grumous, granulated or dissolved. Even where the haemorrhage 
 is inward, its sources can generally be detected by the patient 
 forcibly pressing down as at stool, and especially under the ope- 
 ration of a purgative. 
 
 More apt, perhaps, are piles to be confounded with other 
 tumours, and, above all, with prolapsus of the rectum. Yet there 
 is this obvious difference in the two cases, — that in the former, 
 the mucous membrane covering the tumour, comes down alone 
 with them, — whereas, in the latter, an entire portion of the intes- 
 tine protrudes. 
 
 It happens, too, that an internal haemorrhoid suppurating and 
 continuing to discharge pus, the notion of fistula in ano arises. 
 But here any doubt may be at once cleared up by a careful 
 examination. With greater facility are those excrescences which 
 sometimes appear within or around the verge of the anus, dis- 
 tinguished from genuine piles. 
 
 Not uncommon is the error of misapprehending lesions of 
 the prostate gland and strictures of the rectum for inward piles, 
 of which I have known several instances. But of all blunders 
 of the kind, the most serious ever witnessed by me remains to 
 be mentioned. Either from pressure by a mass of dilated vessels 
 
HAEMORRHAGE. 243 
 
 on the neck of the bladder, or from sympathetic irritation merely, 
 there is occasionally extreme difficulty of making water, or a 
 total suppression of it, leading to a conviction of the existence of 
 a urethral stricture. Two most distinguished personages, whom 
 I saw some years ago with the late Professor Physick, were speed- 
 ily relieved by the extirpation of inward piles, after excruciating 
 sufferings for several months, in vain attempts by other practi- 
 tioners to remove strictures, under which they were supposed 
 to labour. These mistakes are less excusable, since they may 
 be prevented by proper explorations of the parts. 
 
 Existing with integrity of constitution, and of the active kind, 
 little is to be apprehended from haemorrhois. Mostly, indeed, 
 critical and salutary, it is seldom of undue profusion, and proves 
 readily manageable. Different, however, is it when the product 
 of a sluggish abdominal circulation, with much general weakness 
 and pravity of system. The haemorrhage here is sometimes 
 enormously copious, and immediately alarming in its menaces. 
 
 Lieutaud mentions a person who bled six quarts in two days, 
 and by Panaoli we are told of another who voided a pint of 
 blood daily, for two years. 
 
 Copernicus and Arius, the heretic, are said to have died in 
 this way. The death of the latter, however, is ascribed to a 
 very different cause by Gibbon, the historian, who, from the 
 accuracy with which he examined most subjects, is probably 
 correct. An instance is related, by Hoffman, of a woman with 
 amenorrhea, who evacuated upwards of twenty pounds in less 
 than twenty-four hours, — and Borelli alludes to a case of a man 
 where ten pounds were lost at one time. 
 
 These accounts would seem the more exaggerated, were there 
 not well-authenticated statements of prodigious haemorrhages of 
 this nature. Calvert, a late writer, has presented us with the 
 history of a woman, "who purged three chamber pots full of 
 bloody fluids in less than two hours,— and of another, from whom 
 escaped a pint of pure blood daily, for near a fortnight." Not im- 
 probably, in some of these cases, there was maelena, — the blood 
 proceeding from congested liver or spleen, — these organs being 
 very often in such a state in the haemorrhoidal affections. Yet 
 I have seen several instances where the effusion was excessive 
 and exceedingly intractable, evidently from the rectal vessels, 
 among which, that of a gentleman attended by the late Professor 
 
244 HEMORRHAGE. 
 
 Physick and myself, who informed us, that he must, on an 
 average, have lost half a pint of pure blood daily, for eighteen 
 months, and on several occasions, the amount could not have 
 been less than two quarts. 
 
 Contemplating the causes of hasmorrhois, very little may suffice 
 to render intelligible its anatomical characters. These are varied 
 according to the nature or seat of the affection. There may 
 be detected merely a turgency of the veins, which collect the 
 blood from about the verge of the anus, as well without as within 
 the sphincter, of an arborescent aspect,— though sometimes one 
 or more of these vessels are so distended as to appear varicose, 
 or knotty, or irregularly protuberant. 
 
 In some chronic cases the veins present this state for several 
 inches up the intestinal tube, even as far as the colon, as large as 
 a quill, and Morgagni saw a single one of the size of his thumb: 
 — on other occasions, by extreme dilatation at a point, a cyst-like 
 formation takes place of considerable dimensions. The veins, 
 too, thus enlarged, their ramifications, by interweaving, are found 
 accumulated in a mass covered by the lining tissues of the rec- 
 tum, exhibiting a globular shape, situated within, or extruded 
 out of the anus, and sometimes of prodigious magnitude. 
 
 Commonly, however, more definite tumours are exhibited and 
 of diverse conditions, soft, compressible, or of several gradations 
 of firmness and consistency. Cut into, some are found to con- 
 tain either fluid or coagulated blood, or lymph — are celiulated 
 or dense, or more solid, or, as now and then occurs, are empty 
 sacs, with sometimes an aperture. They have little vascularity, 
 are often of a somewhat pyriform shape and attached by a neck. 
 
 Tumours of another character are also exhibited, which have 
 the appearance as if formed out of an erectile tissue. Generally, 
 three or four co-exist in a case, one being larger and more promi- 
 nent than the rest. They are of a florid, or oftener of a purplish 
 hue, with a very vascular surface, soft, spongy feel, and bleed 
 profusely. When small, they are usually found retracted within 
 the gut, and otherwise, extruded, sometimes in considerable 
 masses. Dissection shows, I think, that they consist of a portion 
 of the mucous tissue, separated, as it were, from its connections, 
 is pushed down, and by the grip of the sphincter becomes of a 
 tumoroid nature. 
 
 Moreover, we meet occasionally with tumours situated exter- 
 
HEMORRHAGE. 245 
 
 nally — when recent, soft, and covered with mucous membrane, 
 and in the chronic state, hard, and with a thick round margin, 
 the whole invested with skin, this conversion of the tegument 
 being effected by exposure to the atmosphere. Not inflamed, 
 they are of a brownish hue, having sometimes their surface 
 broken into fissures, oozing forth ichorous or impure purulent 
 matter of some kind. They seem to be composed essentially of 
 cellular membrane, into which fibrin has been extravasated, and 
 are so destitute of vascularity, that they scarcely bleed. 
 
 Of these several kinds of tumours, by far the most common, I 
 think, are those induced by a protrusion of mucous membrane. 
 But a very different opinion seems to be entertained by some of 
 the eminent surgeons of London, including Bell, Home and 
 Brodie, all of whom adhere to the notion of the "olden time," of 
 their origin in varicose veins. Brodie has recently told us that 
 " those ultimate changes which take place in piles, are similar to 
 what happens in varicose veins of the legs. The veins, at first, 
 simply dilated, become inflamed when lymph is deposited in the 
 surrounding cellular membrane, producing a great mass of in- 
 duration, in which the blood-vessels are, as it were, imbedded. 
 Exactly so is it with the veins of the anus and rectum. They, 
 at first, become merely dilated, repeated attacks of inflammation 
 cause extravasations of lymph into the adjacent cellular tissue, and 
 then the pile appears like a solid tumour, — in the centre of which, 
 however, is still to be found the dilated vein from whence the dis- 
 ease originated." It is with unfeigned diffidence that I dissent 
 from such high authority, and should not do it, were I not sus- 
 tained by very numerous writers entitled to equal confidence, 
 among whom of the continent are Le Dran, Richter, De Mon- 
 tagre,&c. — and of the British Isles, Abernethy, Calvert, Colles and 
 Kirby, &c. No one, probably, has investigated the anatomical 
 structure of hemorrhoidal tumours with more care, or to a greater 
 extent than the latter, — and he declares that he never met with 
 even a solitary instance of varicose tumour. These are the local 
 lesions properly appertaining to the hemorrhoidal condition, any 
 one of which may exist separately, or two or more, or the whole 
 together. Combined with them there are, also, in some instances, 
 what may be deemed extraneous or accidental productions, as 
 prolapsus, stricture, abscess or fistula, ulcerations, &c. 
 
 Extending our researches into the cavity of the abdomen, more 
 
 21* 
 
246 HEMORRHAGE. 
 
 or less disorder of its viscera will sometimes be revealed. An 
 infarction of the liver or spleen is most common — though diverse 
 lesions are sometimes discoverable in the prima? vise, among 
 which is turgescency of vessels to the varicose condition, in any 
 one part, even in the stomach itself. 
 
 From the preceding exposition it is deducible that these haemor- 
 rhages may be mostly traced to one common source, an obstruc- 
 tion in the return of blood to, or through the hemorrhoidal, the 
 inferior mesenteric veins, or the branches of the vena portarum. 
 The effect of this is to accumulate the fluid in those veins more 
 immediately concerned in the parts implicated, and when the en- 
 gorgement is excessive, a rupture of a vessel may possibly take 
 place, followed by a haemorrhage to a greater or less degree, or 
 by an extravasation of blood or lymph into the subjacent cellular 
 tissue, forming the varieties of tumours incident to the disease, 
 or what more commonly occurs, the gorged state of the veins 
 fills the capillary arteries, and the effusion, or the other conse- 
 quences described, are produced in this mode. 
 
 Not very often does any blood escape from the tumours them- 
 selves, they serving merely to irritate the neighbouring capillaries 
 to the hemorrhagic effort. The only exception, perhaps, and 
 this can be hardly considered as such, since it is not a tumour in 
 the sense in which the term is here used, is in that sort of swelling 
 or tumoroid appearance formerly described as arising from a 
 congeries of enlarged veins. No doubt these do bleed, and very 
 copiously too, of which we have the most conclusive proof in a 
 remarkable instance, reported by Sir James Earle, of the kind, 
 measuring nine inches in circumference, out of the surface of 
 which blood emanated most alarmingly. 
 
 Not unknown to me is it, that till lately, an opinion almost 
 universally prevailed that the haemorrhage was occasioned either 
 by rhexis or diapedesis, rupture of the vessel, or transudation 
 through its texture. Excepting, however, the instance already 
 stated of varicose veins, where probably the effusion is sometimes 
 assignable to rupture, though a very rare event, recent and more 
 accurate inquiries have shown the fallacy of each of the former 
 hypotheses, and that it is owing to anastomosis, or effusion from 
 the exhalents. Calvert, a respectable writer previously cited, 
 affirms the fact, and Montagre, perhaps a higher authority, in 
 accounting for this haemorrhage, declares that, "on a sanguine- 
 
HEMORRHAGE. 247 
 
 ous determination to the rectum, under certain circumstances, 
 a flow of blood ensues by a kind of exhalation from the mucous 
 membrane, without any lesion or erosion of the tissue whatever." 
 
 Nor is the equally received notion more correct, that the haemor- 
 rhage proceeds from the veins in any other manner. Dependent 
 on a varicose state of these vessels, such may occasionally be the 
 fact. But otherwise, it undoubtedly comes from the arteries, 
 in absolute demonstration of which, florid blood has been seen 
 oozing out of the arterial extremities on the surface of the rec- 
 tum. This is positively asserted by Calvert and Montagre, who 
 are well entitled, from their accurate observations, to be heard 
 authoritatively on the subject. 
 
 Hsemorrhois, when active, seldom requires any treatment, sub- 
 siding spontaneously on the removal of the state, for the cure of 
 which it is designed by nature, and where it does not, the plan 
 is simply depletory and antiphlogistic. General or local blood- 
 letting over the lumbar region, — perhaps a blister in the same 
 position, gentle evacuation of the bowels, so as to obviate cos- 
 tiveness, and the nitrate of potash, with rest in the recumbent 
 posture, and low diet, constitute the best means of fulfilling the 
 indication. But it is very different in regard to the other form 
 of the affection. There is in this case, a condition much the 
 reverse of the preceding one. The circulation is languid, with 
 general debility, and the indications of pravity of system. By a 
 copious discharge at once, or very frequent repetition of it in 
 smaller quantities, an almost exsanguineous state takes place, 
 attended by frightful exhaustion and general disorder of health. 
 
 It is plain, that the object here is to check the effusion as 
 quickly as possible, and the best means of doing it is by injections 
 of the styptics and astringents, or of intensely cold water, or by 
 filling up the rectum with pulverulent matters, or by compres- 
 sion by the sponge tent, with rest in bed, the breech considerably 
 elevated. Not much advantage is derived from the internal exhi- 
 bition of the acetate of lead, or similar articles in which confi- 
 dence is placed in other haemorrhages. Lately, the ergot has 
 been proposed, I presume merely from analogy, which I am 
 sure would prove useless. Dry cupping and a blister to the 
 lumbar region might be proper. That an emetic would be so, I 
 cannot pretend to say from any experience, though, on general 
 
248 HEMORRHAGE. 
 
 principles it promises so well, that I should certainly venture on 
 it in an emergency. 
 
 These means being unavailing, the case must be resigned to 
 the resources of surgery, consisting mainly of an application of 
 ligatures, or of the actual or potential cautery to the bleeding 
 vessels. 
 
 Notwithstanding the subject does not belong to me, I cannot 
 forbear to throw out a few suggestions for the management of 
 haemorrhoidal tumours. 
 
 Diversified as these are, in any instance where the circulation 
 is full or active, or there is local inflammation, we have recourse 
 to venesection, and to obviate constipation, to a gentle evacuant 
 of the bowels. Let it be mentioned here, as a practical precept 
 of some value, that if the patient is obliged to sit up to attend to 
 business, the purge should invariably be taken at night, as by 
 the recumbent position much of the distress from the operation 
 is prevented. Topical measures may also be employed for the 
 purpose of allaying the pain and swelling, and among these, 
 leeches would seem to be well adapted. It has, however, been 
 objected to them, that they increase by a fluxionary movement, 
 the determination of blood to the tumours, and more directly 
 aggravate the phlogosis by their bites. This is true when they 
 are applied to the tumours themselves, and equally holds with 
 regard to all other analogous cases. Even ordinary phlegmons 
 are exasperated by such practice. It never fails scarcely so to 
 heighten the inflammation of a boil or bubo, as to hurry on sup- 
 puration: whereas, if the leeches are put on the surrounding 
 parts, they, by acting revulsively, produce directly an opposite 
 effect, or abate or completely resolve the swelling, — and such is 
 the course which ought to be pursued in regard to haemorrhoids. 
 Yet not as much is gained from them in the latter application as 
 might be expected, and hence they are nearly abandoned by our 
 best practitioners. 
 
 We are told that relief is speedily afforded by puncturing these 
 tumours. As the circulation is maintained with the varicose 
 species, it is not prudent in them to do it, from the danger of 
 haemorrhage. Calvert relates a case which came under his own 
 observation, "where the individual bled to death from punc- 
 turing some tumours formed by a varicose state of the haemor- 
 rhoidal veins." Though such a result must have been owing to 
 
HEMORRHAGE. 249 
 
 utter negligence, or a disreputable want of discrimination and skill, 
 it were well, perhaps, to avoid the operation, from the possible 
 occurrence of such a haemorrhage as to require the application of 
 means of suppression of an inconvenient or painful description. 
 
 In the spongy tumours, scarifications, and even deep incisions 
 into them, are said to have been practised with advantage. 
 Merely to puncture them, however, were useless, as the fluid is 
 so enclosed in the cellular tissue, that it is not discharged, and in 
 chronic cases, there is, indeed, none at all. 
 
 As palliatives, the following applications may be tried. 
 
 1st. The steam of warm water, by sitting over a bidet. 
 
 2d. Lotions of lead water and laudanum, or of diluted vinegar. 
 
 3d. Embrocations with a soft liniment, or pure lard, to which 
 are added Goulard's extract and laudanum, or with the liniment 
 or the carbonate of lead, or with the weak blue mercurial oint- 
 ment or that of the narrow leaf dock, or of stramonium, or the 
 mullen. The latter, especially, is truly a lenitive. 
 
 4th. The application of the pulp of gourds, or of a rotten apple 
 or lemon, or a cataplasm of camomile or elder flowers, or poppy 
 heads, and especially a saturnine poultice with laudanum, which 
 last I have found, on the whole, most serviceable. 
 
 5th. An anodyne injection, or suppository of opium, where 
 the use of these means is not very painful, may be tried, and 
 Montagre speaks highly of enemata of cold water. But the 
 administration of these and other injections is generally resisted 
 in this exacerbated state of the affection, and under such circum- 
 stances, where the tumours are protruded and highly inflamed, 
 pulverized ice, enclosed in a bladder, may be applied to them 
 occasionally, not being permitted to remain on long at any one 
 time. 
 
 Delicately touching the tumours with lunar caustic is declared 
 to be the most effectual of all remedies, it at once allaying sen- 
 sibility and assuaging pain, of which I know nothing myself. 
 Burnt alum, I have long been aware, has this effect on inflamed 
 tonsils, and from analogy, I am disposed to believe in the report 
 regarding the former application. Rest and elevation of the 
 breech afford considerable relief in this state of the tumour, 
 though much more is attained by returning it, so as to extricate 
 it from the grip of the sphincter ani, by which it is incarcerated, 
 and should always be attempted. 
 
250 HEMORRHAGE. 
 
 Having overcome the activity of inflammation, we may next 
 exhibit what is called Ward's paste, a nostrum of great repute, 
 very strongly recommended by the English surgeons, particularly 
 Cooper and Brodie. It is prepared as follows.* 
 
 In what mode this strange compound operates is not very 
 intelligible. It is said, from its indigestibility, to pass down to the 
 rectum, and to act locally, in confirmation of which notion, we 
 learn that when thus directly applied, though excessively painful, 
 it proves ultimately very beneficial. But of this explanation I 
 am entirely distrustful. 
 
 There are some other articles now to be mentioned of a similar 
 character, and, probably, of equal erncacy, the modus operandi 
 of which can be on no such principle. Among these are cubebs, 
 and I have used the balsam copaiva with success. Even the 
 spirit of turpentine, heating as it may seem, and hence centra- 
 indicated, was a favourite remedy with the late Professor Kuhn, 
 and pills of tar or pitch I find to be recommended. As most of 
 these articles do good in moderate gonorrhoea or gleet, or other 
 similar affections of the mucous surfaces, so I presume they do in 
 the present case, by allaying, or rather counteracting irritation. 
 
 The local means, in this state of the hemorrhoidal tumours, 
 are the gall and tar ointments, or that made of black hellebore, 
 in the proportion of a drachm to an ounce of lard. This I have 
 not tried, for though represented as very effectual, it is confessed 
 to be severely painful. Compression is also practised, when the 
 tumours are low down and little sensible, by a conical tent kept in 
 by a bandage, and when high up, by the rectum bougie, or as a 
 substitute, a piece of wax candle. It is an interesting fact, that 
 though violent or continued riding on horseback is a common 
 cause of this affection, gentle equitation, when it exists in a par- 
 tially subdued state, has a contrary effect, sometimes even dis- 
 persing the tumours. 
 
 No great deal, however, is to be expected from any of these 
 
 * R. 
 
 Piper. Niger. 
 Rad. Elicap. aa 3viij. 
 Sem. Fosnicul. 3xxiv. 
 Mel. et Sacch. aa Ibj. 
 Misce in mortar, et ft. Electuar. 
 The dose is a piece of the size of a nutmeg, twice a day. 
 
HEMORRHAGE. 251 
 
 expedients, according to my experience. Most of the chronic 
 cases of the disease are kept up by great disorder of the system, 
 particularly of the abdominal viscera, and the only practice from 
 which any uniform success can be anticipated, must be dictated 
 by a careful determination of the precise pathological condition. 
 Without this prerequisite it is utterly impossible so to adjust the 
 remedies as to attain any efficient operation from them, and with 
 it, cures are very often accomplished. More of this presently. 
 
 Nevertheless, defeated in our design, and should the tumours 
 prove exceedingly inconvenient or detrimental, it will be best at 
 once to extirpate them by a surgical operation, the reluctance to 
 submit to which has probably been increased, in part, by the 
 unnecessarily tedious and often agonizing manner in which it is 
 performed by ligature. No operation is more excruciating, or 
 where the sufferings are protracted to so lengthened a period. 
 Nor is it always exempt from danger. Examples of death are 
 reported from excessive nervous irritation, — from tetanus, — from 
 the intensity and diffusion of inflammation to other parts, — and 
 from the violence of secondary fever, not unfrequently arising 
 from phlebitis. It is wonderful, indeed, that such catastrophes 
 have not oftener happened, — for no demon of wickedness ever 
 devised or practised greater torture than is here sometimes in- 
 flicted. Clipping off the tumours, on the contrary, by scissors, 
 the pain is limited to a moment only, and the dread of hsemor- 
 rhage, hitherto serving to deter from this mode, has been greatly 
 exaggerated. Excepting in the varicose tumour, any extent of 
 bleeding cannot possibly ensue, and as to it, not much is to be 
 apprehended, since it would probably be checked by retraction 
 of the vessel, and at all events it may be artificially controlled. 
 
 Granting the very worst, I still suspect that comparing the 
 instances of disastrous results of the two operations, those from 
 excision would not be found more numerous, even in this appli- 
 cation of it. Excluding, however, the varicose cases, and which 
 are readily to be discriminated, for the most part, its general 
 propriety will scarcely be affected, owing to the extreme rarity 
 of their occurrence. Determining, however, to adopt the other 
 course, the wire is much preferable to the string ligature, it being 
 more prompt, less painful, particularly when the skin is not em- 
 braced, — though bad enough! Nevertheless, since there is great 
 difference of opinion among the regular surgeons on this subject, 
 
252 HEMORRHAGE. 
 
 and, perhaps, a preponderance of authority against the safety of 
 excision, except under special circumstances, it may be right to 
 state what was the practice of the late Professor Physick, so 
 cautious, so wise and so experienced ! External piles, covered 
 by skin, he uniformly cut off by scissors, and the internal, coated 
 with mucous membrane, when of any size, removed by the 
 wire ligature, introduced by himself in place of the string here- 
 tofore adopted. The practice he thus varied, from the ligature, 
 in the first case, giving great pain, sometimes followed by inflam- 
 mation and other evil consequences, and excision he deemed 
 entirely safe, and without these objections. But in regard to 
 the second case, the suffering being comparatively slight, and 
 the haemorrhage sometimes alarmingly copious and difficult to 
 restrain, — having even proved fatal, according to testimony on 
 which he relied, he thought that excision should be avoided, 
 with the exception just stated, and always employed the other 
 mode of procedure. But who shall decide when surgeons dis- 
 agree ? My friend, Dr. Harris, of equal judgment, and very wide 
 experience, on the contrary, invariably practises excision, and 
 has never met with, in his numerous operations, any of the 
 objections so strenuously urged against this plan. 
 
 It may be asked, is there no tendency in this disease to a 
 natural cure ? As to the acute states of it, such an event very 
 often happens, as I have previously said, and with very little 
 difficulty. There are, too, other modes in which it occasionally 
 takes place. The blood or other fluid contents of the pile may 
 be absorbed and the cavity obliterated, or the tumour suppu- 
 rates and discharges, and a cure follows pretty much in the same 
 manner. This result is chiefly incident to the external affection. 
 Cases, however, have been met with where large masses of 
 internal tumours being protruded and firmly grasped by the 
 sphincter ani, strangulation ensued, leading to mortification, 
 and the sloughing of the whole away, to the permanent eradica- 
 tion of the disease. It is somewhere related that the celebrated 
 Home Tooke, who suffered from piles many years, was finally 
 relieved by this process, and when utterly despaired of by his 
 medical attendants. 
 
 In returning again to the more immediate consideration of the 
 hemorrhoidal flux, some of my remarks will refer equally to 
 the other form of the disease. Little would be accomplished in 
 
HEMORRHAGE. 253 
 
 many instances were that condition permitted to remain which 
 predisposes to or excites an attack. Not .to dwell on this point, 
 rendered unnecessary by the instructions delivered under some 
 preceding heads essentially similar, I shall be content to observe, 
 in the first place, that constipation, or the reverse, active purging, 
 should be guarded against, the food and drinks moderate in 
 quantity, and not at ail stimulating, and the habits of indolence 
 overcome, to which may be added cold ablutions daily of the 
 parts. Being persuaded, however, of an obstructed or other 
 depraved state of the abdominal viscera, an alterative course of 
 mercury usually becomes proper, and when the case is of a 
 vicarious nature, proceeding, for example, from suppression of 
 the catamenia, endeavours are to be directed to the restoration 
 of the function. But, as in other haemorrhages, extreme weak- 
 ness, with tenuity of blood, sometimes exists, leading to the pre- 
 sumption that the recurrence of the discharge is owing to those 
 conditions. The martial preparations are here the best remedies, 
 and great confidence is reposed by some practitioners in mode- 
 rate purging with aloes, which, though held to be pernicious in 
 the excited condition of the disease, is represented as acting 
 otherwise when such feebleness and laxity prevail. But such a 
 course I cannot advise. 
 
 Notwithstanding all that has been said, it is not easily to be 
 conceived how infinite is the relief from the appearance of the 
 hsemorrhoidal affections in many diseases, as fevers, cerebral dis- 
 turbances, and the congestion or inflammation of the abdominal 
 viscera, &c. Considering the intimate connection of the hemor- 
 rhoidal vessels with the whole of the portal circulation especially, 
 this, in regard to the latter lesions, might be expected. The salu- 
 tary effect, however, is not altogether owing, as is usually sup- 
 posed, to the blood effused. Nearly as much is to be ascribed 
 to a revulsion in the circulation, establishing a new centre of 
 fluxion, in proof of which, tumours not bleeding are scarcely 
 less serviceable. This natural process of cure may be success- 
 fully imitated by the application of leeches about the verge of 
 the anus. French practitioners particularly, very highly appre- 
 ciate it, and justly, according to my own observations, having 
 resorted to it in a wide circle of cases. 
 
 To attempt at all the cure of haemorrhois, some have doubted 
 the propriety. That a sudden suppression of it has, in some 
 22 
 
254 HEMORRHAGE. 
 
 instances proved hurtful cannot be denied. To restore it when 
 such is the effect, is a most important consideration, and which 
 may usually be accomplished by active purging with those ar- 
 ticles, operating specifically on the rectum, or by stimulating 
 enemata,— by an application of leeches around the anus, and 
 the frequent use of a semicupium. Yet haemorrhois is trouble- 
 some,— occasionally leads, as we have seen, to serious conse- 
 quences, and should be cured when admissible, of which an 
 enlightened practitioner will determine. Cases forbidding it are 
 very rare according to my experience. Doubts, however, of its 
 propriety being felt, the apprehended consequences may be avert- 
 ed by certain preventives, as a low abstemious course of living, 
 occasional bleedings and purgings, or, at least, due attention to 
 the bowels, and a vicarious drain or divellent, by a seton or issue. 
 The individual, however, not promising to submit to this course, 
 or, from his character or habits, distrusting his resolution to con- 
 tinue it faithfully, it were better to decline the radical cure, and 
 leave him to his fate. 
 
 In conclusion, I cannot forbear to observe, that between the 
 rectum and some parts of the body, and with the lungs especially, 
 there is a very close sympathy. Fistula in ano often ends in 
 phthisis pulmonalis, and should the latter pre-exist, the former 
 is rarely cured, or if cured, the consumption becomes aggravated. 
 An irritation of the rectum, from any cause is, indeed, very apt 
 to induce no inconsiderable constitutional derangement. We 
 see it strikingly exemplified in strictures of that intestine, not to 
 advert to the influence of other of its affections. Cherry stones 
 collected in this position, I once knew to excite a general tetanoid 
 state, and ascarides have, at different times, occasioned the whole 
 class of neuroses, as well as many other diseases. Even an 
 accumulation of indurated faeces has done very extensive mischief 
 in the same way. Curious in themselves, and as leading to im- 
 portant practical results, these facts should not be forgotten. 
 
 I have purposely discussed with brevity this subject, perhaps 
 the most important and interesting of all the haemorrhages when 
 viewed in its several relations, under the conviction that the 
 deficiencies of the mere sketch I have given will be amply 
 supplied by my colleague of the surgical chair in this school, into 
 whose province it enters. 
 
HEMORRHAGE. 255 
 
 CUTANEOUS HAEMORRHAGE. 
 
 Early in the history of medicine, certain red or purple maculae 
 or blotches were recognized on the cutaneous surface, to which 
 the titles petechias, vibices, &c, were given. These, however, 
 having, I think, been sufficiently ascertained to be merely con- 
 tingencies on fever and other acute diseases, subjected, with bad 
 ventilation, to heating or alexarpharmic practice, I exclude from 
 my present consideration. Differing entirely from Willan, by 
 whom the case I have in view is deemed an eruption, and is 
 placed by him in the order exanthemata, I hold it to be a variety 
 of haemorrhage, which, while conspicuously displayed externally, 
 belongs also to the mucous surfaces, as well as other parts of the 
 interior. It has, in comparatively modern times, been denomi- 
 nated, 
 
 PURPURA HEMORRHAGICA. 
 
 The first of these terms is said to be derived from a supposed 
 analogy in the colour of the spots to that of the shell-fish from 
 which the ancient purple dye was procured, — and the second 
 added to express the improved pathological view of the affection. 
 Founded on gradations of violence only, some distinctions have 
 been made in this haemorrhage by the more formal systematic 
 writers, which will not be regarded by me. 
 
 The mode of invasion of this haemorrhage is different. In 
 some cases it slowly approaches with the manifestation of gene- 
 ral disorder of the system, and particularly extreme lassitude, 
 weariness, disinclination to motion,— sometimes a tendency to 
 syncope, and depression of spirits uniformly. Deep-seated pains 
 are pretty constantly complained of in the limbs, — the back or 
 loins attended by a sense of anxiety and oppression, — anorexia, 
 — constipation, — flatulent distension, — embarrassed respiration, 
 or more acuteness of suffering in the praecordia, stomach, bowels, 
 lungs, &c. During this precursory stage, the circulation is most- 
 ly feeble, and may be decidedly so, with diminished heat and 
 moisture of the surface. But in other instances it is otherwise. 
 Even fever is not uncommon, more, however, of an irritative 
 or hectic character, — coming on in paroxysms, ending in per- 
 
256 HAEMORRHAGE. 
 
 spiration. These prelusive symptoms may continue for weeks. 
 Nevertheless, it as frequently comes on with little or no premo- 
 nition whatever, — the effusion of blood apparently anticipating 
 every thing else. Be its introduction in either mode, when the 
 attack is actually formed, there will be perceived, unless the 
 internal hemorrhage has been rapid and profuse, an indication 
 of reaction. The pulse becomes slower, fuller and stronger, with 
 greater warmth of surface and diffused excitement. Examples, 
 on the contrary, occur in which an aspect is presented of great 
 debility, owing to exhaustion from the cause just assigned, or the 
 oppression of vital energy by heavy engorgements. 
 
 Bateman thus accurately describes the cutaneous affection. 
 " The petechia? are often of a large size, and are interspersed 
 with vibices, ecchymosis, or livid stripes and patches, resembling 
 the marks left by the strokes of a whip, or violent bruises. They 
 commonly appear first on the legs, and at uncertain periods after- 
 wards, on the thighs, arms and trunk of the body,— the hands 
 being more rarely spotted with them, and the face generally free. 
 They are usually of a bright red colour when they first appear, but 
 soon become purple or livid, — and when about to disappear, they 
 change to a brown or yellowish hue, so that, as new eruptions 
 arise, and the absorption of old ones slowly proceeds, the variety 
 of colours is commonly seen in the different spots at the same 
 time. The cuticle over them appears smooth and shining, but 
 is not sensibly elevated: in a few cases, however, the cuticle has 
 been seen raised into a sort of vesicle, containing black blood. 
 This more frequently happens in the spots which appear on the 
 tongue, gums, palate and inside of the cheeks and lips, when the 
 cuticle is extremely thin, and breaks from the slightest force, 
 discharging the effused blood. The slightest pressure on the skin, 
 even such as is applied in feeling the pulse, will often produce 
 a purple blotch like that which is left after a severe bruise."* 
 
 * In a modification of the affection, the blood, instead of being thus deposited, 
 penetrates through the pores of the skin, as serum does in the perspiratory 
 process. 
 
 Both Aristotle and Theophrastus notice the occurrence, and I formerly cited 
 a passage from Lucan in which it is described. It has been met with in low 
 fevers, as stated by Huxham and other writers, though more generally it seems 
 to have been produced by extreme mental or bodily anguish, or the two united, 
 or whatever, indeed, throws the nervous system into vehement commotions. 
 Examples without number might be collected to this purpose, some of the most 
 striking of which I shall give. Charles IX., of France, a cruel and infamous 
 
HEMORRHAGE. 257 
 
 Moreover, it happens that, simultaneously with the affection 
 of the tegumentary tissues, the internal structures are simlariy 
 involved, and where the covering of the part is delicate and 
 readily ruptured, immense losses of blood ensue. These dis- 
 charges may be continued or intermittent, recurring daily, or at 
 more distant intervals, so that the duration of the disease is very 
 indefinite, terminating suddenly, or in a few days, or is protracted 
 for weeks, or months, or years. Not a little curious is it that, in 
 some chronic instances of it, though the purpura may remain, 
 vigorous health shall be enjoyed. The late Professor Duncan, of 
 Edinburgh, was in the habit of mentioning a boy whose skin 
 continued in this state for years, with proneness to ecchymosis 
 from the slightest injury, though seemingly otherwise so well as 
 to be capable of hard labour or the athletic exercises. Most of 
 the instances of the kind, however, sooner or later have ended 
 fatally by the supervention of enormous haemorrhage from an- 
 other part, and such was the fate of the boy who died ultimately 
 a victim to haemoptysis. The case I am to relate is analogous to 
 the preceding one. There was brought to me, in 1832, from the 
 country, a young woman, stout, full and strong, to be cured of a 
 series of livid blotches that occupied the surface of her body, and 
 of one of her legs. Eighteen months before, they had appeared 
 coincidently with hsematemesis, from the effects of which she 
 shortly recovered, with the retention, however, of the blotches. 
 No service did she derive from my prescriptions or those of other 
 physicians, and died, after a considerable interval, by a loss of 
 blood from the nostrils. 
 
 Not much is satisfactorily determined as to the causes of pur- 
 sovereign, tortured by remorse on the approach of death, thus perished. Meze- 
 ray, the historian who furnishes this fact, also mentions that of a Commander 
 of a garrison, who, condemned to die for having cowardly surrendered it, broke 
 out in such a sweat as soon as he saw the gallows on which he was to be exe- 
 cuted. Lombard tells us of a General similarly affected by the mortification or 
 dread of the consequences of losing a battle, — and of a woman, at the terror of 
 robbers, into whose hands she had fallen. We have, from Fabricius, the instance 
 of a mother who, in the depth of grief for the loss of an only son, thinking that 
 she had beheld his apparition, imploring her prayers for his relief from purga- 
 tory, became violently agitated, and was seized with this cutaneous exudation. 
 The Saviour of man himself, in the moment of his most excruciating sufferings, 
 presented this heart-rending spectacle. "By thine agony and bloody sweat," is, 
 indeed, one of the touching invocations addressed to his mercy, in the Litany of 
 the Church. 
 
 22* 
 
258 HEMORRHAGE. 
 
 pura. The highest authorities, however, seem to be agreed that 
 it is mainly associated with a bad habit of body, acquired by 
 some positive antecedent disease, or by inhabiting low, damp, 
 dark, ill-ventilated dwellings, with the other incidents insepara 
 ble from poverty,— penurious diet, defective clothing, — labour to 
 fatigue and exhaustion, — all aggravated by mental anxiety or 
 sharper misery. But no less is it admitted, that the affection 
 occurs, and, perhaps, nearly as often among persons seemingly 
 in sound health, and in the full enjoyment of the comforts and 
 felicities of life. These are the representations of the books, 
 which I am inclined to suspect refer to two states of disease 
 not identical, — the one a modification of scurvy, and the other 
 purpura proper, — thus indiscriminately confounded. Much have 
 I seen of the former, in the final stages of cholera infantum espe- 
 cially, and only some five or six cases of the latter, — every one 
 of which was in a healthy subject, of respectable condition, with 
 no privations or inconveniences of living. 
 
 The principal difficulty in the diagnostication of purpura arises, 
 indeed, from its analogy to these scorbutic bleedings. Contrast- 
 ing, however, the two affections in their prominent features, we 
 shall perceive sufficient individuality in them without descending 
 into details. Genuine purpura seems to me to be of sudden 
 access,— often without an appreciable cause, — takes place in 
 sound individuals, and is a singularly pervading and an active 
 haemorrhage, — the dermoid tegument participating to a limited 
 extent only. Extravasations of blood incident to scurvy, are 
 reversely slow in development, — uniformly preceded by extreme 
 pravity of system, brought on by obvious causes, — are more 
 local and of smaller amount, the blood being also different. Yet 
 much perplexity existing, the whole history of the case must be 
 surveyed in its rise, progress and present condition, so as to render 
 a correct decision attainable. 
 
 This is held to be a very serious, and not unfrequently a fatal 
 disease. But it has its gradations of violence, and in proportion 
 to this is the danger. Many cases of it are so slight as to pass 
 away spontaneously, or to exact very trivial remedies. There 
 are others, again, more alarming, to be cured by vigorous treat- 
 ment, and sometimes we have to encounter such as defy the 
 united resources of nature and art. Disastrous consequences are 
 here induced by the quantity of blood lost, and where we have 
 
HEMORRHAGE. 259 
 
 reason to suspect a large extent of internal surface to be con- 
 cerned in the haemorrhage, or it is poured out copiously of a 
 sudden, or continues long more moderately, or returns on a 
 temporary suppression of it with depression of the vital forces, 
 immediate death is to be apprehended, or a wretched state of 
 system to be entailed, which may finally lead to the same catas- 
 trophe. 
 
 Considerable attention has been paid of late to the anatomical 
 characters of purpura. The appearance of those of the exterior 
 has partly been noticed. I have only to add that, according to 
 Rayer, who made a careful dissection of the tegumentary tissues, 
 the effusion is not uniformly in the same position. He found it 
 on the rete mucosum, — in the alveoli of the cutis and in the sub- 
 cellular membrane. The first contained it when it exhibited the 
 petechial, and the last when the ecchymosed aspect. As the 
 deposits of blood were small or large, so was it fluid or coagu- 
 lated. 
 
 Evidence is afforded of the liability of the whole of the viscera 
 of the great cavities to share in the affection. The lesions con- 
 sist of petechias, vibices, or large ecchymosed spots, and effused 
 blood in clots or fluid, with softening of texture in certain organs. 
 These have been observed in the brain and meninges, — the lungs 
 and membranes, — the heart and pericardium, — the liver, the 
 spleen, — the uterus, and, above all, the mucous surface of the 
 primes vise. Not uniformly are phenomena so wide spread, met 
 with, — though pretty generally, — few instances severe enough 
 to occasion death it is presumable, being without them, and I 
 am not aware of a single case on record, in which there was an 
 entire exemption. 
 
 The peculiar obscurity confessed by many in the pathology 
 of purpura, I cannot perceive. That it is not of the nature of 
 scurvy, nor of the petechias of fever, is clear. Neither can it be 
 placed among the exanthematous eruptions. As an haemorrhage 
 it must be considered, varying from others in this respect chiefly, 
 that while the generality of them are assignable to obvious 
 causes, this one comes on in the absence of every thing to explain 
 its production. Coupling this circumstance with the extensive- 
 ness of its prevalence over the body, I know not to what else it is 
 referable than the constitutional state, vaguely called the haemor- 
 rhagic diathesis or tendency. Great reason have we to suppose 
 
260 HEMORRHAGE. 
 
 that it is independent of any of the ordinary organic lesions, and 
 proceeds from derangement of innervation, producing the change 
 in the capillaries and in the blood itself, favouring sanguineous 
 effusions, and which condition may be natural or acquired, the 
 latter, sometimes, also permanent or very enduring. 
 
 Not less established and more important in relation to prac- 
 tice is the fact that the disease does prevail in two very different 
 states of the system, with a full and febrile pulse, warm skin, — - 
 flushed face,— or the reverse. 
 
 Called to a case of any activity, venesection should be instantly 
 performed. It is the only decisive remedy. Nor is the amount 
 of blood detracted to be small, or any timidity to deter from a 
 repetition of the operation, where the necessity for it exists. I 
 drew as much as sixty ounces in one case, and in another, half 
 this amount, in several successive bleedings, with the most de- 
 cisive advantage. The course is justified by the state of the 
 circulation, by the appearance of the blood, which is thick and 
 sometimes heavily sized, by the albuminous urine, by the acute- 
 ness of pain in the cavities, and by the relief afforded from the 
 haemorrhage itself when not excessive. Many of the European 
 practitioners, as Parry, Mcintosh, &c, give to it their support, — 
 though not so intrepidly as I have ventured. But it is not to be 
 supposed that under any other circumstances than stated, and in 
 the extremest emergencies, would I carry it to such an extent. 
 Generally, my bleedings are far more moderate, and especially 
 in an advanced stage, where the loss of blood is ill borne. 
 
 Next in value of the remedies is purging deemed, with the 
 saline articles, and there are facts to render it probable that the 
 sulphate of soda is specially adapted to the disease. Great bene- 
 fit, however, is derived by cold applications to the surface, — 
 either sponging or covering it over with cloths wrung out of 
 water of a moderate temperature. Nay, on one occasion, in con- 
 sultation with Dr. Meigs, we immersed a girl in a cold bath, and 
 with such effect, that henceforward she speedily recovered. It 
 was on the second day of the attack, — the purpura pervaded 
 her skin, and though she had been previously depleted, the pulse 
 was still full and strong, and the surface warm. 
 
 No confidence do I place in the astringents and acids usually 
 appropriated to haemorrhage, and have little experience of the 
 alkalies and neutral salts recently recommended on the authority 
 
HEMORRHAGE. 261 
 
 of Stephens. But I am disposed to believe that opiates are de- 
 serving of attention, more, however, from analogy than any better 
 evidence. Emetics and the spirits of turpentine I would, for the 
 present, place on the same footing. 
 
 In the less active states of this disease, some variation in the 
 treatment is required. Blood-letting, if admissible at all, must 
 be practised cautiously, as well, indeed, as whatever else is cal- 
 culated to increase debility. Debarred of the former, however, 
 we are nearly destitute of means of any certainty of advantage 
 in an urgent emergency. Those previously enumerated, and 
 commonly employed, have proved nugatory in my hands. My 
 trust would be mainly in the sulphate of soda, the spirits of tur- 
 pentine, the sulphate of quinine, opiates and wine. 
 
 The skin, I have said, is sometimes left with purpura long after 
 the affection in other parts seems to have ceased. Too slender 
 is my knowledge of it, to express any decided opinion, either of 
 its nature or treatment. From what I have seen of it, however, 
 I suspect that the blood thus deposited, undergoes a change in 
 these particular instances, rendering it irremovable by the natu- 
 ral or assisted powers of absorption, or, perhaps, the blood itself 
 previously absorbed, some colouring matter separated from it 
 remains so intermixed with the texture it occupies, — so dyed in 
 the grain, as it were, as to constitute an indelible stigma or stain, 
 of which we are not defective in analogies. Be it, however, as 
 it may, I could not find any remedy for it in the only case of the 
 affection which has ever come under my care. 
 
 The disposition of purpura to return is very considerable. 
 There is a case reported where it reappeared annually, for six 
 successive summers, and many at shorter intervals, — -though of 
 less duration, — sometimes observing with tolerable exactness 
 the law of periodicity. Tendencies of this sort are carefully to 
 be guarded against by a strict avoidance of the exciting causes, 
 and by an endeavour to rectify the pathological condition, whe- 
 ther of the solids or fluids, which may be supposed to affect the 
 case. 
 
HYDROPS, OR DROPSY 
 
 Dropsy may be defined a preternatural collection of serous 
 or more viscid fluids, chiefly in the cavities or cellular mem- 
 brane of the body, and receives different appellations from the 
 particular situation in which the deposition takes place. The 
 principles, however, in the one instance, being essentially appli- 
 cable to the treatment of the whole, I shall call attention only 
 to the leading and more important forms of the disease, or, in 
 other words, to such as appertain to the practice of medicine. 
 
 Dropsy has been variously divided and classified. But the 
 most proper collocation of the cases is surely the one that has 
 reference to the tissues in which they may occur. Conformably 
 to this view, then, ascites, hydrothorax, hydrops, pericardii and 
 hydrocephalus internus, ought to be placed together as belonging 
 to the serous — and anasarca stand by itself, as the affection of the 
 cellular membrane. Effusions of the skin are too insignificant 
 to claim attention, and dropsy of the stomach and of the womb, 
 though noticed by some writers, as proceeding from the mucous 
 lining of these organs, may, in the same manner, be pretermitted 
 as of very doubtful existence.* 
 
 * Nevertheless, it is true that, from the internal surface of the stomach and 
 womb, there is, sometimes, a very copious exhalation of serous fluids. This, 
 indeed, often happens in the gastric affection denominated pyrosis, and I have 
 repeatedly seen analogous discharges from the uterus in very large quantities. 
 Cases of this description, however, can no more be considered as dropsy than 
 certain forms of watery diarrhoea. By hydrometra proper, seems to be under- 
 stood an affection of the womb, where, from some previous lesion, its mouth 
 becomes sealed up by a secretion of gelatinous matter, as in the early stage of 
 gestation, or by adhesion, or thickening, or by tumours, whereby the fluid poured 
 into its cavity is retained. The accumulations, under such circumstances, may 
 be to a prodigious extent, and, among other instances to this purport, not the 
 least remarkable, is one related by Vesalius, amounting to an hundred and 
 eighty pints, in what period we do not learn. But, several years ago, I attended 
 
HYDROPS. 263 
 
 Dropsy, in its practical relations, may be limited to the products 
 only of the serous and cellular textures. 
 
 In the management of the subject it may, perhaps, be best to 
 present, at first, a general view of it, withholding the details till 
 we come to the consideration of each variety of dropsy, when 
 it will be proper to notice the peculiarities by which they are 
 severally distinguished. 
 
 Diversified greatly by its locations, it is nearly impossible, 
 in any general description, to embrace the symptoms of the 
 modifications of the disease. Each form has its peculiarities to 
 a certain extent, and between some of them there are scarcely 
 any common features of resemblance. Pathologically the same, 
 they are still as different in their external physiognomy, as affec- 
 tions the least allied. 
 
 In the ensuing sketch, I shall refer to dropsies of the thorax, 
 abdomen and cellular tissue, these having the closest affinities. 
 Cerebral effusions are too distinctive to be included in it. Even 
 thus limited, there is an additional difficulty in the just delinea- 
 tion of dropsy, from the commingling of its own symptoms with 
 those of the lesion whence it proceeds. 
 
 Taken in the average, however, the hydropic condition in 
 view, is very strongly characterized. First, there is distension or 
 bloatedness : the complexion pale or sallow, or dingy, the skin 
 dry, harsh and unperspirable, the temperature of the surface low, 
 or unequally diffused, the urine scanty and high-coloured, the 
 bowels costive, the appetite deficient, the process of digestion 
 impaired, — thirst considerable, or even intense, and the tongue 
 furred and moist, or clean, parched and red. As to the pulse, it 
 is vigorous and tense, or small and corded, or feeble, diminutive 
 and accelerated, or full, soft and compressible. Cough and 
 
 a lady who, in six days, I am sure evacuated nearly this amount, and I was 
 assured that some time before and afterwards it was not less. The case was 
 connected with caries of the dorsal vertebra. The lesion giving rise to such 
 effusions is, usually, inflammation, followed by ulceration of the mucous coat — 
 though, in the more chronic states of the disease, every variety of disorganization 
 of the uterus has been detected, as well as of other portions of the abdominal 
 contents. The sufferings in this affection are mostly severe, and occasionally 
 excruciating, modified by the state and degree of the injury. It need scarcely 
 be observed that, in pregnancy, the uterus is liable to enormous distension from 
 an undue secretion of the amnios, in which, however, the viscus itself has little 
 or no concern. 
 
264 HYDROPS. 
 
 oppression, languor and disinclination to exertion exist, with 
 hebetude of mind, and disposition to somnolency. Debility and 
 emaciation rapidly advance, exactly, indeed, as the intumescence 
 increases and the circulation is more disturbed, becoming quicker 
 or slower, and may be intermittent. Feverish irritation now 
 steadily prevails, exasperated in the evening, — palpitations of 
 the heart occasionally are felt, respiration is farther embarrassed, 
 so that recumbency can no longer be endured, and sleep is inter- 
 rupted by agitating dreams, or a sense of suffocation. As deline- 
 ated, such is the tenor of the disease, which, however, independ- 
 ently of the position it occupies, may be varied by other causes, 
 and particularly by the degree of its activity, either inflammatory 
 or the reverse. It sometimes comes on suddenly, and runs through 
 its stages with force and expedition, — while oftener, perhaps, its 
 approach is gradual and it lingers out a feebler and more pro- 
 tracted existence. 
 
 Dropsy is one of those affections from which no age, or sex, 
 or temperament or condition is wholly exempt. But it is more 
 apt to occur after the meridian of life, rather in males than 
 females, more in the phlegmatic and attenuated than the san- 
 guine and robust, and in the humbler than elevated classes of 
 society. 
 
 Climate seems to exercise no inconsiderable influence in creat- 
 ing a predisposition to the disease. Thus in that of Egypt, Syria, 
 Arabia and Nubia, so steadily warm and dry, we are told that 
 dropsy is scarcely known, — while the fact is better ascertained 
 that in regions chilly, damp and austere, it greatly prevails. 
 Even temporary states of such weather are not without a similar 
 effect. Much, also, has been assigned in the same way to cer- 
 tain habits, occupations and diet. It is probable that the indolent, 
 or those who work in a sedentary position are more predisposed to 
 it than the followers of the active employments, or that the poor 
 who are fed inadequately, may suffer in consequence from it, to 
 a greater extent, and which has been remarked especially among 
 this class of people in seasons of scarcity or famine. But, though 
 undoubtedly nutritious, it is a common opinion, sanctioned in 
 some degree by professional authority, that a too exclusive use 
 of pork or fish conduces to the same end. 
 
 Dropsy, when acute, and of an active character, is the imme- 
 diate result of phlogosis of some tissue, and is excited by all those 
 
HYDROPS. 265 
 
 causes by which such a pathological condition is ordinarily in- 
 duced. These I shall not now enumerate. Cases, however, are 
 occasionally of a very anomalous character in their mode of pro- 
 duction, some of which may be deserving of recital. Exposure 
 to cold, or whatever checks perspiration, we are aware, is a 
 common cause of the disease, and not the least curious illustra- 
 tions of it have come under my own observation. 
 
 Many years ago, I was called in consultation with the late 
 Professor Physick, to a gentleman from Virginia, with general 
 dropsy, who traced its commencement to his having imprudently 
 plunged into a cold bath, while heated and sweating from severe 
 exercise. We were told by him, that the effusion took place a 
 very few hours after coming out of the bath, and that previously 
 his health had been perfect. 
 
 Nearly about the same time Dr. Physick and myself attended 
 a gentleman from South Carolina, with the same disease, by 
 whom we were informed that, in robust health, returning from 
 a tiresome and dusty ride, he went into a bath, the water of 
 which was so hot that he could scarcely bear it. Continuing 
 in it, however, for only a short time, on leaving it, he found his 
 skin very florid, even scalded, and soon experienced the disten- 
 sion of ascites, to which succeeded anasarca and next hydro- 
 thorax, so that when he came under our care he had general 
 dropsy. 
 
 Cases I have sometimes seen to follow almost immediately flat- 
 ulent colic. During the winter of 1812, 1 attended, with the late 
 Professor Wistar, a lad, who having become heated and fatigued 
 by skating, laid on the ice, and after a short period was seized 
 with colic, attended by a distension of the abdomen amounting to 
 tympanitis. By carminatives, opiates and external warmth, he 
 was very quickly relieved from pain. But on our next visit, a 
 few hours afterwards, we were astonished to find that he laboured 
 under ascites and oedema of the lower extremities. 
 
 In the summer of 1825, a lady from the country consulted me, 
 who after eating water-melon and some other fruits was attacked, 
 as she said, with colic, quickly converted into tympanitis, and 
 ultimately into dropsy of the abdomen and of the legs and feet. 
 This was the state of things when presented to me, which was 
 relieved in a few days by a copious watery discharge from the 
 kidneys and bowels. 
 23 
 
266 HYDROPS. 
 
 Crapulent colic in another and more recent instance, which, at 
 first, induced the most extraordinary degree of tympanitis I have 
 ever seen, ended in confirmed ascites. 
 
 Draughts of cold water have immediately excited the disease, 
 of which, probably, the most remarkable instance is afforded by 
 De Haan, who informs us that a large portion of the army of 
 the Emperor Charles V., when proceeding against Tunis, fell 
 into dropsy almost instantly after drinking freely of cold water, 
 while heated and exhausted, on a march in hot sultry weather. 
 
 Bateman reports a case still more extraordinary, where the 
 disease was at once induced by fright, and LudolfT de Meza 
 insists on its having occasionally followed violent paroxysms of 
 rage. But though dropsy may be thus suddenly brought on, it 
 is more commonly the result of some antecedent chronic lesion, 
 by which the animal economy is disordered. These lesions are 
 numerous and infinitely diversified, as will presently appear 
 when we come to describe the anatomical characters of the 
 disease. 
 
 Chiefly, in this country, it is consequent on ill-cured intermit- 
 tent or other autumnal fevers, or the inveterate habit of drunk- 
 enness, by which obstructions, or other depraved states of the 
 chylopoietic viscera are induced. That such conditions of the 
 liver and spleen, as well as of the pancreas and mesenteric glands 
 occasion it, is universally admitted. But it seems to be less 
 known that it proceeds from derangements of the primae via?. 
 Long-continued dyspepsia very frequently causes it, also pro- 
 tracted dysentery, and diarrhoea, and in still more instances, a 
 lengthened course of purging by the harsh and drastic articles, 
 according to my experience. 
 
 Moreover, it may be traced to depravation of the kidneys and 
 uterus, functional or otherwise, — to disorganizations of the lungs, 
 the heart and great vessels, and, in short, to all those affections 
 which exhaust the energies of the constitution or vitiate it, among 
 which are the ravages of irregular or misplaced gout or rheuma- 
 tism, the repercussion of eruptions, a dry, husky, unspirable skin, 
 following particularly scarlatina and other rashes, — profuse or 
 repeated haemorrhages, the abuse of mercury, or arsenic, or such 
 like articles, and lastly, a peculiar state of the blood itself, either 
 too abundant and rich in crassamentation, or the reverse, deficient 
 in quantity and impoverished, so as to become thin and watery. 
 
 External dropsy excepted, every other variety is involved in 
 
HYDROPS. 267 
 
 such obscurity as to render it more or less difficult of a precise 
 recognition. But a just discrimination, in many instances, is of 
 the highest practical importance. This consideration will lead me, 
 when I come to the discussion of the special dropsies, to devote 
 sufficient attention to their respective diagnoses, and to which 
 occasions, as the most appropriate, I mean to postpone the more 
 minute examination of the subject. 
 
 Transiently, I shall now remark that, in establishing the loca- 
 tion of the effusion, we may be greatly assisted by an accurate 
 investigation of the preliminary phenomena, — these being such 
 as denote ordinarily phlogistic or other disturbance of particular 
 organs or tissues. Thus, the dropsies of the chest are preceded, 
 and, indeed, very often accompanied by indications of some pul- 
 monary or cardiac affection, — those of the abdomen in a similar 
 manner of its contents, and so in regard to the rest of the effu- 
 sions. Next we are to inquire into the character of the case, — 
 how far it is acute or chronic, actively inflammatory or the 
 reverse, the degree of integrity of the constitution, and here our 
 course is illuminated by so many circumstances that we shall 
 experience comparatively little difficulty or embarrassment. 
 
 On the same account just mentioned I think it best to reserve, 
 for the future, the indication of those circumstances that help 
 us to decide on the event of the case, indulging, at present, in 
 only a few general reflections. Dropsy is a disease of no easy 
 cure, under whatever aspect it may be presented. Even cases 
 of recent date, originating from simple phlogosis, in a sound con- 
 stitution, too often perplex or baffle our efforts. But when of 
 long standing and dependent on any material organic lesion, with 
 vitiation of habit, the difficulty is so enhanced, that very seldom 
 can a permanent or essential sanative impression be made, and 
 we must be content to mitigate sufferings, and retard the catas- 
 trophe which we have not the power to control or prevent. It 
 is the organic lesion or lesions that constitute the difficulty, and 
 not the removal of the effusion, which is merely an effect, and, 
 for the most part, easy of attainment. (Edema, uncomplicated, 
 and arising out of local irritation of the cellular membrane, is, 
 perhaps, the only form of the disease in which our resources are 
 with any certainty exercised, or where we may, in a tone of 
 confidence, predict a speedy and absolute recovery. 
 
 My intention, and for reasons similar to those already ox- 
 
268 HYDROPS. 
 
 pressed, is now to dispose, in a succinct statement, of the autop- 
 sic appearances in dropsy. But, hereafter, my aim will be to 
 compensate for this deficiency by an ampler exposition. These 
 must be modified by the nature of the case, its cause, its location, 
 the degree of severity, its duration and simplicity or complica- 
 tion. The tissue immediately concerned exhibits the characters 
 of phlogosis, acute or chronic, with the effects of that process, 
 though not invariably. None such are sometimes discernible, 
 inflammation having been removed by the effusion in the slight 
 acute attacks, or never existed, as in those induced by an anemic 
 condition, with tenuity of the circulating fluids. 
 
 Derangements of structure, however, from the trivial to the 
 most serious, are pretty constantly detected in some one or more 
 of the organs of the two great cavities. Generally speaking, we 
 may expect to find, with copious effusions, the serous mem- 
 branes, whether of the thorax or abdomen, thickened and opaque 
 — sometimes harder or more dense, while, in other instances, 
 softer than natural — and, occasionally, though much less common, 
 extravasations of lymph, with false adhesions. It so seldom, 
 indeed, happens that there is any evidence of active inflamma- 
 tion, it may reasonably be suspected, when such appearances are 
 presented as just mentioned, that they are the product of some 
 antecedent phlegmasia, pleurisy or peritonitis, &c. The principal 
 changes to be observed in the cellular membrane are, thickening 
 or attenuation and dilatation of the cells, with here and there 
 several converted into one, forming large sacs or pouches. It 
 is predicable of both tissues, that all the anatomical phenomena 
 are rather the result of a slow, feeble and diffused phlogosis than 
 of a rapid, intense and concentrated state of the process. 
 
 As to the lesions of the solid viscera, every one to which these 
 organs are liable has been noticed in connection with dropsy. 
 There are some, however, more uniformly exhibited than others, 
 and these it may be well briefly to indicate. 
 
 Commencing with the lungs, I have to state that, perhaps, the 
 most frequent appearances are those of bronchitis, sometimes 
 slight traces of inflammation in the mucous coat, oftener only 
 thickened, softened or indurated, with now and then ulceration 
 and some of the bronchi dilated — in the substance of the organ, 
 chronic congestion, hepatization and other conditions of ob- 
 struction, though comparatively seldom any tubercular degene- 
 
HYDROPS. 269 
 
 rations. The heart is found scarcely less in fault, or variously 
 affected: whatever, in short, occasions an irregularity in its 
 functions, and particularly hypertrophy or dilatation of it, or de- 
 struction of its valves. Nearly the same may be asserted of the 
 liver and spleen. These viscera have been reported as altered 
 in every possible mode and degree, simply indurated or scirrho- 
 sified, or tuberculated, or studded by hydatids, or with one large 
 or numerous small abscesses, or of overgrown dimensions from 
 chronic congestion merely without any material change of struc- 
 ture — the latter being more incident to the spleen, which may be 
 enormously enlarged. But, while these increased conditions of 
 the liver incontestably tend to dropsy, it is alleged that, of all its 
 pathological states, the one most conducive to the event is that 
 where, of rather reduced dimensions, the substance becomes 
 granular, sometimes called the nutmeg liver, or, from the yellow- 
 ness of it, cirrhosis. 
 
 As diversified are the lesions of the kidneys. But to certain 
 conditions, as more steadily associated with dropsy, greater im- 
 portance has lately been attached. Bright, of London, who has 
 led the way in this investigation, thinks he is entitled to the con- 
 clusion that there are three states particularly to be met with, — 
 the first consisting of anemia or debility of the organ — the second 
 of induration of its cortical portion especially, and the third, of 
 a further degree of it, amounting nearly to the firmness of carti- 
 lage. This general induration of texture, however, on a more 
 careful inspection, seems, as well on the surface as the interior, 
 to be constituted of granulations, as in the case of the lesion just 
 noticed. Granting the correctness of his observation, it is still 
 true that many other changes in these organs are discovered, as 
 scirrhosity, suppuration, ulceration or adventitious formations, 
 tumours, hydatids or simple hypertrophy merely. Lesions of 
 the uterus and ovaries are frequently observed, which may not 
 be greater than belong to ordinary amenorrhoBa, or menorrhagia, 
 or uterine haemorrhage, or amount to injuries of structure of 
 every grade and kind. The appearances in the prima? via? have 
 been imperfectly recorded. It is to be inferred, however, that 
 they are such as belong to the chronic affections of the mucous 
 membrane of these parts under ordinary circumstances. 
 
 Each portion of the circulatory vessels is, sometimes, impli- 
 cated in dropsy. We are told that aneurisms of the large arte- 
 
 23* 
 
270 HYDROPS. 
 
 ries are not uncommon, that inflammation of their inner surface 
 is less so, though sometimes ulcerated, or the calibre is reduced 
 by thickening of the lining membrane, or choked up by fibrinous 
 clots or polypous concretions or osseous deposits, and that the 
 veins present nearly similar appearances, with the additional one 
 of complete obliteration, which has been particularly remarked 
 of the vena cava in three instances. 
 
 Lesions of the lymphatic system are occasionally displayed. 
 The vessels at all times are more prominent and apparently 
 enlarged, which, however, may be referred to the removal of 
 the adipose matter. But they are, sometimes, actually dilated, 
 and have been known to be ruptured, even the thoracic duct 
 itself, at least in one case. As frequently they are varicose, 
 and have been found entirely obstructed by concretions within 
 or obliteration of their trunks, from which states the thoracic 
 duct does not always escape. More uniformly affected are pro- 
 bably the lymphatic glands, throughout their entire distribu- 
 tion. Those surrounding the great vessels have recently been 
 described as enlarged and indurated, without any essential alter- 
 ation of structure, constituting merely an hypertrophy. But 
 it is to the mesenteric glands that attention has been mainly 
 directed, and with the lesions of which we are best acquainted. 
 These exhibit every modification of organic change. 
 
 The pathology of dropsy, though approaching to more cer- 
 tainty, continues unsettled. Till lately, the opinion was gene- 
 rally entertained that the disease arises from the destruction of 
 that exact balance which exists in health, between the processes 
 of exhalation and absorption. It was alleged that, when the 
 system is in a sound condition, a vapoury fluid or halitus con- 
 stantly escapes into every cavity or interstice of the body, which, 
 without being permitted to accumulate to any extent, is taken up 
 by the lymphatics and disposed of in a way sufficiently intelligi- 
 ble. Hence the conclusion that hydropic collections may take 
 place either by an excess of exhalation or from some decay or 
 imperfection in the powers of absorption. 
 
 Each branch of this doctrine, except with the limitations here- 
 after to be stated, is founded in error, and can no longer be sus- 
 tained. The fluid of dropsy is rarely, or perhaps never, precisely 
 the same as the natural product of the exhalents or the serum of 
 the blood. Even when approaching nearest to an identity, there 
 
HYDROPS. 271 
 
 is still a material difference, if not in the ingredients, in the pro- 
 portions in which they enter into the composition. Commonly 
 there is more water, and less animal and other matters, in the 
 hydropic deposition. But this may present every diversity of 
 character, having been found, according to an authoritative 
 writer,* "of all colours and conditions — yellow, green or black, 
 sometimes as thin as water and incapable of coagulation by heat, 
 which renders it only turbid — while, at other times, it is ropy or 
 gelatinous, so as to obstruct the canula in parenastisis, and has 
 been met with milky, or oily, or bloody, or sanious, or like the 
 glairy ichor of sores and singularly acrid, or so urinous or ammo- 
 niacal as to turn red substances green, or, from the quantity of 
 soda it contained, to form very readily, by the addition of sul- 
 phuric acid, Glauber salts." 
 
 The general diminution of absorption in the disease can no less 
 be disproved. It appears, indeed, that it is rather more vigor- 
 ously performed, since scarcely, under any circumstances, does 
 emaciation more rapidly advance. Much, or the whole, of the 
 adipose matter is speedily absorbed, and, in some instances, mus- 
 cles, cartilage, tendons, even bone itself, have been removed. 
 Extravasations of blood under the cuticle, in the shape of ecchy- 
 mosis or hsemorrhoea, are taken up, and no undue accumulation 
 of synovia] fluid occurs in the joints, which must happen were 
 there any suspension of the powers of absorption. The same is 
 to be remarked with respect to the great cavities of the body. 
 Thus, though one of them may be in a hydropic state, the others 
 are often entirely free, whatever is exhaled being at once re- 
 moved. Constipated bowels, with very indurated faeces, nearly 
 always an attendant on the early stage of dropsy, supplies a 
 further example to the same effect. There is here such quick 
 absorption of the thinner portion of the excrementitious matter 
 that the residue becomes hard and scybalous. 
 
 As far as we have proceeded, all is indisputable. But in 
 relation to the cavity affected, the state of absorption is not very 
 clearly ascertained. The accumulation of fluid, which appa- 
 rently denotes a want of it, is far from being conclusive of the 
 fact, since it may be owing to the increase of effusion. In a 
 very leaky condition, the ship will fill, though every pump shall 
 be sound, and worked with more than ordinary force and industry, 
 
 * Good. 
 
272 HYDROPS. 
 
 and so it may be occasionally, in dropsy, where the one greatly 
 preponderates over the other process. Effusion sometimes takes 
 place with almost inconceivable rapidity and copiousness, as is 
 strikingly evinced in some cases where it is replenished even in 
 a few hours after the operation of tapping. 
 
 Considering, however, the anormal state of the tissue affected, 
 it is not unreasonable to suppose that the absorbents, in common 
 with whatever else enters into its composition, may share in de- 
 rangements by which their functions become impaired or totally 
 suspended. Experience proves, indeed, that inflammation has 
 such an effect, and it no less appears to be incident to certain 
 atonic conditions. Even in health, the absorbents seem to pos- 
 sess a sort of elective affinity as to certain matters,— eagerly 
 seizing on some, — while others are rejected, — and which aver- 
 sion may be invincibly felt in regard to this morbid fluid. 
 
 Declining to decide this point positively, which with our present 
 intelligence, we are perhaps not warranted to do, it may be safer 
 to conclude, that in relation to the fluid thrown out in dropsy, the 
 same activity in the lymphatics is not usually displayed. The 
 conclusion from all I have said is, that the hydropic fluid is, for 
 the most part, widely different from that exhaled in a sound 
 condition, and that, though the absorbent energies generally are 
 not affected, they may be so occasionally, at least as to this fluid 
 particularly. 
 
 Conceding this, or that there is sometimes an aversion in the 
 lymphatics to this peculiar fluid, I cannot consider deficient ab- 
 sorption as a cause of dropsy, or that even the lesions of the 
 absorbent system, functional or organic, have any material influ- 
 ence in the production of the disease. Enough may it be, at 
 present, to state, in support of these conclusions, that the phe- 
 nomena of dropsy do not correspond, to any extent, with im- 
 paired absorption, or are at all reconcilable to such an hypo- 
 thesis, — and that every description of lymphatic derangement so 
 frequently occurs without accumulated effusion, we are scarcely 
 entitled to view the two conditions in the relation of cause and 
 effect. Examples are supplied by Moreton, Cullen, Monro, 
 Bichat, Cooper, Laennec and other writers where the principal 
 lymphatic trunks were obstructed in the absence of any hydropic 
 tendencies, — and Monro and Dupuytren tied the thoracic duct 
 in the lower animals as an experimentum cruets, and no effusion 
 followed. 
 
HYDROPS. 273 
 
 From the lights of my own experience, aided by those general 
 reasonings which never fail to influence more or less our opinions, 
 I should say that dropsy of every description depends on pre- 
 ternatural effusions. But in tracing out its pathology, we must 
 not stop at this point. The real or immediate source of the 
 disease is to be sought in a state of things prior to the serous 
 deposition. Does not the accumulation of fluid itself suppose 
 an antecedent lesion, since without it such could not happen? 
 That the hydropic condition is usually associated with the phe- 
 nomena of inflammation, is shown, in the first place, by most of 
 the remote causes of it, however diversified, operating to this 
 effect. It is not to the acute disease, suddenly induced, that I 
 now only refer, — every form of genuine dropsy seeming to me 
 to be embraced in the same category. For the right understand- 
 ing of the modus operandi of some of the causes, it may be proper 
 to advert to the well-known sympathetic relations which subsist 
 between the tegumentary and some of the internal tissues or 
 organs, by which there is a reciprocity in the vicarious perform- 
 ance of each other's functions. Constantly have we illustrations 
 of this in the interchange of efforts by the skin and kidney espe- 
 cially for mutual relief. Either having its excretory office sup- 
 pressed, the other is strongly disposed to compensate the loss, 
 and protect the general economy from consequent injury by an 
 increase of its own discharge. As such is a natural provision 
 growing out of the great principle of conservation, it can hardly 
 be deemed a morbid process under ordinary circumstances, — 
 though it may become so where the action of the organ is excess- 
 ive or long continued, it then inducing irritation, inflammation 
 or even structural lesions of the kidney. Different is it, however, 
 when any of the other viscera of the abdominal or of the thoracic 
 cavity, or, indeed, the subcutaneous cellular tissue is concerned. 
 It matters not, whether the subsidiary discharge of the fluid be 
 in the form of watery diarrhoea, or of broncorrhoea, or of effusion 
 into the occluded cavities, or of anasarca, the evidence of an ante- 
 cedent phlogistic irritation of the part whence it proceeds may, 
 I think, be always detected. The reason of this difference is, 
 probably, that the kidney being an emunctory, is more calculated 
 to execute such an office with impunity than organs or struc- 
 tures less accustomed to it. 
 
 Cold, therefore, which is a prolific source of dropsy, applied 
 
274 HYDROPS. 
 
 to the cutaneous surface, constricts it, and induces torpor of the 
 capillary circulation, whereby perspiration ceasing, some internal 
 organ or tissue becomes a centre of fluxion, leading to positive 
 inflammation, and sometimes to effusion. This, indeed, is pre- 
 cisely the mode in which all the phlegmasia are excited by an 
 exposure to cold. Generally, the vicarious elimination of fluid 
 takes place from the bowels or kidneys where it passes off harm- 
 lessly. But instead of such outlets for its escape, the serous 
 textures of the cavities being affected, were they to effuse copi- 
 ously, we must have dropsy inevitably ! This, then, is the mode 
 in which cold produces its effects, and most clearly so in the 
 extraordinary instance formerly mentioned, where dropsy imme- 
 diately followed plunging into cold water. 
 
 It may, perhaps, be objected, that, in the case of the hot bath 
 mentioned at the same time productive as speedily of the disease, 
 the result ought to have been the reverse, or an augmentation 
 of perspiration. But here the heat was so excessive it probably 
 closed the pores of the skin or stimulated it beyond the capacity 
 of action, as happens in scarlatina, and other efflorescences of 
 which dropsy is occasionally the consequence. It is proved that 
 perspiration does not take place where the temperature of the 
 surface much exceeds an hundred degrees. 
 
 The agency of colic is not so intelligible in those instances I 
 recited. Was the enormous quantity of gas condensed by some 
 unknown process into a serous fluid, or did it excite inflamma- 
 tion of the peritoneum, and effusions consequently take place ? 
 The latter is the more probable conjecture. Yet it is indisputa- 
 ble that all the secreting surfaces sometimes most abundantly 
 pour out air in place of their natural fluids. We see it in dys- 
 pepsia, in colic and in peritoneal tympanitis. Even the skin is 
 no exception, of which we have a good deal of proof, and espe- 
 cially in a case lately reported by a French writer. It was that 
 of a man who discharged gas in this way to such extent that, 
 being immersed in water, large bubbles came up all around him. 
 
 The modus operandi of the lesions of the viscera is evidently 
 by an extension of their irritations to an exhalent surface. An 
 objection, however, to this explanation has been raised in its 
 application to the kidneys. That by an interruption to their 
 secretory operation, serum may accumulate in the circulation to 
 an extent which, finding an outlet through the exhalents of a 
 
HYDROPS. 275 
 
 cavity or the cellular membrane, might produce dropsy, is not 
 inconceivable. Yet I am still more inclined to believe in the 
 other mode of operation, and that the case does not constitute an 
 exception to the general principle. Be it as it may, there can be 
 no doubt, when dropsy follows disorders of the alimentary canal, 
 such is the fact. 
 
 Nor is it less clear, in those instances arising from the metas- 
 tasis of cutaneous eruptions or other affections, that the primary 
 irritation is transferred to the seat of the effusion. 
 
 Of the blood in the production of this effect, I have to observe 
 that, in plethoric states, it is by causing a phlogistic irritation, 
 and that exhaustion from hsemorrhage, or in any way, may act 
 in one of two modes. Experiments demonstrate that, whenever 
 an exsanguineous condition is suddenly induced, there is an un 
 due determination of blood to the serous and other membranes, 
 by which, very likely, an irritation is raised, leading to effusion, 
 — or where, from the more lengthened influence of other debili- 
 tating agencies, the system suffers a general dyscrasy, the circu- 
 lating fluids may so far participate in the vitiation as to permit 
 the thinner parts to leak out of the patulous mouths of the ex- 
 halents. Not at all militating against my proposition, this fact 
 only lends confirmation to what I shall presently contend for — 
 that there are two species of dropsy occurring in very opposite 
 states of the system, and very differently induced. 
 
 That dropsy is sometimes the direct product of arachnitis, 
 pleuritis, pericarditis, peritonitis, &c, as well as of phlogosis of 
 the cellular membrane and the skin, is undeniable. The opera- 
 tion of a vesicatory is a conspicuous example of the latter. We 
 may refer, also, to the influence of rheumatic and arthritic irrita- 
 tion occasionally on the synovial tissue. Yet it is not less true 
 that these textures may pass through the several states of this 
 process without such an event, and most commonly, indeed, the 
 termination of it is otherwise. The pleura, the pericardium, 
 the peritoneum, at least when phlogosed, extravasate ordinarily 
 coagulable lymph, and the cellular membrane the same, having 
 a tendency, however, greater than the serous tissues, to the form- 
 ation of phlegmon and the secretion of pus. As inflammation 
 thus varies in its terminations, it must be susceptible of modifi- 
 cations, and we are led to inquire into the circumstances which 
 give to it that peculiarity inducing hydropic effusions. Con- 
 
276 HYDROPS. 
 
 nected necessarily with neither intensity nor feebleness of action 7 
 what is the condition required for its production ? 
 
 The question is one of great obscurity, and to attempt to solve 
 it by alleging, as has been done, that the inflammation is of a 
 specific nature, is only to repeat a barren, unmeaning phrase. 
 Little more do we know concerning it than that the disposition 
 to serous eliminations is comparatively seldom met with in recent 
 active phlogosis — most commonly vessels from chronic or sub- 
 acute states of it, and very much in proportion to its diffusiveness 
 and superficiality. Generally this proposition holds true. Can 
 it be disputed, for instance, that, when the cellular membrane is 
 topically, though deeply affected, phlegmon arises, commencing 
 with adhesive and ending in suppurative inflammation, — or, 
 under the other circumstances, that oedema is not as uniformly 
 induced? Equally is the doctrine appropriate to the serous tis- 
 sues, as is shown by the evidence of dissections, nearly always 
 meeting with lymphatic exudations in partial or isolated patches 
 of inflammation, and serous effusions where it is wide and slightly 
 spread over the surface. Take, for illustration, pleurisy and peri- 
 tonitis under different circumstances. More than to any of its 
 kindred tissues does this latter remark apply to the arachnoid, 
 which abundantly effuses serum, even when the phlogosis scarce- 
 ly exceeds an erythism. Delicate in the extreme in its fabric, it 
 is also averse to take on the adhesive or suppurative process, and 
 hence it is that, while these are pretty constant occurrences in 
 the peritoneum, pleura and pericardium, serous effusions are as 
 uniformly the product of its inflammations. 
 
 But is inflammation the sine qua non to dropsy, without 
 which it cannot take place ? That it is consequent on congestion 
 in some way, has been plausibly urged. Besides, the well-known 
 experiments of Lower, where effusion followed the tying of the 
 vena cava and the jugular vein, there is the less equivocal fact 
 of the occurrence of dropsy by the interruption of the circulation 
 from the resistance of diseased viscera, as the liver or spleen, by 
 pressure of the gravid uterus, by a ligature around a limb, and 
 by various other impediments to the return of the blood. These 
 are proofs habitually appealed to in support of the hypothesis, 
 affirming the connection of dropsy with congestion or obstruction 
 of the circulation, and which, at a glance, would warrant the 
 conclusion. But a more careful examination exposes the error 
 
HYDROPS. 277 
 
 and reconciles them to the doctrine of inflammation as the parent 
 of the effusion. This is a point, however, which may require 
 some elucidation. My wish is to convey the impression that, 
 where dropsy is to be traced to an interrupted circulation, an 
 irritation is created in the surrounding or remoter tissues, causing 
 the effusion instead of escaping, as is usually imagined, from the 
 large vessel or vessels so circumstanced. Thus, where the liver 
 or spleen is infarcted, and ascites follows, it is to be ascribed to 
 the inflammation excited in the peritoneum, and in the same 
 manner do organic affections of the lungs, the heart or brain 
 cause their respective dropsies by irritating the pleura, the peri- 
 cardium or arachnoides. As to the experiments of Lower, they 
 are equally explicable on a similar principle. Can it be pre- 
 sumed that a ligature around such vessels, (not to say any thing 
 of the tendency of the incision through the integuments,) should 
 not be productive of inflammation ? Doubtless it was induced 
 in the cellular membrane of the neck in the one instance, and in 
 the peritoneum in the other, productive of oedema and ascites. 
 But it is contended that a state of vascular repletion, what is 
 denominated plethora, may alone, independently of any appre- 
 ciable phlogosis in any one position of the body, induce dropsy. 
 Cases of the disease do unquestionably occur apparently under 
 these precise circumstances. But here a careful examination, I 
 think, will always detect topical congestion in some point, which, 
 as in the preceding instances of organic obstruction, excites in- 
 flammatory irritation in the contiguous tissue,, preliminary to the 
 effusion. 
 
 Discarding this explanation, we are compelled to resort to one 
 of two hypotheses, either that there is a mechanical percolation or 
 transudation of serum through the parietes of the over-distended 
 vessels, or that the accumulation of fluid proceeds from dimi- 
 nished absorption, neither of which is sustainable. Transudation 
 never takes place through the coats of vessels in the living state, 
 and, though the lymphatics do operate feebly when the circula- 
 tion is active or redundant, this alone will not account for the 
 phenomenon. 
 
 As regards the veins, I am aware that a very different doctrine 
 
 has, of late, been espoused. There are some who even contend 
 
 that fluids as readily and habitually percolate the coats of the 
 
 vessels, alternately received and expelled by mere physical im- 
 
 24 
 
278 HYDROPS. 
 
 bibition and transudation, as if this were their chief office. But 
 can there be a notion more mechanical and absurd in relation to 
 an operation of the living body? Did it really take place, the 
 veins would be a common sewer, into which were emptied 
 whatever is vile, or feculent, or deleterious coming into contact 
 with their surfaces, and of the disastrous consequences of such 
 matters getting into the circulation, we need not now be told. 
 Caused in this manner, dropsy should occur wherever there are 
 veins, and in the ratio of the vascularity of the part, especially 
 in the mucous, as of the tissues, the most richly endowed with 
 this property, which is contrary to fact ! There are some, indeed, 
 though very vascular, as the muscular, which never effuse. As 
 the causes of haemorrhage, so do those of dropsy operate. What- 
 ever may be their nature or location, it is on the capillaries of 
 certain membranes alone susceptible of such effects, and never 
 through the great vessels, as now maintained. The mucous is 
 the chief seat of the one, and the serous of the other, and in this 
 do the two processes chiefly differ in this respect. 
 
 Notwithstanding all I have said in support of the doctrine of 
 inflammation, I shall now suggest, as plausible at least, that it is 
 not inflammation only which induces genuine dropsy. Essen- 
 tially associated with this condition, the vessels, however, assume 
 a sort of secretory power by which a peculiar fluid is elaborated, 
 in most instances very distinct in its properties from the serum 
 or any other of the constituents of the blood. It was shown, in 
 the early part of this inquiry, how infinitely varied is the hydro- 
 pic effusion, which, being thus different from serum, must be the 
 result of a secretory action. To this process can only be ascribed 
 new products or changes, where the elements are supplied by 
 the blood. Facts were heretofore related by me which show 
 the great influence of the nervous system in the occasional pro- 
 duction of the disease, and we are aware of its absolute control 
 over the secretory processes, from which consideration, I think, 
 the hypothesis derives no immaterial support. 
 
 This faculty in the vessels often endures long after the phlo- 
 gistic state has subsided, whence it was derived. Cases are 
 without number where the effusion has gone on copiously with 
 the weakest pulse, cold surface and general debility, and, on a 
 post-mortem inspection, the serous tissue has appeared pallid, 
 relaxed and destitute of every vestige of inflammation. The 
 
HYDROPS. 279 
 
 same holds as to the mucous surfaces, in proof of which I shall 
 cite diarrhoea, leucorrhoea, gonorrhoea, broncorrhoea, where the 
 discharges are far more profuse than even in the inflammatory 
 stages of these affections. 
 
 Did the effusion in dropsy depend entirely on the phlogosis, 
 they should simultaneously cease, which is not the fact. The 
 opposite, indeed, is true, so far as regards certain cases at least, 
 that the cure depends on exciting a new inflammation in the 
 tissue, of which hydrocele affords illustration. 
 
 Like haemorrhage, it appears that dropsy is also originally of 
 a passive nature. Cases of this kind are mostly connected 
 with extreme visceral derangements and the general aspect of a 
 bad habit of body. Possibly, under such circumstances, there 
 may be, with general debility, some local irritation, productive 
 of the effasion. But in other instances, especially of anemia, 
 no such cause can be suspected, and hence it is conjectured 
 that it is owing to a certain state of the circulating fluids. In 
 general constitutional depravations, the blood sometimes under- 
 goes great changes — always, however, from previous disorder of 
 the solids, losing nearly the whole of its lymph and much of its 
 red globules, with a correspondent increase of serum, which also, 
 from a diminution of its albumen, is thinner. Thus conditioned, 
 it is not unlikely that a greater facility to effusion prevails, or, to 
 use the language of Andral, "in consequence of the diminution of 
 cohesion, the molecules having lost the force of aggregation, the 
 thinner portion, the serum, exudes." Be this admitted, which I 
 am entirely willing to do in relation to certain cases, I think that 
 much is also to be ascribed, in accounting for the hydropic dispo- 
 sition, to a peculiar state of the extreme vessels themselves, in 
 which we have another analogy to haemorrhage. Evidence of 
 the passive nature of the disease is supplied in the oedema of the 
 final stage of pulmonary consumption, and still more conspicu- 
 ously in paralytic limbs, which often become exceedingly swol- 
 len. The internal exhalents, in the latter cases, are in the same 
 state as the external in colliquative perspirations. 
 
 From the whole, we may conclude that either an excited and 
 full, or an emptied and enfeebled circulation may be productive 
 of the hydropic effect. To do away the first of these conditions 
 nature is disposed, as a salutary expedient, to cause an haemor- 
 rhage, or to resort to some species of extravasation, and under 
 
280 HYDROPS. 
 
 the circumstances stated formerly, to a serous effusion. But in 
 states of exhaustion her powers are so impaired, that she is 
 unable to resist the escape of these fluids, which, as it were, leak 
 out of the exhalents. We have, in this way, haemorrhages in 
 the advanced stages of low fevers, and dropsical accumulations 
 in other diseases of expended vital energy. As was at one time 
 inculcated, there seems to be a very close analogy between 
 haemorrhage and dropsy in many respects, each being active or 
 passive, and that the old notions on this subject have been too 
 hastily exploded. 
 
 To passive haemorrhages especially, the resemblance, in some 
 instances, approaches nearly to identity. I have, indeed, wit- 
 nessed the occurrence simultaneously of serous and sanguineous 
 extravasations from different portions of the exhalents. Thus, 
 while in some one cavity there would be watery eliminations, 
 the skin was purpled by large deposits of blood. Nor are such 
 exhalations confined to the surface. In a child that I attended 
 with the late Professors Physick and Dewees, Isaw a sanguin- 
 eous dropsy, if I may use the phrase, both pf the thorax and 
 abdomen, the skin at the same time being purple,— all brought 
 about by protracted cholera infantum, inducing previously an 
 extreme vitiation of system. 
 
 Most European writers, till lately, have contended that dropsy 
 has invariably its origin in debility, and is associated in all its 
 stages with what they denominated a cachectic condition. De- 
 duced from this opinion, their practice was maple up of the 
 stimulating and tonic remedies, and on the whole proved lament- 
 ably fatal. But we, on the contrary, acting on another view of 
 the character of the disease, have, perhaps, proceeded too far, 
 and here, as probably in most other instances, truth will be per- 
 ceived more in a medium between the two extremes than is 
 usually supposed. 
 
 Sunt certi denique fines. 
 
 Quos ultra, citra que, nequit consistere rectum." 
 
 Closing this introductory part of the subject, it remains very 
 briefly to point out the principles and remedies suited to the 
 management generally of dropsy. The disease, I have shown, 
 may be the result of inflammation in several gradations of vio- 
 lence or of a state of extreme feebleness, descending into absolute 
 
HYDROPS. 281 
 
 passiveness. Conditions so various obviously demand a very- 
 different plan of treatment, and to the disregard of which con- 
 sideration, the failure of our curative endeavours is, in no small 
 degree, to be ascribed. 
 
 To evacuate the collection of fluid is commonly, though, I think, 
 erroneously, held to be the leading indication. Before entering 
 on the execution of this design, we are carefully to ascertain the 
 state by which the effusion was produced and is maintained. 
 Not many years ago, the fact was more formally proclaimed by 
 Blackball than had previously been done by Cruikshank and 
 Wells, that the urine affords a less uncertain means of discrimi- 
 nation, in this respect, than any heretofore possessed. 1. Thus, 
 he avers that in dropsies of high excitement, it will coagulate by 
 heat, or nitrous acid, like the serum of the blood. 2. That drop- 
 sy, with visceral unsoundness from congestion, induration, scir- 
 rhosity, &c, is characterized by urine, scanty and high-coloured, 
 loaded with red sediment, and depositing nothing on the appli- 
 cation of heat. 3. That in dropsies of feeble action, the urine 
 is scanty and pale, not coagulable, and deposits no sediment. 
 
 These are the principal distinctions, though, like all medical 
 generalizations, are subject to exceptions, and, of course, must be 
 received with cautious limitations. Enough, however, has been 
 accomplished on this point to awaken attention, and to induce 
 further inquiries to refute or confirm his observations. 
 
 There is, however, still much uncertainty on the subject, arising 
 mainly from the discrepancies in the reports of those who have 
 engaged in the investigation. By some it is alleged, that coagu- 
 lable urine is confined to effusions in the cellular membrane, in- 
 duced by cold, scarlatina or mercury — it rarely, or, perhaps, never 
 occurring in ascites — and by others to those of the pleura or peri- 
 cardium. Bright maintains that it is exclusively the product of 
 the advanced stage of those lesions of the kidneys which I noticed 
 under a preceding head. The best opinion seems to be that it 
 is a common incident to inflammatory dropsy indiscriminately. 
 Even this, however, is denied by Prout, who considers it as 
 expressive of irritation only, and though it may be taken with 
 other evidence of the state of the case, it does not denote the 
 preference of any particular remedy or plan of treatment. My 
 own views are pretty much the same, or that conceding to it all 
 the value claimed, it is only a solitary indication, and I suspect 
 
 24* 
 
252 HYDROPS. 
 
 it will be very difficult to bring us to exchange the pulse, and 
 the other established sources of diagnostic information, for a 
 urinal as a guide to the detection of the condition of the system 
 in dropsy or any other disease. 
 
 In the inflammatory form of dropsy our aim should be the 
 reduction of action, and the most prompt and certain means of 
 attaining the end are blood-letting, general and local — purging by 
 the saline laxatives — the gentle febrifuge mixtures — the lowest 
 diet — cooling drinks and a state of rest, with whatever else is 
 calculated to temper excessive excitement, and to re-establish a 
 just distribution in the circulation, necessarily affected by partial 
 congestion. 
 
 Having accomplished so much, and the effusion continuing, a 
 resort may be had to mild emetics, purgatives, diuretics or rather 
 the sorbentia* diaphoretics, and sometimes to mercury. 
 
 It is to be recollected that, in dropsies of less activity, while 
 general depression of the vital powers, and of the circulation, too, 
 is apparent, there may be topical irritations and irregular con- 
 centrations of blood. The exhibition of weakness, therefore, 
 which is often muscular chiefly, ought not of itself to dictate the 
 practice under such circumstances. On the contrary, it becomes 
 our duty to be vigilant of these conditions, and to apply the 
 measures fitted to the subversion of them, which are mainly 
 those already enumerated, particularly local bleeding and vesi- 
 cation. 
 
 In reference to the evacuation of the fluid in this, the same 
 class of means is equally appropriate as to the preceding state of 
 the disease, with this difference only, that, in regard to some of 
 them, they should be more energetic, particularly the sorbentia 
 and purgative. 
 
 But we have a hydropic condition so unequivocally charac- 
 terized by debility as to preclude, in any stage, the use of means 
 which might increase exhaustion, and here, in circumstances 
 nearly desperate, our resources are narrowed down to cordial 
 and stimulating sorbentia, with tonics and other measures of 
 invigoration. 
 
 Even, however, when we succeed in removing the effusion, it 
 will sooner or later return, unless that pathological condition 
 
 * Medicines which promote absorption, in contradistinction to diuretics, 
 which increase urination, the one acting on the lymphatics and the other on the 
 kidneys. 
 
HYDROPS. 283 
 
 giving rise to it is completely overcome. It is, hence, of the last 
 importance that it be detected and redressed, till which, indeed, 
 little or nothing is done towards a cure. 
 
 " Sublata causa, tollitur effectus." 
 
 This is truly an occasion when, the cause being removed, the 
 effect will cease. The remote causes of the disease, we have 
 seen, are numerous and diversified, consisting, however, for the 
 most part, of lesions of structure, exacting different and even 
 opposite modes of treatment. Most of these, as distinct affec- 
 tions, have already engaged our attention. 
 
 What hitherto has been stated applies to dropsy generally. 
 The inquiry on which I am now to enter relates to the several 
 varieties or modifications of the disease, as arising from location 
 chiefly, and, first, of 
 
 ASCITES. 
 
 By this is meant a dropsy of the abdomen, a term derived from 
 the Greek askos, signifying a water bottle, no doubt from a sup- 
 posed resemblance of the protuberance of the belly to that utensil. 
 By some writers, particularly the older ones, all the effusions 
 within the abdominal cavity are embraced under this term, as 
 those of the uterus, the ovary and other encysted dropsies. But 
 I shall restrict it to the expression of the effusions within the peri- 
 toneal sac, which might be better entitled hydrops peritoneii. 
 
 The approach of ascites is varied by the condition of things of 
 which it is the consequence. It sometimes comes on suddenly, 
 as an acute original affection, so far, at least, as depends on a 
 primary distinct inflammation of the abdominal serous tissue, 
 and here the early symptoms are essentially the same as those of 
 peritonitis in its feebler or subacute form. But in chronic cases, 
 symptomatic merely of some organic lesion or more general dis- 
 temperature of body, and which are much the more common, 
 the progress is slower, and, in some instances, so gradual as 
 scarcely, for a considerable period, to attract notice. The effu- 
 sion here is almost uniformly preceded by the aspect of cachexy, 
 sallow or waxy complexion, the integuments flabby or dowy, 
 the skin unperspirable, the bowels costive, the urinary discharge 
 
284 HYDROPS. 
 
 deficient and loaded with lateritious or other sediments, the appe- 
 tite and powers of digestion impaired, marked by flatulency and 
 sour eructations, and there are general listlessness and disinclina- 
 tion to motion. These precursory signs are, in the process of 
 time, followed by unequivocal manifestations of the occurrence 
 of the effusion, among the earliest of which is, often, swelling of 
 the feet and ankles, attended by some shortness of breathing. 
 Not long afterwards the belly begins to bloat, usually at first in 
 the epigastric region, gradually extending over the whole abdo- 
 men with an increase of anasarcous swellings. The intumescence 
 is represented as commencing just above the pubes. But to 
 this point I have directed a very careful attention, and am satis- 
 fied that this is wrong. From the resistance of the abdominal 
 muscles, the protuberance slowly forms' in persons of vigorous 
 frame. 
 
 Much aggravation of the preceding symptoms progressively 
 takes place. The surface becomes more dry, even husky — there 
 is burning in the palms of the hands and soles of the feet— con- 
 stipation is greater — urination very small — intense, unquenchable 
 thirst sometimes prevails — dry cough arises, with very embar- 
 rassed respiration, especially in a recumbent posture or upon 
 any exertion, particularly ascending stairs or any acclivity. The 
 swelling of the abdomen is now, in some instances, enormous, 
 extending from the pubes to the ensiform cartilage, the weight 
 of which is very oppressive, especially in the side on which the 
 patient lies, the opposite one being somewhat relaxed. Effusions 
 going on simultaneously in the cellular tissue, much of it may 
 become filled, as well as the thoracic cavity, forming what is 
 called universal dropsy. The pulse, which, in the commence- 
 ment of the more acute forms of the disease, is active, corded and 
 accelerated, with sometimes considerable fever, is here the re- 
 verse, or weak, and little or no indication of the febrile move- 
 ment exists. Towards the close of the case, however, we shall 
 mostly find it diminutive, hard and accelerated, with decided 
 evidence of hectic irritation, or full, soft, compressible and very 
 irregular, owing to general disturbance of the animal economy, 
 from the amount of serous deposits interfering with the natural 
 order of organic action. Extreme debility and emaciation hence- 
 forward ensue — the bowels give way —gastric oppression, as well 
 as dyspnoea, painfully augmented — the tongue becomes red and 
 
HYDROPS. 285 
 
 polished — aphthae appear in the mouth and throat, with difficulty 
 of deglutition, and finally death, from absolute exhaustion, or by 
 syncope in an attempt to move, or by suffocation. 
 
 It is not, however, to be inferred that the disease is uniformly 
 so violent, or presents such a complication of character. Fre- 
 quently it is milder and limited chiefly, or perhaps entirely, to 
 the abdomen, constituting simple ascites, and then, divested of 
 many of the extraneous symptoms enumerated. Yet, com- 
 mencing, as it may, where its progress is lengthened, it usually 
 assumes, sooner or later, the aspect I have described, and which, 
 in many instances, originates with it. 
 
 Dropsy of the abdomen suddenly occurring, is to be assigned 
 to all those agencies by which acute peritonitis is ordinarily 
 excited. But it is usually more gradual in its accession and 
 development, and though still the result of inflammation of the 
 same tissue, this is brought on by a set of causes somewhat 
 different, operating with comparative slowness and feebleness. 
 Derangements of the central organs, the primse vise, the kidneys, 
 the uterus, and particularly the liver and spleen, may be deemed 
 the most common and prolific sources of this dropsy. Certain 
 states of the heart and great vessels, as well as of the blood, do, 
 however, also occasion it, though seldomer, from the comparative 
 rarity of the cardiac lesions, at least in this country. 
 
 From the account I have given of ascites, it would seem so 
 distinctly marked, that little need be said as to its discriminating 
 signs. But there are some cases with which it may be confounded; 
 among these, pregnancy has been mistaken for it, and acting on 
 an erroneous view, very disastrous consequences have sometimes 
 occurred. It will, therefore, be right, in such embarrassment, to 
 proceed cautiously, and more especially as attempts are often 
 made to conceal illicit pregnancies under the simulation or dis- 
 guise of this disease. The most distinctive criterion of ascites is, 
 perhaps, the fluctuation of the water, which becomes audible by 
 pressing the left hand on one side of the abdomen, and striking 
 on the other with the right. But this is not infallible, and par- 
 ticularly if the water be encysted. We must then resort to a 
 general inquiry into the history of the case, and so different are 
 the symptoms which attend the inception and advancement of 
 the two states, that little ambiguity can remain. Contrast care- 
 fully the peculiar phenomena of pregnancy with those of ascites, 
 
286 HYDROPS. 
 
 such in the first, as the morning sickness, the swelling gradually 
 proceeding from the hypogastric region upwards, the state of 
 the mammae, the areola around the nipple, and, in the second, 
 the reverse progress of the intumescence, the hydropic aspect, &c. 
 
 Easy of determination as this point would appear, it is some- 
 times different, and particularly when the abdomen is distended 
 by an enormous collection of the liquor amnii. Even the most 
 skilful and experienced may then be embarrassed. 
 
 On one occasion while I was waiting below for the arrival of 
 an eminent accoucheur, who wished my advice on the propriety 
 of tapping a lady, under an impression of her having dropsy, she 
 retired to her chamber, and in a few minutes was delivered of a 
 child. 
 
 Lately I read, in an English medical journal, of a similar 
 instance, where Sir Astley Cooper was called to perform the 
 operation, in which, while he was making the preparations, 
 labour came on, and saved him the mortification of such a mis- 
 take. Probably, in both of these cases parturition was excited 
 by the alarm and [agitation of the proposed operation. The 
 value of auscultation, now much practised by some of the accou- 
 cheurs, I think has been overrated. What the stethoscope can 
 determine in regard to the movement of the foetus, better than the 
 ear itself, or the hand, I am unable to discern. Blunders, and 
 some ludicrous ones, I have known to be committed by confid- 
 ing in it. Not long ago, a lady of this city who was thus scien- 
 tifically explored in the morning and pronounced free of preg- 
 nancy, was delivered of a full-grown child the night of the same 
 day. 
 
 Even more perplexing are the cases where dropsy is united 
 with pregnancy, which sometimes happens. Chief reliance here, 
 as well as under all circumstances, is to be placed on an exami- 
 nation per vaginam, which, if gestation be advanced, such are 
 the changes in the os tincae and neck of the uterus as to prove 
 very satisfactory. 
 
 Tympanitis is another affection resembling ascites. But they 
 vary in this, among other respects, that in the former those cha- 
 racteristics of dropsy just mentioned are absent, and the abdo- 
 men is more tense and elastic on pressure. The air, too, being in 
 the alimentary canal, frequent belchings and other indications of 
 flatus exist, and sometimes colicky pains. The greatest embar- 
 
HYDROPS. 287 
 
 rassment, perhaps, however, arises as to a species of abdominal 
 dropsy itself. My allusion is to the encysted cases, some of 
 which very closely resemble genuine ascites. The best mode of 
 distinguishing them will hereafter be indicated. 
 
 Mostly it will hold true, that in proportion to the standing or 
 duration of the case, and its complication with visceral derange- 
 ments or more general pravity of system, is the difficulty of the 
 cure. Being the result merely of recent peritoneal inflammation, 
 it proves comparatively of easy management. In aged people 
 it is, under all circumstances, very intractable, and what is extra- 
 ordinary, even more so in children, who, indeed, very seldom 
 recover from it. This observation, which I once thought pecu- 
 liar to myself, I afterwards found fully corroborated by the 
 experience of the late Professor Physick. 
 
 The favourable symptoms are, freedom of urination and regu- 
 lar alvine discharges, soft perspirable skin, a subsidence of febrile 
 irritation, the removal of visceral obstructions, and, as then usu- 
 ally happens, an exchange of a sallow, cadaverous, for a more 
 natural complexion. 
 
 Certain phenomena, on the contrary, always denote imminent 
 danger, as great emaciation and debility — constant dyspnoea, with 
 a tendency to syncope — dry, florid tongue — aphthae of the mouth 
 or fauces — dysphagia and colliquative diarrhoea. 
 
 Dropsy of the belly may be considered, on the whole, as a 
 most formidable affection — when once established is exceedingly 
 unrelenting, and, unless there is integrity of constitution, will 
 sooner or later prove fatal. These, at least, are the safest views 
 by which our prognostications can be conducted. 
 
 Examinations post mortem, in this disease, exhibit, besides 
 the accumulation of fluids which infinitely vary in quantity and 
 quality, great diversity of morbid appearances in the solids. 
 These, however, are to be regarded rather as the causes than 
 the effects of the disease. Dropsy itself can seldom produce any 
 structural lesions. The peritoneum, whence the effusion pro- 
 ceeds in ascites, is usually found, in acute attacks, delicately in- 
 flamed, and, in chronic cases, more or less thickened and other- 
 wise changed, sometimes studded with tubercles or hydatids, or 
 its surface granulated, and the liver, spleen, pancreas, &c, vari- 
 ously disordered. That the hepatic condition, called cirrhosis, 
 is most apt to induce ascites, was previously mentioned as a 
 
288 HYDROPS. 
 
 prevalent opinion in Europe. Whatever may be the fact there. 
 I am sure it is not so in this country. With us it is the over- 
 grown, hypertrophied, indurated viscus, the product of miasmatic 
 influence, with which it is most commonly associated. Cirrhosis, 
 indeed, is, I think, not frequently seen by us. 
 
 The mesenteric glands, particularly in early life, are sometimes 
 both enlarged and hardened — the bowels, for the most part, 
 flabby and relaxed, though occasionally having a very different 
 aspect, or phlogosed or ulcerated, with adhesions among them- 
 selves or to the peritoneum, and the stomach sometimes, though 
 rarely, scirrhosified at the pylorus. The kidneys, in some in- 
 stances, are much and diversely altered in structure, each of 
 which states may conduce to this effect. As to Brig fit's kidney, 
 so called, I have really not perceived the intimate and predomi- 
 nant influence of it, in the production of this dropsy, as at present 
 alleged by many. Even when it exists, which is seldom, effu- 
 sion is by no means a constant result. Diseased states of the 
 uterus sometimes exist, and to great extent. The heart and 
 great blood-vessels are met with, occasionally, in degrees of dis- 
 organization of every kind. Yet it is no less true that, in some 
 anemic instances, no essential organic lesion or change can be 
 detected in any part of the solids, the blood and capillaries seem- 
 ing to be only affected. 
 
 It is scarcely necessary, after the ample discussion which the 
 general pathology of dropsy has received, to notice that of ascites 
 particularly. The doctrine now mostly entertained presumes that 
 the disease, in its ordinary and genuine shape, is the direct effect 
 of peritonitis, which may be a primary or secondary affection — 
 the latter occasioned by a reflected irritation from one or more 
 of the diseased viscera enumerated, on the secerning membranes. 
 Por the most part it is of the second species, and subacute or 
 chronic. No doubt it does, sometimes, follow the acute, though, 
 I believe, where it is comparatively weak and delicately diffused. 
 Extravasations of coagulable lymph, or the secretion of pus, is the 
 product of peritonitis under different circumstances. But, while 
 this is conceded, it is still undeniable, to my mind, that ascites, in 
 common with all other dropsies, may take place, if not merely 
 from debility, by such a change in the vital properties of the 
 exhalents, or in the constitution of the blood itself, as to permit 
 the serous portion to escape, — in this respect conforming to 
 
HYDROPS. 289 
 
 haemorrhage, and hence, in order to successful practice, we must 
 contemplate the disease in each of these states. 
 
 Being satisfied, however, on an adequate examination, of the 
 active form of the affection, it would be a corollary from the 
 views I have indicated of its pathology, to institute a practice 
 having a regard to the phlogistic irritation of the peritoneum 
 and other organs which may be implicated. Great mischief has 
 undoubtedly accrued by mistaking the indication at this stage of 
 the disease, and hence prematurely resorting to the harshest 
 means to evacuate the fluid, when an opposite line of conduct 
 should have been adopted to overcome the condition, of which 
 the effusion is merely an effect. This error I shall endeavour to 
 avoid. 
 
 Fortunate is it that, by proper discrimination, remedies may be 
 selected which, while they reduce the force of the circulation, 
 and, in other modes, conduce to our main design, have also a 
 tendency to invigorate the process of absorption. As the former 
 is emptied or depressed, so are the energies of the latter in- 
 creased, especially in dropsy. This is a practical principle of 
 the highest importance, taught and published by me more than 
 thirty years ago, and long before by Professor Rush, to the first 
 recognition of which M. Magendie has arrogated to himself the 
 merit, without any acknowledgment to his predecessors. Go- 
 verned by this principle in the treatment, those means are to be 
 resorted to calculated to attain these ends. 
 
 Notwithstanding the former prejudice against it, venesection 
 is indispensable. As in all other instances, however, its use is to 
 be tempered by a sound discretion and a due regard to the state 
 of the case. The pulse in the early stage of ascites, such as I 
 am contemplating, is hard, tense and corded, and the blood 
 which may be drawn will be not less constantly found with the 
 signs of a considerable degree of inflammation. To these may 
 be added a hot and dry skin, parched tongue and fauces, great 
 thirst, with many other phenomena of the febrile condition. As 
 long as such a state of things prevails, the bleedings may be 
 repeated, and, sometimes, no inconsiderable portion of blood 
 detracted. Copious haemorrhages, spontaneous or from wounds, 
 having been immediately followed by the most beneficial results, 
 the fact has been assumed as the basis of practice. Among other 
 instances of the kind which might be cited, I had, some years 
 25 
 
290 HYDROPS. 
 
 ago, reported to me the case of a man labouring under inveterate 
 dropsy, who accidentally received a deep cut in the thigh by the 
 scythe of a reaper, from which he lost an immense amount of 
 blood before the vessel could be secured. Exhausted, however, 
 as he was, absorption commenced most rapidly, and, in a very 
 short period, he entirely recovered of the dropsy. 
 
 That venesection should here be successful, is quite con- 
 ceivable. Dropsy of this kind, as I have before stated, consists 
 in some altered action of the vessels dependent on inflammation, 
 which, by the sudden impression made by a large loss of blood, 
 may be subverted, and the natural or healthy condition restored. 
 No one remedial process is more revolutionary in its character 
 than venesection, when profuse, or has such claim to the title of 
 alterative. Yet on the lancet we are not exclusively to rely. As 
 aiding in the intention, a resort may be had to any or all succes- 
 sively, of the subsidiary or co-operating means. The abdomen 
 being tender, with other evidences of peritoneal or other visceral 
 inflammation, topical bleeding frequently renewed, followed by 
 fomentations and ultimately vesication, has proved exceedingly 
 effectual. 
 
 Not true is it, as has been claimed, that sanguineous depletion 
 is a new remedy in dropsy. From our records it will be found 
 as old nearly as medicine itself. By Hippocrates it was occa- 
 sionally used, by Galen, also, and subsequently by the disciples 
 generally of the school of Alexandria, when our science sought 
 refuge in Egypt during the dark and troubled ages of Europe. 
 It had supporters in more modern times in Riverius, Botellus, 
 Etmuller, Stahl and Grapengeengeisser on the continent — and in 
 Britain it was countenanced by Mead, Monro and others. 
 
 To such an extent, indeed, was bleeding carried at one time 
 in France, in this as well as in most other diseases, that, it is 
 said, the character of Sangrado was introduced by Le Sage, in 
 his Gil Bias, to put down, by all the powers of ridicule and 
 sarcasm, the abuse of this particular practice. Never, perhaps, 
 entirely exploded, it seems, however, for a certain period, to have 
 lost confidence, when it was revived, mainly by the late Profes- 
 sor Rush and his disciples, and has now become everywhere 
 fully re-established. 
 
 The preceding treatment has mainly for its object the cure of 
 that pathological condition which may be deemed the immediate 
 
HYDROPS. 291 
 
 cause of the effusion. Next, it becomes important to evacuate 
 the fluid which, confined in a cavity, operates in error loci, as 
 an extraneous irritant, and, by continuance, revives that state 
 which had been previously overcome. This is one of the modes, 
 probably, in which ascites is perpetuated. The analogy of hae- 
 morrhage may again be appealed to as furnishing an illustration. 
 Coming from the nasal or hemorrhoidal vessels, the loss of blood 
 is often harmless, or even salutary, while equally or more per- 
 nicious than the hydropic effusion would it prove, were it to 
 escape into one of the occluded cavities of the body. No doubt, 
 in some instances of dropsy, the parts seem in a great degree to 
 be reconciled to this foreign or adventitious encumbrance, and 
 they, as well as the system at large, suffer little from it, though 
 more frequently otherwise, and its removal is demanded. 
 
 Let me here repeat a remark which I first made many years 
 ago, that the common notion of the fluid being taken up by the 
 lymphatics, conveyed into the circulation, and thence eliminated 
 by the kidneys, is in part, at least, erroneous. To what precise 
 extent the lymphatics and kidneys are concerned in the process 
 of removing the fluid, I shall not now pretend to determine. 
 
 That it does not uniformly enter the circulation, I think is quite 
 certain. Gallons of it are sometimes evacuated in a very short 
 time, — and were such an amount of foreign matter to get into 
 the blood vessels, if it did not speedily destroy life, it must mate- 
 rially disorder the action of the heart and vessels, as well as other 
 functions. But no such phenomena occur, the pulse, on the con- 
 trary, being more languid and empty under such circumstances, 
 which is the reverse of what should happen, as by this repletion 
 it ought to be voluminous, turbulent and struggling, as when 
 fluids are injected into the veins. 
 
 My attention having been for some time directed to the sub- 
 ject, numerous opportunities I have had of remarking, that when- 
 ever the fluid is rapidly withdrawn in this way, the effects are 
 very similar to those experienced from parencentisis. On one 
 occasion, particularly, the case of a man with ascites and ana- 
 sarca, from whom twenty two quarts flowed out in thirteen 
 hours, he gradually became cold, collapsed, pulseless, and, despite 
 of the most powerful stimuli, sank into death from exhaustion. 
 
 Not a few instances, all tending to the establishment of the 
 same fact, have I witnessed alone or in consultation. Even 
 
292 HYDROPS. 
 
 when life is not so immediately extinguished, peritoneal inflam- 
 mation is very apt to follow, ending fatally,— in this further 
 particular, corresponding with the well-known consequences of 
 tapping. 
 
 It has been urged that the fluid is conveyed directly to the 
 urinary bladder by a set of lymphatics, terminating in the cavity 
 of that viscus, — long suspected by physiologists, and the existence 
 of which is not destitute of plausibility. 
 
 Discarding, however, this conjecture as gratuitous or inade- 
 quately sustained, two other modes occur in which the transmis- 
 sion may take place. The cellular membrane is co-extensive with 
 the corporeal structure, pervading even its minutest recesses, and 
 is throughout permeable by the intercommunication of its reticu- 
 lated texture. Entering this tissue at any point, the fluid may 
 reach, by percolation, any and every part,— and, to all appear- 
 ance, does sometimes escape, in dropsy of the interior, by the 
 cutaneous surface, and conversely from that of the exterior into 
 the internal cavities. Cases are recorded of the former, where 
 the fluid was eliminated by the hand, foot, scrotum and um- 
 bilicus. Good cites several of the kind, — and I have seen an 
 ascites thus emptied by the naval in a physician from Virginia, 
 — by the stomach in a man, — and by the vagina in a woman, — 
 patients in the alms-house Infirmary under the care of Professor 
 Jackson and myself. Cellular dropsy, indeed, is so prone to run 
 into the cavities, that it is a fact of very common observation, par- 
 ticularly in relation to the abdomen, and I have frequently seen 
 on the sudden subsidence of oedema of the lower extremities, 
 manifestations of hydrothorax or hydrocephalus. 
 
 But this explanation of the phenomena not proving satis- 
 factory, may it not be referred to endosmos and exosmos, a 
 mode of absorption lately revealed to us ? 
 
 By this is meant a percolation of fluids from one cavity into 
 another, the mode not clearly understood. That such takes 
 place out. of the body in dead tissues, cannot be doubted, and 
 the same process is inferred to be incidental to the living state. 
 Disbelieving the latter, or at all events having seen no demon- 
 stration of the fact, I must continue to think the hypothesis I 
 have offered of depuration through the cellular membrane as 
 better made out than this or any other, and, therefore, entitled to 
 greater confidence. 
 
HYDROPS. 293 
 
 As a question exceedingly interesting in speculation, and hav- 
 ing, perhaps, an important practical bearing, it assuredly merits 
 a further and more careful investigation than it has hitherto 
 received. 
 
 The circumstance having been noticed of ascites occasionally 
 disappearing on the occurrence of spontaneous vomiting, emetics 
 were at one time much prescribed. That they have proved 
 advantageous it were not difficult to show by a recurrence to 
 authorities. Especially are they favourably regarded by Syden- 
 ham, Boerhaave, Duverney, Monro, senr., Richter, Cruikshank, 
 Lentin, Pinot, &c. Duverney and Monro, indeed, report cases 
 cured in this way where tapping had been repeatedly performed. 
 But no one, perhaps, bears stronger evidence in favour of the 
 practice than the celebrated Soemmering, who declares that he 
 has frequently seen the disease promptly yield to it alone, and 
 which is substantially confirmed by Itard, a late and very re- 
 spectable writer. Emetics, however, were here again and again 
 repeated. Granting their efficacy as promoting absorption, which 
 is contended for, I am still disposed to ascribe a part of it, at least, 
 to their agency in correcting the state of the capillaries conducive 
 to effusion, — exactly as we have seen them to operate in the 
 suppression of haemorrhage. But whichever view may be enter- 
 tained of their mode of action, much discrimination is undoubt- 
 edly required as to their use in the early stage of the disease. 
 The case having its origin in phlogosis of the peritoneum, vomit- 
 ing can hardly fail to be detrimental while this condition lasts. 
 Deterred by such an apprehension, I have very seldom prescribed 
 them, and never except where there was an oppressed or dis- 
 ordered stomach, or much torpor of system, and general insensi- 
 bility to the operation of other remedies, as I shall notice further 
 hereafter. 
 
 Emetics, on the whole, have given way to some other classes 
 of medicines, and especially to purgatives, which, indeed, seem 
 to be called for, not less by their acknowledged powers of quick- 
 ening absorption, than with a design of subduing vascular excite- 
 ment, and overcoming the habit of constipation incident to the 
 inception, and the immediate subsequent stages of the disease. 
 
 To evacuate the bowels thoroughly is a plan commenced by 
 Hippocrates and continued to the present times. Too much 
 cannot be said of this sound and highly beneficial course. Yet 
 
 25* 
 
294 HYDROPS. 
 
 in the choice of purgatives some care is demanded. By all the 
 earlier writers, — and they are still much copied, — the drastic 
 articles, or what are called hydragogues, were preferred. Medi- 
 cines of this kind, however, are now known to be detrimental 
 in this state of the disease, and are only admissible where the 
 alimentary canal is torpid, the habit generally phlegmatic, with- 
 out irritation or visceral disorganization. Better is it to resort, 
 in the circumstances before us, to the saline laxatives, and espe- 
 cially to the tartrate preparations. Consecrated, as it were, by 
 common consent to this purpose, is crem. tart, and jalap, the 
 effects of the latter being mitigated when thus united. These 
 articles are prescribed in the dose of a scruple or half a drachm 
 of the former, to five, ten or fifteen grains of the latter, with a 
 few drops of the ol. carui to prevent griping, and so repeated 
 as to keep up discharges almost unremittingly from the bowels. 
 Exhibited in this manner, the results in some cases are prompt, 
 effectual, and even astonishing. I have seen in a few days the 
 utmost intumescense and distension entirely removed by this 
 remedy alone. It is, therefore, with the strongest emphasis, and 
 in the highest tone of confidence, that I press it on attention. 
 Never, I can truly declare, have I had more reason to be de- 
 lighted with any course of practice, in any disease, than occa- 
 sionally with purging by the combination to which I have alluded. 
 Disagreeing, however, with the patient, or for any other reason 
 not answering the purpose, we may substitute a mixture of mag- 
 nesia and Epsom salts, which often proves very useful. Castor 
 oil does equally so in some instances. The superior success of 
 such articles can only be ascribed to the comparative mildness 
 of their operation, by which they are rendered more appropriate 
 to the probably somewhat irritable condition of parts. 
 
 Efficacious, however, as purging may be when properly di- 
 rected, it does not uniformly succeed, and, in this event, it is cus- 
 tomary to resort to the diuretics. By these is understood articles 
 which, operating on the kidneys, promote the urinary discharge. 
 An action of this kind can have very little effect in the cure of 
 dropsy. Doing good at all, it must be by indirectly promoting 
 absorption, from the reduction of the circulation, by lessening the 
 quantity of the serous portion of the blood. It is by exciting the 
 absorbents, whatever this machinery may be, lymphatic or other- 
 wise, to invigorated efforts that any great advantage can be 
 
HYDROPS. 295 
 
 gained, and we are in possession of a set of medicines with such, 
 power, the sorbentia, as they have been called, which are impro- 
 perly confounded with the diuretics. 
 
 Not a little has been said of the antihydropic powers of the 
 vegetable and mineral alkalies, in a state of carbonate, though, 
 of the two, the potash seems always to have been preferred. By 
 the older physicians, and, indeed, they are continued to the pre- 
 sent time as a domestic remedy, the ashes of a variety of vege- 
 tables were employed, particularly of the grape vine and the 
 bitter herbs. Being, however, only operative from the alkali 
 they contain, the carbonate, as now kept in the shops, has sup- 
 planted this crude article in regular practice. Dropsy, in which 
 the potash is more particularly useful, is such as is connected 
 with great depravation of the powers of digestion. Excepting 
 this application of it, the alkali carbonated is very inferior to 
 some of its combinations with the other acids, forming the neutral 
 salts. Most of these have considerable powers, though there is 
 one, the acetate of potash, which has been supposed to possess 
 it in so great a degree as to be called sal diureticus. Notwith- 
 standing its former reputation, I am not disposed to say much in 
 its favour — the trials I have made with it having disappointed 
 my expectations. 
 
 Eminently adapted to this case is the nitrate of potash. As 
 commonly prescribed, in small doses, it is, perhaps, inferior to 
 some others of its congenera, though as an evacuant of water it 
 is not deficient. Its great utility is derived from the depressing 
 power it exercises over the vascular system. The common ob- 
 jection to its use, that, when directed in adequate doses to make 
 such an impression, it so disorders the stomach that we are obliged 
 to discontinue it, may be in part obviated by giving it in very free 
 solution. An ounce in two or three pints of water, sweetened 
 and pleasantly flavoured, may be drunk daily. Combined with 
 a very small portion of tartarized antimony, its value is enhanced 
 in any marked activity of the circulation. This latter article, 
 indeed, is too much neglected under such circumstances. More 
 than any other is it calculated to subdue the force of vascular 
 action, and in doing which it sometimes promotes absorption, 
 and, I am persuaded, exercises, too, a salutary influence over the 
 capillaries. Great confidence has been expressed in it by Frank. 
 of Vienna, when thus administered. 
 
296 HYDROPS. 
 
 Not the least, important of the neutral salts is the supertartrate 
 of potash— most practitioners speaking well of it, and many con- 
 fidently. By some the tartrate of potash is preferred, though, 
 from the almost identity of the articles, I should presume there 
 can be no material difference in their effects. But the union of 
 the tartrate, supertartrate and carbonate of potash, in nearly 
 equal proportions, I have known to act beneficially, when the 
 two former articles separately did otherwise : such are the results, 
 occasionally, from apparently outre composition of medicines. It 
 was a very favourite prescription of the late Professors Rush 
 and Physick. 
 
 The dulcified spirit of nitre, when liberally given, may prove 
 useful. We commit a mistake in directing too small a dose of it. 
 Not less than two drachms, freely diluted, should be exhibited at 
 once, and repeated several times in the day. Diminutive doses, 
 in this application of it, are not of the slightest service, and mani- 
 festing any sensible effect at all, it is on the cutaneous surface. 
 Nor is it undeserving of recollection that, when it does not pass 
 off by either of these emunctories, it is very apt to kindle up a 
 high degree of febrile excitement, which is an admonition to its 
 discontinuance. 
 
 Diaphoretics are another class of medicines in this disease. 
 Celsus speaks very favourably of sweating, and it was, indeed, 
 at one time, a common practice. By adverting to the state of 
 the skin in dropsy, and the influence of it in keeping up the dis- 
 ease, we shall be led by these considerations to appreciate mea- 
 sures which operate on the surface. Beneficial generally, they 
 are particularly so in the cases from cold, or repelled or ill-cured 
 eruptions. 
 
 Many of the diaphoretics are employed, though, on the whole, 
 I have found those into which an opiate enters largely, as the 
 Dover's powder, to answer best. Monro praises a combination 
 of opium and antimony. The following mixture sometimes suc- 
 ceeds well, repeated every two or three hours.* 
 
 * R. — Tinct. Theb. gtt.,x.; Sp. nitr. dulc, 3ij.; Vin. antim. gtt.,xxxx.; Aq. font., 
 §ii. It was originally given by me in one of the very first cases of dropsy I 
 ever attended, merely as a palliative of some urgent distress. But, to my asto- 
 nishment, the patient got well under its use. Not long afterwards, the late 
 Professor Wistar was called into consultation with me, in another case of the 
 disease, which I was treating successfully by the same means. As the remedy 
 
HYDROPS. 297 
 
 By opium alone cures have been accomplished, according to 
 Mead, Willis, Home and Heberden, not to mention some inferior 
 names. But, whenever any very decisive utility accrued from 
 its use, it appears that it was given in very large doses. My 
 own experience does not enable me to say much of this practice 
 with opium itself. But I can readily credit its utility indepen- 
 dently of the direct testimony in its favour. Compositions in 
 which it is a leading ingredient we know are so, and are not less 
 aware of its decided control over all inordinate secretions or 
 exhalations, including, in short, every variety of profiuvia, and, 
 above all, the discharge in diabetes, between which affection and 
 dropsy a parallel might be run to a considerable extent. It were 
 curious to determine whether, as in the former case, while dimi- 
 nishing the amount, it has also the power of changing the cha- 
 racter of the urine in the latter disease, which I strongly suspect, 
 and, if it be really so, it would go far to explain the superior 
 efficacy of the opiate preparations in dropsy. Numerous other 
 diaphoretics, however, are resorted to, and, among these, I am 
 inclined to believe a warm infusion of the thorough wort has 
 strong claims to attention, especially in the acute and simple 
 states of dropsy. 
 
 External means of exciting perspiration sometimes become 
 necessary in very intractable cases. It was the practice of anti- 
 quity, particularly among the Romans, to effect it by covering 
 the body with hot sand. Dampiere, the celebrated circumnavi- 
 gator, relates of himself that, while on the coast of California, he 
 was cured by the same expedient. He says, "I had been a long 
 time sick of dropsy, a distemper whereof many of our men died 
 — so here I was laid and covered all but my head in the hot sand; 
 I endured it near half an hour, and then was taken out and laid 
 to sweat in a tent. I did sweat exceedingly while I was in the 
 sand, and I do believe it did me much good, for I grew well soon 
 after." From the vapour bath I have certainly seen salutary 
 impressions in those cases, above all, induced by cold, attended 
 by sensibility of the abdomen and manifestations generally of 
 
 was new in this application to dropsy, he expressed some surprise at my employ- 
 ment of it, and asked me whence I had derived the practice. Telling him that I 
 had acquired a knowledge of its efficacy accidentally, as it were, he replied, it is 
 not a little curious that, many years ago, the same happened id myself, and I have 
 since prescribed it frequently and advantageously. 
 
298 HYDROPS. 
 
 lingering peritonitis. Neither purging nor the other remedies 
 are here proper or tolerated, and the former is very apt to create 
 acute pain and probably heighten inflammation. The process 
 of sweating having been commenced, it should be continued for 
 an hour or more at a time, then intermitted and renewed till the 
 experiment is fairly tried. 
 
 On the whole, I must say that I consider sweating as a more 
 important means than it is generally held to be. Most absurdly 
 has it been objected to, that on no principle can its modus ope- 
 randi be explained. By sweating, it is truly alleged, there is 
 only drained off the serous part of the blood, without removing 
 any portion of the accumulated fluid. But we divert action from 
 the internal to the external exhalents, and thereby prevent the 
 further increase of the effusion — re-establish the healthy functions 
 of the skin, so particularly deranged—and, sometimes, even suc- 
 ceed in promoting absorption. 
 
 The same objection applies to purgatives of such acknowledged 
 utility. No more is done at first, by stimulating the intestinal 
 exhalents, than in the former case — the circulating blood being 
 only divested of its serum, without touching that fluid already 
 deposited. But in consequence of the translation of action, before 
 mentioned, further effusion is arrested, and, in time, the whole 
 deposition may be taken up. 
 
 These are the remedies and the order of administration which 
 I deem the best adapted to acute inflammatory ascites. Either 
 originally, or becoming chronic, it, however, assumes an opposite 
 complexion, and demands another description of means for its 
 cure. The system here being reduced, venesection and its im- 
 mediate auxiliaries are usually dispensed with. Exceptions, 
 however, arise, and never should we allow ourselves to be de- 
 luded by the counterfeit appearance of debility. With much 
 general prostration, there may be still local phlogosis without 
 appreciable vascular excitement, in which condition the loss of 
 blood, topically at least, becomes indispensable — to be followed 
 by a succession of blisters to the abdomen, to remain on just long 
 enough to irritate the skin. The latter are, sometimes, exceed- 
 ingly beneficial in overcoming the remnant of the pathological 
 condition giving rise to the effusion. Frictions over the same 
 part with the camphorated mercurial or iodine ointment have, 
 
HYDROPS. 299 
 
 of late, been much commended, and which I believe to be wor- 
 thy of trial. 
 
 Now it is, moreover, that emetics may be more safely em- 
 ployed than in the preceding state of the disease, and with a 
 fairer prospect of success. Yet I have rarely resorted to them, 
 and must speak diffidently of their value. Certain it is that, 
 whatever this may be, the active cathartics are greatly preferred 
 by the generality of practitioners. Combinations of calomel with 
 gamboge, or colocynth, or scammony, or hellebore, or jalap, or 
 elaterium are principally selected. That they are productive of 
 advantage in old and protracted, or originally feeble, atonic drop- 
 sy, there can be no doubt. The elaterium, which, for a time, 
 was obsolete, has, since its revival, been much employed. But 
 at present it is superseded by the elatin, its active defecated 
 principle. The latter is usually directed alone, in the tenth of a 
 grain, repeated every two or three hours till copious purging is 
 induced, and proves a hydragogue of immense energy. 
 
 Croton oil is another article of this kind, the use of which has 
 been restored with the strongest pretensions. Both of these 
 medicines are recommended, as well by the facility of adminis- 
 tration as by their extraordinary powers over the hydropic accu- 
 mulations. The dose of the latter, when pure, is a single drop, 
 which rarely fails to operate adequately. 
 
 Better, however, than any other prescription I have ever tried 
 is the subjoined, in a tablespoonful dose every two hours till it 
 purges freely.* That it will with any uniformity cure dropsy, I 
 do not pretend to say. But as an evacuant of the fluid, it is 
 most certain, prompt and effectual. 
 
 Belonging to the active hydragogues, is the root of the Ka- 
 hinha, a plant bearing this title from South America, which 
 has recently been introduced into the treatment of dropsy with 
 such strength of evidence in its favour, that though I have not 
 tried it, I think it deserves to be noticed. Either in extract or 
 decoction it is given, of the former of which the dose is a scruple, 
 and of the latter an ounce or more, — repeated from time to time 
 till it operates freely on the bowels and kidneys. 
 
 Turning from this description of articles, I am to bring into 
 view a set of the sorbentia, of indisputable utility, and among 
 
 * K. Pulv. gambog., gr.iv.; Elatin, gr. ss.; Sp. nitr. dulc, 3i.; Aq. font.. .t-iv. 
 
300 HYDROPS. 
 
 which is the squill. There are several officinal preparations of 
 it, the vinous and acetous tinctures, the syrup and oxymel, &c, 
 though, perhaps, it is more commonly prescribed in substance as 
 a pill, alone or variously united. 
 
 Digitalis is also of great value. Extraordinary as it may 
 seem, it is best adapted to a reduced state of the system. As 
 long as there is any activity of pulse, or considerable portion of 
 general strength, it will prove disserviceable, and, sometimes, 
 even positively detrimental. Nor is this opinion peculiar to 
 myself. Withering, by whom the application of the article to 
 dropsy was restored, states, " that in persons of tense fibres and 
 great natural vigour of constitution, it seldom succeeds, while, 
 on the contrary, if the pulse is feeble, the countenance pale, and 
 the skin cold, it hardly ever fails to do good." This estimate of 
 its properties has been confirmed, and the best practitioners now 
 proceed pretty much on it in its administration. That an infusion 
 of it is the most appropriate preparation to dropsy is a common 
 and just opinion, — though either in substance or tincture it may 
 answer very well. The annexed prescription into which it 
 largely enters, has very extraordinary merit.* Generally, I 
 direct of it a tablespoonful every two or three hours, though 
 the dose and the interval of repetition require to be changed so 
 as to be accommodated to the circumstances of the case. 
 
 Tobacco ought here, perhaps, to be mentioned. Confidently 
 announced by Fowler, a respectable authority, as having great 
 efficacy, it, as in most instances of a new remedy, was for a 
 season exceedingly celebrated. The precise value of it I am not 
 prepared to assert, having rarely prescribed it or seen it pre- 
 scribed. The tincture is mostly used, of which the dose is ten 
 or fifteen drops. Ferriar's prescription, so highly praised by him, 
 is as follows.! 
 
 The Indian hemp, the Apocynum Cannabinum of the botan- 
 ists, is at present attracting considerable attention, and much 
 testimony might be collected in its favour. It is a powerful 
 agent, occasioning nausea, vomiting, purging, sweating and diu- 
 
 * R. Infus. digital., 3vii.; Acid, tart., giij.; Sodae. carb., gij.; Sp.nitr. dulc, gj.; 
 Tinct. scill., gj.; 01. menth., gtt. viij. 
 
 f Jt. Oxymel scill., Oxymel colch., Tinct. nicot., Sp. nitr. dulc, aa3j. The 
 dose is a teaspoonful four times a day, and to purge every morning with cremor 
 tartar. 
 
HYDROPS. 301 
 
 resis, with extreme prostration. These distressing and even 
 alarming effects have deterred me from its use, and hence my 
 own experience is so slender that I decline expressing any opin- 
 ion regarding its utility. It is directed in powder, pill, tincture 
 and decoction — the latter, however, is preferred, made by boiling 
 two ounces of the root in three pints of water to two, the dose 
 of which is one ounce, repeated occasionally. 
 
 Colchicum belongs to the same class. Baron Stoirk speaks 
 well of it in "old and desperate cases of atonic dropsy." That 
 it is occasionally useful, the evidence is too strong to permit us 
 to doubt — though I am inclined to believe that it is less suited 
 to ascites than some other forms of the disease hereafter to be 
 noticed. 
 
 No other indication are the preceding articles capable of ful- 
 filling than merely to remove the effusion. But a series is now 
 to be presented of another description, which, while producing 
 this effect, are supposed, likewise, to be curative of the lesions 
 occasioning the disease. 
 
 Mercury is deservedly at the head of this set of medicines. 
 Yet, owing to its indiscriminate employment, it has probably 
 done quite as much harm as good. Neither suited to the inflam- 
 matory nor the weak and leucophlegmatic conditions of the dis- 
 ease, it always acting adversely in such depraved habits, I have 
 found it alone appropriate where there is integrity of constitu- 
 tion, though obstruction of the parenchymatous viscera or feeble 
 membranous phlogosis may exist. Cautiously administered, it 
 sometimes, under these circumstances, removes both the cause 
 and the effect. Calomel or the blue pill, with the squill, or digi- 
 talis or colchicum, is often preferable to either article separately. 
 
 That iodine bears a resemblance to mercury in some of its 
 leading qualities, particularly as a deobstruent and incitant to the 
 absorbents, is a common opinion, and we are not without facts 
 of its utility in dropsy. But I confess that I have been disap- 
 pointed in all my trials of it — though, from its reputation, I am 
 unwilling to discourage others to its further use. I have, indeed, 
 long entertained the notion that it does not so affect the absorb- 
 ents as to dispose them to take up fluids. Certainly I have 
 never witnessed any such effect in dropsy. Different, however, 
 is it in relation to the solids — it manifesting, pretty generally, a 
 tendency, when long continued, to induce marasmus. 
 26 
 
302 HYDROPS. 
 
 Governed, I presume, by the same analogical reasoning, the 
 nitro -muriatic acid has been proposed with a similar design. 
 But, useful as it may be in certain visceral affections, I have 
 seen no satisfactory evidence of its quickening absorption to any 
 extent, and hence distrust the report of its having, in this respect, 
 proved of much service in dropsy, though, on one occasion, I 
 derived decided benefit from it in a case complicated with a 
 scorbutic diathesis, and, in another, where mercury had been 
 abused. 
 
 Nearly the same estimate have I of the guiaicum, sarsaparilla, 
 pipsisseway and their congenera — they being calculated rather 
 to rectify vitiated states of system occasioning dropsy, or with 
 which it may be associated, than to remove the effusion. But 
 this is an important attainment, since the principal or even ac- 
 cessary cause being eradicated, the great difficulty is overcome. 
 Confessedly the power of the first two articles over a variety of 
 such contaminations is considerable, and I have reason to believe 
 that the last has scarcely less of it. The popular titles of rheu- 
 matism weed and king's cure at least attest its efficacy in fibrous 
 or muscular inflammations and scrofula, both of which are some- 
 times intimately connected with dropsy. 
 
 My course of inquiry has conducted me to that form of the 
 disease where, to disorder of the digestive and nutritive functions 
 is added extreme weakness, with every indication of cachexy 
 both of the solids and blood, the one being flaccid and the other 
 thin and impoverished of its crassamentum. As an evacuant of 
 the fluid, I have known the tincture of cantharides, in large 
 doses, to be here successful, and it is worthy of recollection that 
 it is under such circumstances, and in this mode of exhibition, 
 that it only evinces an agency of the kind. But the relief from 
 it is temporary, and we must resort to remedies of more effect 
 over the general pathological condition, of which, I fear, we have 
 none deserving of any great regard. Much, I am aware, was 
 formerly thought of a combination of the diuretics and tonics, 
 and particularly of the mineral or vegetable alkali, with an 
 infusion of the Peruvian bark, or gentian, Colombo, quassia, 
 camomile, &c. Except palliation, what can such a mixture ac- 
 complish? The alliaceee and silaquosae, variously prepared, are 
 decidedly preferable, and sometimes the popular prescription pre- 
 sently to be mentioned has been found of real service, especially 
 
HYDROPS. 303 
 
 in the case of drunkards, to which the articles entering into it are 
 singularly well adapted.* But, on the whole, most is to be ex- 
 pected from the chalybeates — the best of which are the tartrate, 
 the hydriodate and phosphate of iron — the last being incom- 
 parable in all feeble, leucophlegmatic, exsanguineous conditions, 
 efficiently correcting the process of hgematosis. Yet the tartrate, 
 as more of a diuretic, is usually preferred. 
 
 It remains to notice the direct means of removing the fluid in 
 ascites. This is done by the operation denominated paracen- 
 tesis, for the best mode of performing which I refer to surgery. 
 In the opinion of most practitioners it is admissible only where 
 the distension is so great as to give pain, to disturb respiration 
 and to make the case altogether more aggravated and uncomfort- 
 able. Early tapping, however, has been insisted upon by Foth- 
 ergill, by Baker and other practical writers, and its propriety, 
 perhaps, at present, is more widely recognized than formerly. 
 
 It seems to me, that the vessels being relieved by depletion, 
 were the effusion removed, a cure might possibly follow, pro- 
 vided some remote cause did not endure. An analogy exists 
 between ascites and hydrocele, each being an effusion from a 
 serous tissue, and that a cure sometimes results from merely 
 evacuating the water in the latter affection is indisputable. It 
 was nearly the exclusive mode of the late Professor Physick of 
 managing recent cases of the kind, and I have reason to believe 
 with success. Nay, the accumulations within the thoracic cavity 
 have sometimes been cured by precisely the same process. Yet it 
 is not to be understood that I mean altogether to assimilate these 
 affections, or to inculcate an equal degree of curability in them. 
 There are, I am sensible, much greater obstacles as regards 
 ascites than hydrocele, — though not of so formidable a character 
 as to preclude all hopes from this expedient. Even, however, 
 should a cure not follow, it may afford temporary relief and our 
 medicines are apt to operate more kindly afterwards. 
 
 Extending the analogy of hydrocele, it was long ago proposed, 
 and, indeed, actually tried, in some few instances, to inject the 
 peritoneal cavity with a stimulating fluid, so as to excite such a 
 
 * Take of mustard seed, garlic, horseradish and centaury, each four ounces — 
 of potash and iron filings each half an ounce, and hard cider three quarts. 
 These are to be boiled together fifteen minutes, and the dose is a wineglassful 
 eyery two or three hours. 
 
304 HYDROPS. 
 
 degree of inflammation as to supersede the disposition to serous 
 effusion. But all these experiments failed, — a state of things 
 being induced far more serious than the pre-existing disease, 
 eventuating disastrously. 
 
 Great debility having taken place from the long prevalence 
 of the disease or in originally atonic cases, tapping is productive 
 of brief mitigation only, and, moreover, often proves mischievous, 
 accelerating death by removing the stimulus of distension, which, 
 under such circumstances, is one of the chief props of vitality, 
 or more remotely, by inducing a fatal form of peritonitis. Never- 
 theless, life is undoubtedly sometimes protracted by it, and it 
 may not be uninteresting to learn how often, in certain instances, 
 the operation has been repeated. Many cases might be cited in 
 which it was done forty and fifty times on the same subject. 
 Good has made a collection of such, — one where it was per- 
 formed ninety-eight times in three years, — another, twenty-four 
 times in fifteen months, — and a third, a hundred and forty-three 
 times in a period not stated. Excepting, however, the second 
 case, the quantity of fluid drawn off is not given, in which it 
 amounted to one hundred and sixteen gallons in the aggregate. 
 
 My own experience supplies several instances scarcely less 
 remarkable as regards both the number of repetitions and the 
 amount of the fluid. Yet it is true that the operation mostly 
 proves nugatory or fatal, partly to be referred, however, to the 
 injudicious applications of it. To be of service, I repeat, that it 
 ought to be early resorted to, and only in cases exempt from 
 constitutional or visceral depravations of any extent, at least, 
 with the expectation of any permanent benefit. It is not, how- 
 ever, a little curious that the danger from the operation attaches 
 nearly altogether to the first time of its performance. As well 
 as I can recollect, I have scarcely seen a case where, on the 
 subsequent repetition of it, any thing bad resulted, which lends 
 credibility to the reports of the number of times in which it is 
 said to have been performed with impunity. 
 
 On this subject there is a fact of some interest to be communi- 
 cated. Finding that cures followed the frequent evacuation of 
 the fluid in hydrocele, by acupuncturation, the same process has 
 been applied to ascites, and, we are told, with encouraging suc- 
 cess. The superiority of this over paracentesis, is alleged to 
 consist in so little injury being done to the peritoneum, that no 
 
HYDROPS. 305 
 
 appreciable inflammation has ever ensued. We have tried the 
 practice in this city. The water, in some instances, was entirely 
 removed by it and in a short period, while in others not a drop 
 escaped, as in two cases of my own, though forty needles in 
 each were introduced. Disappointments of this kind are to be 
 expected from the occasional thickness and viscidity of the hy- 
 dropic fluid, it being sometimes so much so as not to pass even 
 through the canula in tapping, and this forms one of the leading 
 objections to acupuncturation. Nor have I heard of any cure 
 from it in this city. 
 
 Before resorting, however, to either operation, it will be right 
 to try the effect of a large blister to the abdomen, which I have 
 known in two instances to prove effectual. 
 
 The first of these occurred in a maiden lady somewhat ad- 
 vanced in life, attended by the late Professor Wistar and myself. 
 Every measure used having failed, and the distension being 
 exceedingly oppressive, we determined on tapping the next day. 
 But, of her own accord, an immense blister was applied in the 
 evening, and at our next visit we were astonished to find the 
 fluid evacuated, it having leaked through the skin of the abdo- 
 men to such an extent as completely to have soaked her bed. 
 Exactly such a case is reported by Professor Caldwell, of the 
 Louisville College, and with which I became acquainted from 
 another and equally authentic source. 
 
 Not easy is it to account satisfactorily for the mode in which 
 a blister operates under these circumstances. But similar dis- 
 charges have, sometimes, spontaneously taken place, as formerly 
 mentioned, probably referable to percolation through the cellular 
 texture. 
 
 HYDROPS SACCATUS VEL HYDROPS CYSTICUS, OR 
 ENCYSTED DROPSY. 
 
 By this is meant a collection of water in sacks or cysts attached 
 to or imbedded in some of the abdominal viscera. The ovaries, 
 however, are principally liable to it, and hence I shall notice it 
 in these organs particularly. Nearly always one of them only 
 is affected. 
 
 26* 
 
308 HYDROPS. 
 
 HYDROPS OVARII. 
 
 Great confusion exists in the history of ovarian dropsy, pro- 
 ceeding as well from its own diversities as confounding other 
 morbid conditions of the ovaries with it, and especially phlegmo- 
 nous inflammation, ending in abscess or some other degeneration. 
 Its commencement is usually obscure, and it advances slowly, 
 creative of little or no uneasiness for a length of time, and often, 
 indeed, eludes suspicion till the protuberance is observable. 
 Early, however, in some instances, pain is experienced in the 
 part, accompanied by irritative fever, and the progress then is 
 far more rapid — while, on other occasions, it does not reach its 
 height for several years. The case being at all developed, the 
 tumour, which is in and rather above the iliac region, can be 
 usually felt and seen. In this state it may remain nearly sta- 
 tionary for an indefinite period, interfering sometimes very little 
 with the comfort of the woman or her capacity for procreation. 
 But where it is of a more active character, or the organ deeply 
 affected, the swelling increases till the whole abdomen becomes 
 as large as in the last stage of utero-gestation, to which it bears a 
 strong resemblance. Even then a tolerable share of health may 
 continue — though a general distemperature is more apt to super- 
 vene, attended by hectic fever, which exhausts strength and leads 
 to a fatal issue. 
 
 No period of adult life is entirely exempt from this affection. 
 I have seen it in girls — in single and married women — in those 
 who have been fruitful, and otherwise. But, I think, it mostly 
 occurs about the season of the cessation of the menses — probably 
 owing to the irritation which the whole uterine system in itself 
 and its connections suffer at this period, and, in some instances, 
 of a malignant character. 
 
 As immediate causes of it, hydatids have been assigned by 
 some, while others maintain that it really consists in an exorbi- 
 tance of these parasites. Those of the former opinion hold that, 
 as extraneous irritants, they serve only to worry the adjacent 
 secerning surface into effusions. Be this as it may, though I 
 shall presently more distinctly express my doubts of their being 
 at all concerned in the affair, it is more obviously the result of 
 blows or falls, or any injury inflicted on the region of the ova- 
 
HYDROPS. 307 
 
 ries, or the more ordinary agencies of inflammation of these 
 organs or of their serous envelope. But it sometimes comes on 
 without any appreciable cause whatever. 
 
 To distinguish these cases from ascites, we must attend to the 
 following circumstances. It is usual with the latter to be pre- 
 ceded by a peculiar diathesis, or hydropic condition, and the 
 swelling is gradually and equally extended over the abdomen, 
 while at the same time, there is more or less osdematous affection 
 of the extremities or elsewhere, and particularly the face. In 
 ovarian dropsies, on the contrary, these signs are absent, and we 
 have afforded some positive and peculiar indications, such as the 
 swelling being mostly local and prominent, inclined to one side 
 or part of the belly. It is also said to be movable, when the 
 patient is placed on her back, and by passing the fingers up the 
 vagina, the os tincse is found to move with the tumour. More- 
 over, little or no thirst or fever usually exists, and the urine is 
 neither diminished nor sensibly changed, and menstruation con- 
 tinues, when one organ is only affected, which it very rarely 
 does in ascites. 
 
 There are other affections bearing such a similitude to it that 
 they may be confounded, and among which is ovaritis, tending 
 to suppuration. But here the pain is violent, sometimes even 
 agonizing, throbbing or pulsatory, with high fever, and the 
 career of the case is infinitely more rapid and decisive. Tu- 
 mours are, however, sometimes of a very gradual formation, and 
 without any acuteness or pain, ultimately attaining great size, 
 and these prove exceedingly perplexing. Tumours, also, of an 
 adventitious nature, occupying the same position, are liable to be 
 mistaken for it, and to come to a just conclusion, the nicest exa- 
 mination is often demanded. Even this, however carefully con- 
 ducted, will not always succeed. 
 
 I once attended a lady with Dr. Physick, who was placed 
 under our care by two very skilful practitioners of one of our 
 large cities, for ovarian dropsy — and on a very thorough investi- 
 gation of the case, we were satisfied of the correctness of their 
 opinion of its nature. But on a post-mortem inspection, some 
 months afterwards, when she died, it was found that we all had 
 been entirely deceived, — the affection consisting of a mass o( the 
 omentum, of a tumoroid condition, with effusion into the peri- 
 toneal cavity, and the ovaries perfectly sound. 
 
308 HYDROPS. 
 
 Many examples are recorded of mistakes of this kind, among 
 which are two committed by a surgeon of Edinburgh, who, ope- 
 rating to extirpate a supposed ovarian tumour, discovered that 
 there was only a collection of flatus in the colon in the one, and 
 in the other a deposition of fat. We have an instance also, 
 where, in tapping for this dropsy, an immense lodgment of faeces 
 in the colon formed the tumour, — a second, in which it consisted 
 of an overgrown liver, and a third, where it was agreed by a 
 consultation of surgeons to cut out the ovary, a child was actually 
 born before the appointed day for the operation. As to the dis- 
 crimination from pregnancy, I have nothing to add to what was 
 said under a previous head. 
 
 To distinguish the varieties of this dropsy itself, dependent on 
 hydatids, or otherwise, is utterly impossible. 
 
 Taken in the commencement, where it arises from simple 
 inflammation, the case may be frequently arrested or cured. But 
 permitted to advance to the production of an abscess or of other 
 structural lesions, it almost uniformly proves unrelenting, and 
 equally so when caused by hydatids. Those serous effusions 
 constituting ovarian dropsy properly, are less intractable, and 
 even when not relieved, may endure with a tolerable existence 
 for a great length of time. Frank has given us a case which, 
 commencing at thirteen, was protracted to the age of eighty-eight 
 years. There are now in this city two women, still in very good 
 health, though prodigiously distended, in whose cases I was first 
 consulted more than thirty years ago. Yet such instances are 
 rare. 
 
 From the vague notions hitherto entertained of the nature of 
 the affection, very different appearances have been represented 
 on dissection. None, indeed, of the lesions of the ovary, and 
 these are infinitely diversified, perhaps as much so as of any 
 organ of the body which has not been detected associated with 
 its hydropic effusion. But such details can be only embraced in 
 a general review of its distemperatures. More immediately be- 
 longing to this special affection, are cysts of different textures 
 and sizes, sometimes a single one, on other occasions several, or 
 even a congeries of them attached to the surface, or in the sub- 
 stance of the ovary, — containing pure serum or fluids of various 
 kinds and degrees of purity;* the multilocular sacs communicating 
 
 * They may be serous or bloody sanies, or puruloid or purulent or granulated, 
 
HYDROPS. 309 
 
 or not, and the surrounding substance merely solidified, or very 
 malignantly affected. Yet such degenerations are not uniform. 
 Cases have occurred that with considerable integrity of the ovary 
 itself, the peritoneal covering may be chiefly concerned. — Be- 
 tween the membrane and the viscus, a firm adhesion prevails 
 around the circumference of the latter, so that a sort of cul-de- 
 sac is produced, constituting a receptacle for the effusion, gradu- 
 ally enlarged, as the deposition of fluid accumulates. But hyda- 
 tids are represented to have occurred occasionally, some one or 
 more of prodigious growth, forming a vesicular-like bag, filled 
 with a pellucid fluid. This may be so,— though I have never 
 seen such, and the fact of the hydatid character of the cysts, 
 when of any magnitude, wants authentication. 
 
 For the most part, the ovary is enlarged, — we have an instance 
 where nearly solid, it weighed upwards of fifty pounds, and 
 another in which it contained within a sac, one hundred and 
 forty pints of fluid. This is reported by Muller and Monro, Hal- 
 ler, Wepfer, Frank, and others have given instances of nearly an 
 equal quantity. The fluid is rapidly replenished. 
 
 Martineau drew off four hundred and ninety-five pints of fluid, 
 in a case, within a year, and it continuing, six thousand six hun- 
 dred and thirty-nine pints in twenty-five years, by eighty opera- 
 tions. There is another, in which nine hundred and sixty-four 
 pints were discharged in a year, at fourteen tappings, making a 
 daily secretion of two and a half pints, and which lasting for five 
 years, two thousand seven hundred and eighty-seven pints were 
 drawn off by forty-nine successive operations. It is contained 
 in the second volume of the Medical Communications of London, 
 and there is a second in the seventy-fourth volume of the Trans- 
 actions of the Royal Society, where in eighty tappings the quan- 
 tity amounted to thirteen hogsheads. Exaggerated as these 
 reports would seem, they come to us, at least, sanctioned by the 
 authority of two of the learned bodies of Europe. There lately 
 died in this city a lady of my acquaintance, who, labouring under 
 this affliction, was actually tapped on an average once a month 
 for several years, and each time lost about three gallons of fluid. 
 
 — thin, or as viscid as honey, and of various colours, limpid, or green, or yellow, 
 or dark, or black. But in some of these cases pure dropsy does not exist, — there 
 being either a complication with very different lesions of the ovary itself, or it 
 may be independently affected by abscess, &c. 
 
310 HYDROPS. 
 
 Much obscurity is confessed in regard to the pathology of this 
 disease. But presuming the account of its anatomical characters 
 I have given to be correct, I think there may be deduced from 
 it a more clear and satisfactory view. The disease is a local 
 dropsy, the proper seat of which is the portion of the peritoneum 
 enveloping the ovary, and is induced by inflammation of that 
 membrane, either originating in itself or derived from the sub- 
 stance of the viscus. Exactly the same happens with regard to 
 other viscera invested by a serous tissue, the brain, the lungs, the 
 liver, &c. But, perhaps, as the aptest illustration of the mode in 
 which it takes place, hydrocele may be cited. The ovary and 
 testicle are kindred glands, covered by the same tissue, and as 
 the one, so may the other be brought into a condition for hydropic 
 effusion. Nor does the parallel stop here. Each organ has the 
 same susceptibility to intenser inflammation, ending in suppura- 
 tion, induration, scirrhus or other consequences. 
 
 Collections of a serous fluid in hydatids can scarcely be deemed 
 genuine dropsy. Doubts, indeed, do 1 entertain in opposition 
 to the tenour of authority, whether those cases of extraordinary 
 accumulations have been faithfully represented as of a hydatid 
 character, — it appearing to me more likely that they are refer- 
 able to depositions, within the peritoneum reflected over the 
 ovary, which becomes thus distended. It may be particularly 
 mentioned, among other grounds for this hypothesis, that all 
 such sacs which I have seen or have read a description of, were 
 totally different from a hydatid, being thicker, opaque and highly 
 vascular, whereas the former is uniformly thin, translucid and 
 utterly devoid of vessels. 
 
 As a conjecture only, I will further suggest, that in some 
 instances, at least, what have been apprehended to be hydatids 
 were in reality the blighted vesicles of the ovary, which once 
 excited, though not successfully as to the object of fecundation, 
 acquired a vital energy capable of vast developments. That the 
 latter should occasionally happen in regard to these vesicles is 
 as readily to be conceived as the extraordinary hypertrophies of 
 other minute structures, which undoubtedly take place. The 
 subsequent wonderful growth and expansion of the chorion and 
 amnios, those membranes forming the ovum as it issues from 
 one of these vesicles, and which at the time is a mere atom, sup- 
 plies a striking illustration of the fact. Yet still more does the 
 
HYDROPS. 311 
 
 vast increase of the ovary itself, which, in a natural state not 
 weighing an half ounce, may, as we have just seen, attain the 
 weight of fifty pounds. 
 
 To this conjecture I was originally led by the appearances 
 presented in two examinations I made twenty-seven years ago 
 of ovarian dropsy in the Almshouse Infirmary. These, how- 
 ever, were unavoidably hurried and incomplete, and I have had 
 no farther opportunities of pursuing the inquiry with greater 
 precision. But the hypothesis I have since constantly main- 
 tained in my lectures and in private conversation, and similar 
 views have subsequently been adopted by some of the Euro- 
 pean pathologists. Lee, no common authority, especially de- 
 clares, " that it scarcely admits of doubt, from the progressive 
 enlargement observed of the Graaffean vesicles, that the cysts 
 supposed to be hydatids often originate in the morbid distension 
 of the former bodies." Taking this extract from a review of, 
 and not from his work, I do not, however, know that I quote 
 him correctly. 
 
 Destitute, then, of positive evidence to support this notion, I 
 dismiss it for the present with a very few observations. That 
 it helps in some degree to an explanation of the peculiar liability 
 of the ovary to this variety of dropsy, may possibly be allowed. 
 What else is there in the constitution of this organ to occasion 
 such affectability ? Can it, indeed, be shown that hydatids in 
 any other viscus ever attain to so great a size and with an equal 
 amount of fluid, or exhibit a similar aspect? On the contrary, 
 are they not comparatively small and distinctly characterized ? 
 But the whole subject is mysterious, and I commit it to further 
 and more exact investigations. 
 
 Considering, in the present state of our knowledge, an effusion 
 from the peritoneal investment of the ovary as only claiming 
 among the diversity of affections confounded with it, to be legi- 
 timately dropsy, I shall confine my remarks on the medical treat- 
 ment to it exclusively. The condition antecedent to any of the 
 essential lesions is, perhaps, alone medicable. By bleeding, gene- 
 ral and local, the latter particularly, often repeated, then a suc- 
 cession of blisters, low diet, rest, and finally an alterative course 
 of mercury with cicuta, henbane or opium, or as recently advised, 
 the iodine preparations, we may hope to arrest the case. 
 
312 HYDROPS. 
 
 Effusions having taken place to any extent, independently of 
 other aggravating lesions, the chance of cure is nearly desperate. 
 Means ordinarily promotive of absorption are here impotent 
 and nugatory. Many, indeed, concur in the opinion of the cele- 
 brated William Hunter, that "the patient, under such circum- 
 stances, will have the best chance of living longest who does 
 the least to get rid of the disease." Medicines of any power act 
 for good or evil, and where such are employed as have no cura- 
 tive effect, the contrary must take place by keeping up a perni- 
 cious irritation of the system. The remark is so far true. 
 
 But surgery offers some resources meriting consideration. Ex- 
 tracting the fluid by tapping the sac has unquestionably afforded 
 frequently immense relief for a time and lengthened life with 
 tolerable comfort. Yet it is only palliative on account of the 
 rapidity of the replenishment of the fluid, and objectionable from 
 the necessity of the frequent renewal of the operation, and the 
 uncertainty and hazard attending it. Death from exhaustion 
 has sometimes followed it, and oftener peritonitis has been ex- 
 cited, ending fatally. The tumour, too, being multilocular and 
 the cells not communicating, or the fluid very viscid, or, and 
 which has happened from the ambiguity of the diagnosis, instead 
 of a sac containing a fluid there is a hypertrophied ovary or 
 some other solid tumour, the operation utterly fails and may be 
 productive of serious injury. 
 
 An interesting summary has lately been presented by Mr. 
 Southam, an English surgeon, of the history of twenty cases of 
 the disease in which paracentesis was performed. It appears 
 that out of this number fourteen died within nine months after 
 the first operation, four of whom survived it only a few days. 
 Of the remaining six, two died in eighteen months and four 
 lived for periods varying from four to nearly nine years. Thus 
 it results that paracentesis does not prolong life, on an average, 
 for more than eighteen months and nineteen days, and that one 
 in five dies from the effects of the first operation." These statis- 
 tical reports, however, especially on a small scale, are very falla- 
 cious, and I am persuaded that such a degree of mortality from 
 the operation does not correspond with general experience and is 
 assuredly contradictory to my own. Contemplating it in its most 
 unfavourable aspect, it is a resource to which we shall be com- 
 
HYDROPS. 313 
 
 pelled to resort to relieve insufferable distress. As in ascites, the 
 danger seems to attach very much to the first operation. Dissatis- 
 factory on the whole, several improvements of this operation have 
 been suggested, though none adopted, some too absurd to be tried, 
 and those which were, proving otherwise. Dropsy of the ovary 
 is, however, sometimes spontaneously cured. Baillie mentions 
 an instance where it thus disappeared after an existence of thirty 
 years, and several are recorded from the bursting of the cysts 
 externally or into some portion of the alimentary tube. Yet 
 facts of the kind are too few to confide much in these natural 
 efforts, and they are noticed here rather as affording some en- 
 couragement to the performance of paracentesis. 
 
 An extirpation of the whole ovarian mass in this and other of 
 its affections, has been practised to a considerable extent and 
 with diverse results. The merit of this bold attempt belongs to 
 Dr. McDougal, an intrepid surgeon of Kentucky, of which some 
 European writers have vainly endeavoured to despoil him by 
 the allegation that he had been anticipated. He first performed 
 the operation in 1809, and successfully. But a case is produced 
 of its having been earlier done by Laumonier, of Rouen, in 
 France, very imperfectly authenticated, and at all events for an 
 acute abscess of the ovary, and not dropsy with its chronic dis- 
 orders. The operation, indeed, seems to have been wanton and 
 unnecessary. That a discussion prevailed, perhaps half a century 
 before, on the expediency of the operation, among some of the 
 leading men of the profession is true, without, however, having 
 been actually carried into execution, and of which agitation of 
 the subject I am very doubtful whether the American had any 
 knowledge, it being confined to the continent, and our medical 
 reading at the time was wholly English, in which scarcely any 
 notice was taken of the proceedings of other countries. To 
 originality, both in the conception and performance of this ex- 
 periment, I think he is entitled. 
 
 Not long since Churchill, of Dublin, with exemplary industry, 
 collected sixty-six cases of the operation, perhaps nearly the 
 whole ever performed, which are very carefully analyzed, and 
 the following results given. Of forty-nine cases in which the 
 ovary was extirpated, sixteen died. Of nine cases in which the 
 operation could not be completed, four died, and in eight cases 
 27 
 
314 
 
 HYDROPS. 
 
 where the operation was unnecessary, four died. But the an- 
 nexed tables will show these points more in detail.* 
 
 * Table I. — Cases of Extirpation of the Ovary. 
 
 No. AND 
 
 Date. 
 
 Operator. 
 
 AGE 
 
 Incision. 
 
 Result. < 
 
 Character of Dis- 
 ease. 
 
 Adhesions. 
 
 1 
 
 L'Aumonier. 
 
 
 4 inches. 
 
 Recovered. 
 
 Abscess of ovary. 
 
 
 2— 1S09 
 
 Dr. M'Dougal. 
 
 
 9 do. 
 
 do. 
 
 Gelatinous matter. 
 
 
 3— 1316 
 
 do. 
 
 
 Long. 
 
 do. 
 
 Scirrhous ovary. 
 
 
 4 
 5 
 6 
 7—1321 
 
 do. 
 
 do. 
 
 do. 
 
 Dr. N. Smith. 
 
 
 
 do. 
 
 do. 
 Died. 
 Recovered. 
 
 Cyst, fluid. 
 
 Adhesions. 
 
 
 
 
 .... 
 
 33 
 
 3 inches. 
 
 S— 1525 
 
 Mr. Lizars. 
 
 36 
 
 L0Dg. 
 
 do. 
 
 
 
 9-1325 
 
 do. 
 
 35 
 
 do. 
 
 Died. 
 
 
 Adherent. 
 
 10 
 
 Dr. A. G. Smith. 
 
 30 
 
 do. 
 
 Recovered. 
 
 Cyst, fluid. 
 
 
 11 
 
 Dr. Quittenbaum. 
 
 
 About 4 in. 
 
 do. 
 
 
 
 12-1 S29 
 
 Mr. D. Rogers. 
 
 
 About 3 in. 
 
 do. 
 
 Solid and fluid. 
 
 Adhesions. 
 
 13 
 14 
 
 Dr. Granville. 
 Dr. Chrysmer. 
 
 
 
 Died. 
 
 do. 
 
 Cart, and lardaceous 
 
 
 47 
 
 Long. 
 
 
 
 
 
 
 matter. 
 
 Adherent. 
 
 15 
 
 do. 
 
 38 
 
 do. 
 
 Recovered. 
 
 Honey-like and green 
 sanies. 
 
 do. 
 
 16 
 
 do. 
 
 
 do. 
 
 Died. 
 
 
 
 17 
 
 Dr. Ritter. 
 
 31 
 
 do. 
 
 Recovered. 
 
 Cyst, fluid. 
 
 
 
 13— 1S36 
 
 Mr. King. 
 
 57 
 
 Short. 
 
 do. 
 
 ' do. 
 
 
 19-1833 
 
 Mr. Jeafferson. 
 
 
 do. 
 
 do. 
 
 do. 
 
 
 20 
 
 M. Dolhoff. 
 
 23 
 
 Long. 
 
 Died. 
 
 Cyst and fluid. 
 
 Adhesions. 
 
 21—1336 
 
 Mr. West. 
 
 
 Short. 
 
 Recovered. 
 
 do. 
 
 
 22 
 
 do. 
 
 
 do. 
 
 do. 
 
 do. 
 
 
 23 
 
 do. 
 
 24 
 
 do. 
 
 Died. 
 
 do. 
 
 
 24 
 
 do. 
 
 
 do. 
 
 Not cured. 
 
 do. 
 
 
 25 
 
 Mr. Hargraves. 
 
 40 
 
 do. 
 
 do. 
 
 Multiloc. cysts. 
 
 Adhesions. 
 
 26 
 
 Dr. ClayT 
 
 46 
 
 27 inches. 
 
 Recovered. 
 
 Cysts, solid and fluid. 
 
 do. 
 
 27 
 
 
 67 
 
 14 do. 
 
 do. 
 
 do. 
 
 Est. adh. 
 
 23 
 
 
 39 
 
 23 do. 
 
 do. 
 
 do. 
 
 do. 
 
 29 
 
 
 40 
 
 14 do. 
 
 Died. 
 
 do. 
 
 do. 
 
 30 
 
 
 22 
 
 14 do. 
 
 Recovered. 
 
 do. 
 
 Adhesions. 
 
 31 
 
 
 40 
 
 14 do. 
 
 Died. 
 
 do. 
 
 None. 
 
 32 
 
 
 43 
 
 14 do. 
 
 Recovered. 
 
 do. 
 
 Ext. adh. 
 
 33 
 
 
 59 
 
 15 do. 
 
 Died. 
 
 do. 
 
 do. 
 
 34 
 
 
 46 
 
 16 do. 
 
 Recovered. 
 
 do. 
 
 do. 
 
 35—1340 
 
 Mr. B. Phillips. 
 
 
 2 do. 
 
 Died. 
 
 
 
 36—1341 
 
 Dr. Stilling. 
 
 
 6 do. 
 
 do. 
 
 
 
 37-1342 
 
 Mr. Walne. 
 
 58 
 
 Lons. 
 
 Recovered. 
 
 do. 
 
 None. 
 
 33—1343 
 
 do. 
 
 57 
 
 do. 
 
 do. 
 
 do. 
 
 do. 
 
 39 
 
 do. 
 
 21 
 
 do. 
 
 Died. 
 
 
 
 40-1343 
 
 do. 
 
 20 
 
 do. 
 
 Recovered. 
 
 do. 
 
 do. 
 
 41-1343 
 
 Mr. Morris. 
 
 
 do. 
 
 do. 
 
 
 
 42-1343 
 
 Mr. Southam. 
 
 
 do. 
 
 do. 
 
 Cystic sarcoma. 
 
 do. 
 
 43—1343 
 
 Dr. F. Bird. 
 
 
 3 or 4 in. 
 
 do. 
 
 Cyst and fluid. 
 
 do. 
 
 44-1344 
 
 ; do. 
 
 
 do. 
 
 do. 
 
 Cysts and solid mat- 
 ter. 
 
 do. 
 
 45 
 
 Mr. Atlee. 
 
 
 9 inches. 
 
 do. 
 
 
 Adhesions. 
 
 45 
 
 ;Mr. Lane. 
 
 
 Long. 
 
 do. 
 
 Cysts, fluid. 
 
 None. 
 
 47 
 
 Mr. Key. 
 
 19 
 
 do. 
 
 Died. 
 
 do. 
 
 do. 
 
 48 
 
 |Mr. Greenhow. 
 
 29 
 
 do. 
 
 do. 
 
 
 do. 
 
 49 
 
 [Mr. B. Cooper. 
 
 32 
 
 do. 
 
 S do. 
 
 
 
HYDROPS. 
 
 315 
 
 It seems to me, on a review of all the considerations which 
 bear on the question, that this operation is justifiable under cer- 
 tain circumstances. Nothing is. better established than the in- 
 utility of purely medical treatment in the advanced stage of the 
 disease, and the imperative demand of something to relieve 
 extreme suffering, and, indeed, to preserve life. 
 
 " Extremis malis, extrema remedia." 
 
 Even in this view a resort should not be had to the expedient 
 unless a case of necessity is clearly made out, or that the hope of 
 benefit, in a fair estimate, is greater than the danger of the ope- 
 ration. Could the diagnosis be so improved as to enable us to 
 separate with precision the favourable from the unfavourable 
 states of the organ, then I suspect that ovariotomy might be 
 brought to as much certainty as any of the great cuttings or 
 mutilations of surgery. Nay, at present it is not, perhaps, more 
 fatal than lithotomy, the excision of the mammae, or even ampu- 
 tation, so generally practised. Connected with it there is a cir- 
 cumstance peculiarly encouraging. The ovaries are not vital 
 
 Table II. — Cases of Ovarian Disease in which the Operation could not be completed. 
 
 Date. 
 
 Operator. 
 
 Cause of Failure. 
 
 Result. 
 
 Incision. 
 
 50 
 
 Dr. M'Dougal. 
 
 Adhesions to bladder and 
 
 
 
 
 
 uterus. 
 
 Recovered. 
 
 Long. 
 
 51 
 
 Mr. Lizars. 
 
 Solid and very vascular 
 
 
 
 
 
 tumour. 
 
 do. 
 
 do. 
 
 52-1826 
 
 Dr. Granville. 
 
 Finn adhesions. 
 
 do. 
 
 6 inches. 
 
 53 
 
 Dr. Dieffenbach. 
 
 Vascularity. 
 
 do. 
 
 Long. 
 
 54-1826 
 
 Dr. Martini. 
 
 Solid and fixed tumour. 
 
 Died. 
 
 do. 
 
 55 
 
 Anonymous. 
 
 Fixed tumour. 
 
 do. 
 
 
 56 
 
 M. Dolhoff. 
 
 do. 
 
 do. 
 
 About 6 in. 
 
 57 
 
 Dr. Clay. 
 
 Extensive adhesions. 
 
 do. 
 
 Loner. 
 
 58 
 
 Mr. Walne. 
 
 do. 
 
 Recovered. 
 
 5 inches. 
 
 Table III. — Cases in which the Operation failed from an Error in Diagnosis. 
 
 Date. 
 
 Operator. 
 
 Result. 
 
 Disease. 
 
 59-1823 
 
 Mr. Lizars. 
 
 Recovered. 
 
 No tumour found. 
 
 60-1834 
 
 Mr. Kins. 
 
 do. 
 
 do. 
 
 61 
 
 M. Dolhoff. 
 
 do. 
 
 do. 
 
 62 
 
 Dr. Clay. 
 
 Died. 
 
 Uterine tumour. 
 
 63 
 
 do. 
 
 Recovered. 
 
 Hydatid. 
 
 64 
 
 do. 
 
 Died. 
 
 Pelvic tumour. 
 
 65 
 
 do. 
 
 do. 
 
 Uterine tumour. 
 
 66 
 
 Mr. Heath. 
 
 do. 
 
 do. 
 
316 HYDROPS. 
 
 organs, and lengthened experience goes to show that they may- 
 be removed in a sound condition from the domesticated animals 
 with scarcely any fatality. No reason do I perceive why the 
 same might not be done in the human subject. The male suffers 
 little danger from the excision of his testicles, healthy or diseased, 
 and it is not unlikely the female system is as nearly tolerant of 
 similar ablations. But the subject belongs to surgery, and I turn 
 it over to the professors of that art further to investigate and to 
 fix it on more definite grounds. To these few remarks I have 
 been led in consequence of the recent brilliant success of my 
 friend, Dr. Atlee, of Lancaster, Pennsylvania, in extirpating both 
 ovaries simultaneously, — an operation which ought to place him, 
 where I have long known him to be entitled, among the most 
 skilful of the surgeons of our country. 
 
 In another form of abdominal dropsy, the effusion is deposited 
 externally to the peritoneum, in the space between that mem- 
 brane and the parietes of the abdomen. Looking at this interval, 
 in a natural state, we shall find it partly occupied by a layer of 
 loose cellular texture, and it may be from this, rather than the 
 external peritoneal surface, that the effusion proceeds. By pre- 
 vious inflammation, adhesion probably takes place in a portion 
 of the membrane, and a sac is formed, giving the character of 
 encysted dropsy. 
 
 Cullen and other writers allude to this variety of dropsy, with- 
 out, however, describing it. Two instances of it came under my 
 own observation some years ago, each in girls, preceded by much 
 abdominal uneasiness of a spasmodic or crampy nature. Effu- 
 sion was rapid, producing a large and regular intumescence of 
 the belly, very like pregnancy. 
 
 Limited as my experience is, I cannot draw any precise diag- 
 nosis between this affection and ascites. But in the cases men- 
 tioned, there was an entire absence of the hydropic diathesis 
 and symptoms, except the swelling, the skin being natural ; no 
 extraordinary thirst existed, and the alvine, urinary and men- 
 strual discharges were unaffected. From the want of fluctuation, 
 I was persuaded, too, that the water was not in the cavity of the 
 peritoneum. 
 
 Cupping, leeching, blistering, purgatives, diuretics, diaphoretics, 
 mercury alone and combined afforded no relief, and after con- 
 tinuing for a year or more, they both spontaneously disappeared 
 
HYDROPS. 317 
 
 with watery discharges, recurring again, as I understood, several 
 times, at different intervals. What ultimately became of the 
 cases I do not know. Meeting with such hereafter, I should not 
 hesitate to resort to an operation to evacuate directly the fluid. 
 
 HYDROTHORAX, VEL HYDROPS PECTORIS, VEL 
 HYDROPS THORACIS. 
 
 These, which are the common technical titles of this affection, 
 mean only dropsy of the chest. More accurately denoting its 
 situation and pathology, would be the term hydrops pteurse, or 
 effusion into the pleural cavity and which ought to be adopted. 
 
 It may be original or secondary dropsy, one of the imme- 
 diate sequelas of acute, subacute, or chronic inflammation of the 
 serous membrane of the lungs, or indirectly the product of di- 
 verse lesions of other organs and general derangement of health. 
 Caused in the former mode, it is, previously to the effusion, mere- 
 ly pleurisy in its several modifications, the symptoms of which 
 need not here be described. In the second form of the affection, 
 the most common and important, I have known the attack of 
 very sudden development, even in a few days, the chief pre- 
 monition being some thoracic weight and uneasiness. 
 
 Taken, however, in its general character, the invasion of the 
 disease is gradual, and continues its course so imperceptibly, as 
 sometimes scarcely to attract observation for a considerable time. 
 Most, of the early symptoms in this form of it are indicative of 
 some antecedent disorder of other parts. But, at length, more 
 characteristic, signs arise, as a dull pain at the lower end of the 
 sternum, accompanied by a slight difficulty of breathing, increased 
 by any exertion, particularly ascending an acclivity, as going up 
 stairs, though it is always most considerable and permanent 
 during the night, when the body is in an horizontal posture. 
 With these phenomena, there is cough, at first dry, which, how- 
 ever, is soon attended by an expectoration of thin, glairy phlegm 
 or mucus, and now an increased uneasiness amounting, occasion- 
 ally, to positive pain, steady or fluctuating, dull or lancinating, 
 is experienced, more or less, over the chest. The pulse is gene- 
 rally hard, somewhat accelerated, or slow, full and variously irre- 
 gular. There are likewise, paleness of complexion, an oxiema- 
 
 27* 
 
31S HYDROPS. 
 
 tous swelling of the feet, ankles and hands, some thirst, and a 
 diminished flow of urine. The bowels are little affected. These 
 symptoms become progressively aggravated, though still slowly, 
 and some time usually elapses before the attack is fully formed. 
 
 The sleep then is frequently interrupted on a sudden, some- 
 times by alarming dreams, out of which the individual quickly 
 starts up in bed with impending suffocation. Convulsive efforts 
 of the muscles subservient to respiration, resembling a paroxysm 
 of spasmodic asthma, with palpitations of the heart, generally 
 accompany such attacks, which may be excited by the most 
 trifling voluntary motion or even by a fit of coughing, — or by 
 any mental emotion or perturbation. 
 
 Labouring under the more aggravated of these distressing 
 affections, the sufferer is required to be propped up, — his mouth 
 open, and betraying the utmost anxiety for fresh air. His face 
 and extremities are cold, the pulse more anormal, intermitting in 
 a degree, seldom experienced in other disorders, — and a pain or 
 feeling of numbness extends itself from the heart towards the 
 insertion of the deltoid muscle of one or both arms, down, in 
 some instances, to the extremities of the fingers. Excepting, 
 occasionally, a livid hue of the lips, the countenance continues 
 pale, betraying a peculiar anxiety and ghastliness, and, together 
 with the upper parts of the body, is often covered with a pro- 
 fuse, clammy sweat. Drowsiness, coma, sometimes with deli- 
 rium, occasioned remotely by the impeded transmission of blood 
 through the lungs, and want of sleep not unfrequently attend the 
 latter period of the disease, and from the former cause the sputa 
 may be bloody. 
 
 Continuing in this way for a while, the paroxysm gradually 
 subsides, and an interval of comparative ease is enjoyed, till, by 
 some cause, it is re-excited, with a renewal of the same degree 
 of distress. 
 
 Let it not, however, be supposed that this description is appli- 
 cable to all cases of the disease. Like other morbid affections, 
 it has its gradations of severity, and the delineation I have pre- 
 sented is of the very worst form of it. Cases are, indeed, re- 
 ported by Morgagni, Rufus, Lentin, Stoerk and many others, 
 without any indication, whatever, of its existence, or so very 
 slight or vague as to elude suspicion. The same has been ob- 
 served by myself. Dissections in the Almshouse Infirmary, 
 
HYDROPS. 319 
 
 especially, so often showed a considerable quantity of fluid in 
 the chest, and in some instances on each side, where it had been 
 not at all denoted by symptoms, that the conclusion is almost 
 warranted, that unless it be enormous or of some continuance, 
 or coupled with effusion into the pericardium, it is productive of 
 little or no disturbance. Of this, at least, I have scarcely a doubt, 
 that most of the affections usually attributed to dropsy of the 
 pleural cavities, are owing to that of the pericardium. 
 
 Death takes place either from the slow wasting of strength 
 or by a paroxysm of anhelation, or orthopnia, or unexpectedly 
 without any assignable or obvious cause. I have known it to 
 happen merely by an effort in changing the position, as in at- 
 tempting to get out of bed, or moving from one chair to another, 
 and this when the urgent symptoms had so much remitted as to 
 have led to the hope of convalescence. 
 
 In the introduction to this inquiry I so far anticipated the etio- 
 logy of the disease, as to have stated that it may proceed from a 
 primary phlogosis of the pleura, or secondarily as a consequence 
 of some other and remoter lesion. 
 
 Not unfrequently it follows pertussis, asthma and protracted 
 catarrh or bronchitis, especially in weak, lymphatic persons. It 
 is also and more frequently consequent on disorganization of the 
 heart and the great vessels, — or disorders of the chylopoietic 
 viscera, including the stomach — sometimes misplaced or irregular 
 gout, or rheumatism, or repelled or imperfectly cured eruptions, 
 above all scarlatina, as well as a state of anaemia, however in- 
 duced, particularly by excessive losses of blood. The fact is too 
 important not to be mentioned, that it very often happens where 
 the pleurisy of aged or otherwise feeble people is thus treated, — 
 though that disease may be cured, an effusion into the pleura 
 becomes entailed. During my long attendance in the Almshouse 
 Infirmary, such an event so commonly occurred among the in- 
 veterate drunkards of that establishment, that I became exceed- 
 ingly discouraged from the use of venesection to any extent in 
 that affection under these circumstances. 
 
 Lastly, it should not be forgotten that the disease may be 
 occasioned by a metastasis of the fluid from other parts, and 
 particularly the lower extremities. 
 
 Nevertheless, it is still affirmed by Andral,* the most accurate 
 * Clinique Medical. 
 
320 HYDROPS. 
 
 of the cultivators of morbid anatomy, that out of six thousand 
 cases of hydrothorax examined by him, he met with only five 
 which were not dependent on a structural lesion of some part of 
 the body. But I apprehend he has here assumed as causes what 
 might more correctly be deemed coincidents, or in other words, 
 that, though from the shattered constitution of those most liable 
 to the disease, disorganizations are pretty constant, it cannot so 
 uniformly as he is disposed to do, be referred to these as the 
 causes of it. 
 
 Few diseases are more obscure and difficult to be distin- 
 guished than this, it having, in common with a number of other 
 affections, such a similarity of features. Those with which it 
 is most likely to be confounded are, an abscess in the lung or 
 empyema, angina pectoris, asthma, pulmonary oedema, certain 
 gastric and cardiac lesions, and, above all, dropsy of the pericar 
 dium. By close attention to the history of these cases, they may, 
 however, generally be discriminated, though sometimes the com- 
 plication is so intricate, or they are otherwise so ambiguous that 
 it is impossible to establish the diagnosis. 
 
 Of the most striking characteristics of hydrops pectoris, are 
 pallor of the face and occasionally a lurid tinge of the lips, inter- 
 mittent pulse, short, laborious breathing, particularly on going 
 up stairs, more in the inspiration than the expiration, habitually 
 cold feet and hands, with oedema of them, and startings in sleep. 
 Baglivi, an exceedingly accurate observer, pronounces the two 
 last symptoms, when accompanied by lividness of the lips, as pa- 
 thognomic. But I am sure they are not implicitly to be trusted, 
 having seen thoracic dropsy without them and other affections in 
 which they occurred. It may be added as a circumstance entitled, 
 perhaps, to more regard, that where the effusion is confined to 
 one side only and is copious, there is usually an enlargement of 
 that side, and should oedema follow, it will be, as I have observed 
 myself, for a time in the lower limb of the same side. 
 
 Great reliance has been placed on the fluctuation of the water 
 in the chest, and to produce it, succussion or shaking of the 
 patient was formerly much practised, which I have found to be 
 fallacious. Corvisart, however, says, by striking the sternum 
 in an erect posture we shall detect it more certainly and dis- 
 tinctly. Even admitting this, which I can scarcely do, from my 
 own experience, it would prove the existence of a fluid in the 
 
HYDROPS. 321 
 
 pleural cavity, which might be pus, for example, and thus empy- 
 ema be mistaken for hydrothorax. 
 
 Bichat tells us, that in a state of recumbency, compression of 
 the abdomen aggravates all the symptoms, and especially the 
 sense of suffocation. But it, too, is deceptive, — exactly the same 
 degree and kind of distress being occasioned as well in empyema 
 and other lesions of the lungs as the organic affections of the 
 heart and large blood-vessels. 
 
 Confidence, to a certain extent, is to be reposed in percussion, 
 the sound being heavy and inelastic on the side containing the 
 effusion. Yet it is not without uncertainty, since the same sort of 
 tone is emitted in empyema, in ordinary hepatization, and in the 
 tubercular and other states of the lungs. Nor is the stethoscope 
 exempt from objections. When applied to the part containing 
 the fluid, whatever may be its nature, we perceive, on the patient 
 speaking, the voice to be remarkably thin, sharp and tremulous, 
 denominated segophony, or bleating like a goat. But as the 
 case advances and the cavity is filled with the fluid, this pecu- 
 liarity of voice is lost, — the sound becoming dull, and respiration 
 no longer heard. The fluid being partly evacuated, the sego- 
 phony again returns. But as to the kind of fluid, it affords no 
 discrimination. 
 
 In equivocal cases, all these means may be employed, without, 
 however, confiding in any one exclusively. We must collect the 
 diagnosis from a strict perquisition into the history of the case, 
 coupled with the aids I have just pointed out. Thus, if it be 
 empyema or an abscess in the lung, we shall learn, that there 
 had been previously active pleurisy or peripneumony : — if it be 
 a sympathetic affection of the stomach, symptoms of dyspepsia 
 will exist, and so with regard to the other cases which resemble 
 the disease, each having, to a certain extent, its distinctive signs. 
 Between the effusions into the pericardium and those of the 
 pleural cavity, and especially when co-existent, such is the re- 
 semblance in every feature, that I believe they cannot, with any 
 precision, be discriminated. Many criteria, however, have at 
 different times been pointed out, and some are still retained as 
 deserving of regard, which hereafter I shall notice. 
 
 Cullen pronounces hydrothorax to be nearly incurable, and 
 such is the prevalent opinion among the older writers. That it 
 proves fatal in a large majority of instances, when dependent on 
 
322 HYDROPS. 
 
 serious organic lesions, or occurs among old people, or such as 
 have a very impaired constitution from depraved habits or other 
 causes, or is complicated with effusions into the pericardium or 
 pulmonary tissues, is unquestionably true. But arising under 
 more favourable circumstances, and especially as the production 
 of simple pleurisy, I have reason to believe that, for the most part, 
 so far as regards the fluid, it may be removed. We have, indeed, 
 of late, been taught, that in primary pleuritic eliminations of the 
 kind, absorption is performed with such extraordinary rapidity 
 and certainty, that scarcely any danger is to be apprehended in 
 the case, in which opinion, however, I do not concur, — my own 
 observations warranting infinitely less success. 
 
 On the whole, for reasons previously mentioned, the sudden- 
 ness and unexpectedness of death, and with every prospect of 
 recovery, our prognostications should always be cautious and 
 qualified. Yet, it is to be added, that spontaneous cures may 
 happen under circumstances apparently desperate, of which 
 several very striking examples are known to me. Two of these 
 in men, resulted from the percolation of the fluid through the 
 cellular texture down into the lower extremities, and escaped 
 by transpiration. The third was, perhaps, still more remarka- 
 ble. It occurred in a lady whom I attended, in consultation 
 with the late Professor Dewees, some years ago. From the 
 time of her confinement, nearly five weeks prior to my seeing 
 her, she had suffered from slight diminutive fever, and had 
 become senemic, with thoracic oppression, impeded respiration, 
 and the other indications of pleural effusion. Early one morning 
 we were urgently called to her, and finding her propped up in 
 bed, gasping for breath, the lips livid, — speechless, unable to 
 swallow or to speak — without consciousness — the pulse scarcely 
 appreciable, and she altogether seemingly in articulo-mortis, 
 we left her to die, but in a few minutes after we quitted the 
 room, a copious diuresis came on, and I speedily returning, had 
 the happiness to see, by the continuance of the flow of the fluid, 
 her entire relief. No relapse ensued, and she soon recovered 
 perfectly. 
 
 As proceeding from such numerous lesions, the appearances 
 on dissection must be exceedingly diversified in thoracic dropsy. 
 Many of these, however, belong rather to a remote or some 
 
HYDROPS. 323 
 
 distinct pathological condition than that which immediately pre- 
 ceded or caused the effusion. 
 
 The pleura is generally found inflamed or variously changed 
 by thickening or otherwise, as in the weaker states of pleurisy ; 
 or where the contrary is observed, or the marks of an intenser 
 inflammation exist, they are probably referable to some antece- 
 dent and more violent attack which the membrane had sustained. 
 Not uncommon, indeed, is it to meet with the pleura apparently 
 healthy or even preternaturally pale, flaccid and attenuated, espe- 
 cially in aenemic cases of the disease. As much do the lungs 
 suffer occasionally in their substance and mucous membrane as 
 in the serous tissue itself. 
 
 The fluid is usually contained in one of the pleural cavities, 
 though it may be in both. To any great extent I presume it 
 could not continue for any length of time in each side with a 
 retention of life, — since when it is confined to one only in large 
 quantity, the lung is compressed, — pushed towards the spine or 
 mediastinum, and destitute of air, showing its functions had been 
 suspended. The fluid varies in quantity and quality. Morgagni 
 states it at an average of two or three pints. Walfius, however, 
 reports a case where it amounted to sixteen, and Itard several 
 of twelve and fourteen pints. I have seen instances in which it 
 was immense. Mostly thin and of a light straw colour, it may 
 be, however, purely serous, or sero-lymphatic, or albuminous, 
 or sero-purulent, or sero-sanguineous, and it has been observed 
 dark and granulated like coffee grounds. Besides the pleural 
 cavity, the fluid is sometimes contained, also, in the duplicative 
 of the mediastinum, — in the cellular pulmonary texture, and in 
 the pericardium. 
 
 The preceding are some of the proper anatomical characters 
 of thoracic dropsy. But these embrace only a very small portion 
 of the mass of disorder which the disease usually exhibits. 
 Mainly the effect itself of an unsound constitution, the evidence 
 of the latter is brought into view in the lesions of a greater or 
 less extent of the most important organs of body. These, how- 
 ever, do not now appertain to my inquiry. 
 
 Of the pathology of hydrothorax I have scarcely a word to 
 say, it being similar to that of the serous tissue of the abdomen, 
 on which I so recently descanted that my views must be known. 
 Diversified as are its causes, they all unite to produce either a 
 
324 HYDROPS. 
 
 phlogistic condition of the pleura, mostly subacute or chronic, or 
 such changes in the exhalents or the blood itself, as to allow a 
 serous leakage. This refers to the simple or elementary forms 
 of the disease. But its complications are diversified, among the 
 most conspicuous of which are, as just intimated, oedema of the 
 cellular tissue of the lung and effusion into the pericardium. 
 Laennec and his disciples, however, maintain that the effusion 
 from pleurisy is not a genuine dropsy, the latter being very 
 different in most of its prominent features. An absurdity so 
 obvious is undeserving of criticism, and, therefore, I shall only 
 ask, must we not for the same reason place in the same category 
 ascites, hydrocephalus, hydrocele, anasarca, consequent on the 
 phlogistic irritations of their respective tissues? Exactly, indeed, 
 is the reverse, or that in no other mode than this is legitimate 
 dropsy produced. 
 
 In the management of this affection we are to be guided, to 
 a certain extent, by those general principles, and, with some 
 exceptions, to adopt the remedies suited to the preceding species 
 of dropsy. 
 
 It is to the inflammatory form I am first to address myself. 
 Connected as effusions of the chest are with unsoundness of 
 constitution, there is still, in the early stage, mostly, some con- 
 siderable activity of phlogosis, indicated by the pulse, thoracic 
 pain, — the appearance of the sputa, &c. 
 
 Commencing here with venesection, this is to be repeated so 
 long as this condition continues or the remedy can be borne. 
 Diseases of the lungs and their serous tissue require, perhaps, 
 more than any other, the loss of blood for their cure. The gene- 
 ral may be greatly aided by topical bleeding, and preferably by 
 cups. These should be applied to the back, where they act 
 most efficaciously, leaving the breast for a succession of blisters. 
 Much of the want of success, in the early stage of this affection, 
 is to be ascribed to the neglect or inadequate employment of 
 these means. There is at this time phlogosis of the pleura and 
 neighbouring structures, and all experience goes to prove that 
 it is peculiarly remediable by such a plan. My remarks, of 
 course, refer to the disease in persons of some vigour and integ- 
 rity of constitution. As formerly mentioned, those of reverse 
 habits, especially broken-down drunkards, so far from bearing 
 
HYDROPS. 325 
 
 such depletion, are rendered worse by it, sometimes even leading 
 to the effusion, or, if already existing, increasing it. 
 
 Nitrate of potash, given freely by itself or with tartarized anti- 
 mony, is the appropriate internal remedy. It reduces vascular 
 action, promotes the evacuation of the fluid and prepares the 
 way for the more active sorbentia. Of these, the best is a com- 
 bination of squill and calomel, from which effects are produced 
 not derivable from either article alone. The manifestation of the 
 specific influence of mercury is an auspicious sign. Dyspnoea 
 and other distressing symptoms are often relieved on its happen- 
 ing. But never should the mercury be urged further, and it will 
 be found best, even in the attainment of this moderate effect, to 
 insinuate it very gradually. 
 
 Not a little has been said of digitalis in these cases. Neither 
 in substance nor tincture, however, have I ever derived any very 
 striking advantage from it. Given at all, it should be as an 
 infusion, and particularly as Withering's infusion, which is the 
 best formula I have ever tried. Yet, by combining it with some 
 other articles, it is sometimes improved, as in the complicated 
 prescription given under the head of ascites. Nevertheless, it 
 seems to be an opinion pretty well established that digitalis is 
 much better adapted to dropsy of the pericardium, or affections 
 of the heart imitative of it, than to the pleural effusions. 
 
 The preparations of colchicum alone, or diversely united, have 
 been much praised at this conjuncture. What is their precise 
 value I do not know. Cases, however, may be conceived, as 
 those proceeding from gout or rheumatism, where this article 
 might be useful. 
 
 Directed by that liberal spirit of inquiry which so eminently 
 belonged to him, the late Dr. Ferriar, for several years previously 
 to his death, conducted a series of clinical experiments to ascer- 
 tain the most certain and active diuretic, and especially in relation 
 to the cure of hydrothorax. The result of his numerous trials 
 was that the following mixture is entitled to that distinction. 
 No doubt this is an excellent prescription.* 
 
 Emetics, from their well-known effects on the chest, might 
 reasonably be supposed to be beneficial, and hence are recom- 
 
 * R. — Ext. elat., gr. i.; Sp. nitr. dulc, 3 i j .; Tine, scill.; Oxymel. colch., ua 3$S 
 Syrup, rham., 3j. — M. The dose one drachm every three or four hours. 
 28 
 
326 HYDROPS. 
 
 mended by some of the authorities. Excepting, however, to 
 exonerate the lungs from oppressive accumulations of phlegm, 
 mucus, &c, vomiting is not generally appreciated. On this point 
 I cannot speak from any adequate experience. But I concur in 
 the more common opinion of the utility of emetic substances in 
 nauseating doses. The instances I have witnessed are not a few 
 in which the most irksome uneasiness of the chest has been 
 speedily relieved, followed ultimately by active absorption, from 
 keeping up gastric distress for several days, with occasional 
 intermissions. 
 
 Eminently advantageous as purging is in most dropsies, it is 
 here very slenderly countenanced. The condemnation of the 
 process has, indeed, been extended to the whole of the pulmo- 
 nary affections. But however true it may be as a general maxim, 
 I am sure it is false, in its particular application to this affection. 
 Great reason have I to believe, that in every stage of thoracic 
 effusion, unless there is irritation of the prima? viae, the pulse 
 being active and the constitution tolerably sound, in the decided 
 advantage of purging, and the more so in women. Whether this 
 be owing to the fact that they bear the operation better, I will 
 not pretend to determine positively. Two important practical 
 lessons have been taught in regard to women. They have more 
 tenacity of life, and allow of longer and greater freedom of evacu- 
 ations from the bowels than men. 
 
 Drastic articles answer best, and above all the elatin and cro- 
 ton oil. The former I usually prescribe in the tenth or fifteenth 
 of a grain every hour or two, a few doses of which, nay a single 
 dose, when of good quality, will often purge copiously. No less 
 successful does the croton oil sometimes prove, though it is not 
 as much to be relied on as the former article. The very nrst 
 dose of it probably ever employed in the United States, was by 
 myself in consultation with the late Professor Physick in a very 
 confirmed case, coupled with ascites and anasarca. Given in 
 the morning, and only a single drop, such was the copiousness 
 of the hydragogue effects, that on my visit in the evening, all the 
 intumescence had subsided, and convalescence henceforward took 
 place. Even those who refuse here to purge freely, admit the 
 propriety of keeping the bowels soluble. But be not content 
 with this limitation of the process. Where it can be borne, and 
 
HYDROPS. 327 
 
 by the most active articles, rely upon it, we have no means more 
 decisive. 
 
 Expectorants are the only remedies remaining to be noticed, 
 which, however, are prescribed rather as palliatives than with a 
 design to the eradication of the disease. Hydrothorax is a com- 
 pound case, in which the mucous membrane and the pulmonary 
 substance, as well as the pleura, may be affected by inflammation 
 or its consequences, preternatural secretions, combined with the 
 hydropic effusion. Nature, to overcome phlogosis of these struc- 
 tures, aims at the institution of a healthy expectoration, though 
 she does not always alone succeed, and hence obviously, what- 
 ever aids her endeavours to this end, or even facilitates the rais- 
 ing up and discharge of oppressive, bronchial accumulations, 
 must have a salutary effect. It so happens, too, that most of the 
 expectorants are promotive of absorption, as the squill, the digi- 
 talis, the colchicum, the garlic, the seneka, the lactura virosa, not 
 to mention others, and they are those, in various states of mixture, 
 which are used. 
 
 With this, I complete the consideration of the acute and inflam- 
 matory form of the disease. As concerns the opposite state of it, 
 little need be said, our powers being exceedingly limited, and 
 which, for the most part, is uncontrollable, from irreparable local 
 disorganization or universal pravity of system. Depleting reme- 
 dies are here, to any extent, precluded, from the existing weak- 
 ness. But local bleeding, blistering of the chest, and most of the 
 articles just enumerated, with a view to the removal of the fluid 
 by absorption, as well as those calculated to facilitate expectora- 
 tion, may be employed. Correctives of the cachectic condition, 
 and the means of invigoration, may also be brought into requisi- 
 tion, particularly some of the martial preparations, the phosphate 
 or tartrate of iron. But these and every thing else, so seldom 
 meet our wishes, that our confidence soon ceases in them, and 
 left without efficient resources, our efforts are limited to assuage 
 harassing symptoms as they may arise. From its importance I 
 must again recall attention to the fact of the unquestionable 
 gravitation of the fluid from the thoracic cavity to the lower ex- 
 tremities, and the relief thereby afforded. The patient is hence, 
 at times of great distress, to be placed in a sitting posture, with 
 his legs down, so as to promote the process, and as soon as the 
 
328 HYDROPS. 
 
 fluid accumulates, it is to be evacuated by punctures with a sharp 
 pointed lancet or by acupuncturation. 
 
 The profession have long practised the expedient without 
 knowing its mode of operation. Experience showed it eased 
 thoracic oppression, and it was resorted to accordingly. Not the 
 least interesting case where it appears to have been often used 
 with advantage, was that of Dr. Johnson, the renowned lexico- 
 grapher. Greatly suffering for a lengthened period, from dropsy 
 of the chest, we learn that, on the occurrence of anasarca, the 
 operation mitigated his distress, and on one occasion, when in 
 agony, I recollect he called vehemently to Cruikshank, his sur- 
 geon, to cut deep and freely, so as to get out the water, as the 
 only source of relief. For many years, I have never failed to 
 recur to it, under proper circumstances, and am entirely satisfied 
 of its utility. Not curing the disease, it is still the most effective 
 of palliatives and protracts life. 
 
 In circumstances thus desperate, a resort may be had to punc- 
 turing the chest itself. 
 
 Before, however, performing this operation, we ought to be 
 assured of the existence of effusion, as very serious blunders 
 have been committed. The only test of it implicitly to be trusted, 
 it is said, is the fluctuation, which is a rare occurrence, and the 
 fluid may be in the pericardium or the duplicative of the medi- 
 astinum, or cellular tissue of the lungs, or in cysts, in which 
 cases it would not be drawn off and the attempts must hence 
 prove abortive. But to use the language of Van Swieten, "a 
 paracentesis of the chest is an operation which has been per- 
 formed both by the ancients and moderns with good success.' 5 
 Even in the rude times of Hippocrates, this seems to have been 
 done, and by himself. Down to a comparatively recent date it 
 was continued, and we have the sanction of Senac, Du Verney, 
 Bianchi, and other high authorities in favour of the practice. 
 
 Good declares that, on the continent of Europe, it is very fre- 
 quently tried, and that the German miscellanies are full of cases 
 of a favourable event. The quantity of fluid stated to have been 
 evacuated in several of these is so enormous as to exceed credi- 
 bility. Thus, in one instance, a hundred and fifty pounds at a 
 single time, in others between four and five hundred pounds by 
 different tappings within the year, and in a single case nearly 
 seven thousand pints in eighty operations during a period of 
 
HYDROPS. 329 
 
 twenty-five years. But there are others of later date with so 
 much of the aspect of verisimilitude, that they cannot be doubted. 
 
 The Berlin Medical Transactions record a cure effected by an 
 accidental wound made into the thorax, by which the whole of 
 the water escaped at once. During the winter of 1820, the 
 operation was performed by Professor Gibson, at the request of 
 Dr. Jackson and myself, on a man in the Almshouse Infirmary, 
 which seemed for a time to be doing well, and probably might 
 have been successful had not a catarrhal affection supervened 
 from an exposure to cold. But in subsequent cases it answered 
 no other end than temporary alleviation, and in two instances it 
 manifestly hastened death, in the one by exhaustion and in the 
 other from the violent inflammation excited. It appears that 
 throughout Europe this expedient has been very frequently re- 
 sorted to within the last few years, and that the result of such 
 general experience corresponds pretty much with my own. 
 
 The operation being usually ineffectual from the rapidity with 
 which the fluid reaccumulates, it occurred to Prof. Jackson and 
 myself, though we were not sanguine of success, that this obstacle 
 to a cure might possibly be done away as in hydrocele by mode- 
 rately stimulating injections. These were accordingly thrown 
 into the pleural cavity, and for a time with the effect of repress- 
 ing the effusion. But after several days the individual died. 
 
 Discouraging as these trials have proved, I still think the ope- 
 ration warrantable where other means have been unavailing, 
 and the suffering extreme. Evidence we have of its occasion- 
 ally succeeding; — it never fails of temporary relief, and viewed 
 in the worst light it should not be opposed in a state otherwise 
 of such hopelessness. 
 
 Boerhaave wisely says, on this very point, "that doubtful are 
 better than no remedies," and his commentator cites a case which 
 admirably illustrates the truth of the maxim. It is taken from 
 Du Verney, an eminent surgeon, who relates "that in a woman 
 labouring under ascites and hydrothorax, little or no expectation 
 existed from the character of the symptoms, particularly the low- 
 ness and irregularity of the pulse and the difficulty of breathing; 
 he wrought an entire cure by successfully puncturing the belly 
 and chest and letting out a large quantity of fluid." Nevertheless, 
 with my low estimate of the operation, I must repeat, that I 
 consider a resort to it only vindicable as a dernier resource. 
 
 28* 
 
330 HYDROPS. 
 
 HYDROPS PERICARDII VEL HYDROPERICARDIUM. 
 
 As supplementary to the preceding dropsy, that of the pleura, 
 I shall here make a few remarks on the effusion into the sac 
 of the heart. Much, however, of what I should otherwise have 
 had to say on this affection, belongs with more propriety to the 
 general consideration of the cardiac lesions. 
 
 Between these two dropsies there is so much in common, that 
 I may be further spared the necessity of some details. Espe- 
 cially in the mode of origin and progress are they similar, and 
 each may be active or the reverse. 
 
 For the most part, when of the former variety, with a retention 
 of some of the phenomena of the antecedent pericarditis, giving 
 rise to the effusion, such as cardiac pain, there is a febrile 
 state with exacerbations of distress which progressively increase 
 in force and the frequency of repetitions, till the case becomes 
 more evolved and distinctly marked. Considered, as it is, a rare 
 form of the disease, I still think that I have seen it frequently 
 to follow pericarditis, — whether induced by gout, rheumatism, 
 or the more ordinary causes of inflammation, — coming on at the 
 decline of the phlegmasial attack, — sometimes when conva- 
 lescence seemed to have been secured, and as speedy in its 
 termination as sudden in its development. 
 
 Nevertheless, in its tenour this dropsy is different in the mode 
 of its rise and progress. Generally, it is met with in persons of 
 ill-conditioned health, who had long complained of some thoracic 
 uneasiness which may be ascertained to consist in a sense of 
 weight and straightness in the precordial region. The respira- 
 tion is difficult, sometimes even approaching suffocation in the 
 recumbent posture, — the pulse small, quick and irregular, and 
 above all, by intermittency, — though rarely any intensity of pal- 
 pitations, — sometimes extreme pallor and bloatedness of counte- 
 nance and a disposition to syncope. 
 
 Connected with these symptoms, may be perceived a sort of 
 instinctive propensity to lean over the back of a chair, or some- 
 thing else, by which mitigation is procured to the impeded 
 breathing and other urgent affections. This has been conjec- 
 tured to be owing to the gravitation of the fluid from the heart 
 to the sac, which I do not think is true, having seen an equal 
 
HYDROPS. 331 
 
 degree of relief procured in the same way in nearly all the dis- 
 orders of the heart, many of which were surely without effusions. 
 The credit of this observation, which was long since published 
 by me, and now abundantly confirmed, I think I am entitled to. 
 
 During the paroxysm, usually lasting from one to several 
 hours, to return again, however, after a short respite, such is the 
 degree of suffering that a state of mental distraction may be 
 induced, at first in the shape of wild delirium, or even frenzy, 
 gradually subsiding into stupor or insensibility with lividness of 
 the lips, or face, or nails, or the whole together, and stertorous, 
 slow, laborious breathing, as in apoplexy. Desperate as this 
 condition may appear, and often as it does prove fatal, it is not 
 necessarily so, having again and again seen instances of recovery 
 from it, though never an actual cure. 
 
 Let it not be supposed that we have always this terrible state 
 of things: every gradation of it exists, and more frequently in 
 some mitigated shape. Not uncommon is it to see individuals 
 supposed to have the disease to get through paroxysms of it of 
 even great severity, and to enjoy for weeks a very tolerable 
 share of ease, — the oppressive effusion having been removed 
 for a season. Many, too, where the collection of fluid is mode- 
 rate, may escape such attacks and suffer scarcely more than in 
 chronic bronchitis, or other affections of anhelation. But by the 
 advance of the disease, or some indiscretion, an exacerbation takes 
 place, and then the sufferings I have described will be realized. 
 
 It may be enough, at present, to state of the etiology of this 
 affection, that while proceeding from primary pericarditis, it is 
 also the result of many of the disorders of the heart, the great 
 vessels, the lungs, and those of the abdominal viscera, each of 
 which, though more especially the cardiac lesions, is productive 
 of it indirectly, by inducing pericarditis. The tendency to 
 such effusions is probably far greater than is usually suspected. 
 No disease, perhaps, is there in which it is not found, however 
 remotely seated from the heart or slenderly connected with it. 
 Tables, comprehending some fifty of the most diversified affec- 
 tions, show that it is a pretty constant occurrence, and, above 
 all, in tubercular consumption, and to a considerable extent. 
 Experiments, indeed, long ago proved this disposition to effusion 
 wherever the heart is vehemently excited. The celebrated anato- 
 mist, Vesalius, had informed us, that he uniformly observed a 
 
332 HYDROPS. 
 
 collection of fluid in criminals who were quartered alive, and 
 Littre noticed the same in decapitated animals, occasioned no 
 doubt by the violent efforts of the heart in the act of dying. 
 
 Need I repeat the remark of the extreme difficulty of the 
 diagnostication of the disease ? Laennec declares, that unless the 
 effusion be large, not less than a pint, it is impracticable, and by 
 no means certain where double or treble the quantity exists. 
 Candour has compelled a very general confession of this fact. 
 
 No one of the most peculiar of the symptoms I have already 
 enumerated, may not be found in hydrothorax, and also in 
 many of the disturbances of the heart itself. Even the pro- 
 tuberance of the prsecordial region, with widening of the inter- 
 costal spaces, which only takes place when the amount of fluid 
 is enormous, and has long continued, nor the dulness of sound of 
 the chest, nor the feebleness nor tumultuousness of the actions of 
 the heart, nor any thing else is at all conclusive. This declara- 
 tion is supported by the amplest authority. Not to cite the older 
 writers, Morgagni and his immediate successors, by whom the 
 language is held, we learn from Testa, Kreysig, Darwell and 
 others, all having profoundly studied the subject, that, to use the 
 words of one of them, " every sign is equivocal, and trustless, in 
 distinguishing hydropericardium from hydrothorax, as well as 
 diseases without effusion." 
 
 Yet it is true that some have of late vauntingly proclaimed 
 their ability to detect a very small amount of fluid, by a newly- 
 discovered indication. They state that by making the patient, 
 while in recumbency, turn from side to side alternately, percus- 
 sion reveals a correspondent dulness with the change of posture, 
 more particularly to the left of the upper part of the sternum. 
 Not many have been silly enough to pay any attention to the 
 suggestion, and even admitting the fact, it would still remain to 
 determine whether the fluid was in the pericardial, or pleural 
 cavity. Nor have we more capacity to detect the co-existence 
 of the fluid in the two cavities. 
 
 As a criterion, however, we are told that in this state the in- 
 dividual cannot bear the horizontal position, and when the fluid 
 has largely accumulated in the pericardial sac only, it is the con- 
 trary — he then preferring it, and with the head very low. 
 
 For the difference in these cases, the reason assigned is, that 
 in the one, the fluid is transferred from the diaphragm to the spine, 
 
HYDROPS. 333 
 
 whereby oppression is lightened, while in the other, it gravitates 
 to the root of the lung, obstructing the ingress of air, inducing 
 anhelation, or even a deeper sense of suffocation, all of which, I 
 suspect, is more conjectural than demonstrated. As soon as we 
 have acquired the means of satisfactorily determining the fluid, in 
 the one, we will then seek the skill of doing the same in regard to 
 the other cavity. Let us finish our present work before we 
 embark in new enterprises. With the exception of the simple 
 and strongly marked forms of it, and even here there is much 
 obscurity, the fact must be confessed, that we are without the 
 grounds of diagnostication in this disease. 
 
 The prognostications of the event of the case should be guided 
 very much by the same considerations that influence us relative 
 to its kindred affection. Not so tractable, ceteris paribus as 
 pleural effusion, it is still like it less or more alarming as pro- 
 ceeding from a primary phlogistic state of the membrane, or 
 secondarily, through derivative irritations of even the heart itself, 
 or of other organs, and as the system may be sound or depraved. 
 But in all its presentations, it proves very unmanageable, and 
 though complete cures are occasionally accomplished, they are 
 not common, or to be anticipated with much certainty. 
 
 The only anatomical characters proper to the affection are the 
 effusion, and the appearances of the membrane from which it has 
 escaped. Numerous as are the other lesions, these are the 
 causes, and not the effects of the dropsy, and have already been 
 sufficiently described. 
 
 The fluid may be purely serous, and nearly pellucid, or sero- 
 albuminous, or sero-sanguineous, or sero-purulent, and of a tur- 
 bid, or greenish, or yellowish, or citron hue, the latter perhaps 
 the most common, and varies in quantity from a few ounces to 
 one, two or three pints. As to the pericardium, it exhibits the 
 marks of inflammation, such as redness, and increased vascularity, 
 extravasations of lymph on its surface, thickening, and other 
 changes of texture, and even suppuration, and ulceration, or it 
 may be preternaturally pallid, attenuated and relaxed. These 
 differences of appearance, in regard both to the fluid and mem- 
 brane, are ascribable to the opposite states of the disease, inflam- 
 matory or the contrary. 
 
 As at all times the pericardium eliminates a serous fluid, and 
 which, from the agitations of the heart in nearly every disease. 
 
334 HYDROPS. 
 
 particularly in the struggles of death, some augmentation of effu- 
 sion may be anticipated, the question has arisen, and been much 
 discussed, as to the extent of accumulation required to constitute 
 dropsy. Corvisart was the first to fix the amount, at six or eight 
 ounces, and with few exceptions, the subsequent writers on the 
 subject seem to have adopted his estimate. Yet cases have 
 undoubtedly occurred, where even more fluid has been detected, 
 without any cardiac disturbance during life, and hence it is 
 thought by some that the matter is not satisfactorily determined. 
 No force is there in this objection. It is very readily to be con- 
 ceived, that from peculiarity of constitution, or of states of the 
 heart itself, or other circumstances, it may be very differently 
 affected in different cases by the same amount of effusion. We 
 have seen constantly illustrations of it in the other dropsies. 
 
 In the management of the affection, let it be recollected that, 
 like the hydropic effusions generally, it presents the opposite 
 conditions of activity or the reverse, and to be governed accord- 
 ingly. Essentially the remedies are the same as previously 
 detailed, in relation to hydrothorax. 
 
 The loss of blood, I will merely remark, is oftener and more 
 largely demanded here, not so much on account of the effusion, 
 as for the relief of those great cardiac lesions with which the case 
 is usually associated, and that an infusion of digitalis is pre-emi- 
 nently useful. 
 
 Nor, perhaps, ought I to omit mentioning, that even the peri- 
 cardium has been tapped, and a cure thereby effected. It was 
 done by acupuncturation, the needle having been introduced 
 into the sac through an incision between the ribs. The fluid 
 trickled out of this small aperture into the pleural cavity, and 
 thence escaped by the external opening. The case was reported 
 in one of the London Medical Journals some years ago. But 
 whatever may be its merits, the operation is not new as claimed 
 to be, except in the substitution of the needle for the trochar or 
 lancet, to puncture the sac. The operation was proposed by 
 Senac, and actually performed by Dessauit nearly a century 
 since. Laennec, who highly approves of it, suggests an improve- 
 ment, by trepanning the sternum, instead, as heretofore, making 
 an incision through the ribs. This operation, says he, is not at 
 all dangerous, and is easy of execution. By means of it, we are 
 
HYDROPS. 335 
 
 enabled to see and touch the pericardium, and may thus verify 
 our diagnosis before proceeding to lay open the pericardium. 
 
 Notwithstanding, however, this encouragement to the opera- 
 tion, I cannot recommend it with any confidence, and presume 
 the same distrust is generally entertained of it, from its having 
 so seldom been practised. Every objection to it in hydrothorax 
 seems to me to apply, a fortiori, to the present case. Nor on 
 the evacuation of the fluid in either of these dropsies, in any 
 mode, is it to be forgotten that the difficulty is far from being 
 overcome. Commonly there remains to remove the lesions 
 of structure with pravity of system, the accomplishment of 
 which too often defies our best-concerted endeavours, and, con- 
 sequently, a speedy return of the effusion, with its terrible dis- 
 tress, — to end in death. 
 
 HYDROCEPHALUS INTERNUS. 
 
 As now understood, this disease was probably not known to 
 the ancients, or, at least, they have left us no description of it. 
 That a passage in Hippocrates has been sometimes cited as 
 warranting an opposite conclusion, I am aware. But to deduce 
 from it such a meaning, the construction must be forced, and at 
 most, it conveys only a seminal hint. The claim thus set up for 
 him is further invalidated by the declaration of Celsus, who, 
 having given a digest of the knowledge of his predecessors, 
 becomes the highest authority on the subject. By him we are 
 told that the term hydrocephalos was applied by the Greeks to 
 an oedema of the scalp, and he uses it in the same sense.* Fi- 
 nally, however, it came to be extended to those enormous col- 
 lections of fluid within the cranium, connected with a defective 
 ossification of it, — and then arose the division of external and 
 internal hydrocephalus, to the latter of which I shall confine my 
 attention. 
 
 The merit of the earliest recognition of the affection I am to 
 describe, is usually accorded to Petit, an eminent French surgeon, 
 by whom it was noticed upwards of a century ago. Not a great 
 
 * "Ubi humor antem inflat, eaque inturaescit et prementi digeto cedit vtyoxt- 
 <pa.\oy Graci appellant." — Lib. iv. cap. ii. p. 187. 
 
336 HYDROPS. 
 
 while afterwards it attracted the attention of Whytt, who, in his 
 account of it published in 1768, has delineated it with such pre- 
 cision, that later writers have been content to do little more than 
 copy from him with some amplification. 
 
 The common division of the disease, at present, is into acute 
 and chronic hydrocephalus, or rather hydrencephalus, which is 
 more accurately expressive of it, — the one term meaning, ac- 
 cording to its etymology, effusion within the head, and the other 
 within the brain. Lately it has been called hydrocerebris with 
 equal propriety, though even this is less apposite than to desig- 
 nate it, as is done in regard to some of the other dropsies, after 
 the membrane which is the immediate source of the effusion. 
 
 As a primary or secondary cerebral affection, a proper regard 
 to precision, however, requires it also to be presented, and such 
 is the course I mean to pursue, — embracing in the account of it 
 to be delivered these several modifications, of which the acute 
 form will claim priority of attention. 
 
 The first stage of the disease is, in some cases, exceedingly 
 insidious, so much so as to elude suspicion when proper vigi- 
 lance is not practised. But usually the child complains of lan- 
 guor, as from fatigue, — has a furred tongue, capricious appetite, 
 thirst, irregular bowels, alternately torpid and loose,— the stools 
 being white and glutinous, — scanty, high-coloured urine, heavy, 
 foetid breath, pallid countenance, with a dark line under the 
 eyes, — harsh skin, uneasiness of the head, more tenderness of 
 the scalp than positive pain, — tumid or rather puffy abdomen, 
 epigastric oppression and soreness on pressure. Much irrita- 
 bility and fretfulness are sometimes exhibited, — the sleep is dis- 
 turbed by moanings, and by day and by night there are inquiet- 
 ude and discomfort, with little appreciable irregularities of the 
 pulse, in the whole expressive of derangement of the digestive 
 organs. But there may be more distinct manifestations of cere- 
 bral disorder, and among which is unsteadiness of gait, the foot 
 being raised as if to be placed on a step, with a sort of tottering 
 or staggering, as in drunkenness.* 
 
 This state lasts from a few days to several weeks. But sooner 
 or later, the phenomena of excitement or phlogosis begin more 
 clearly to be disclosed, in the shape of a febrile movement, with 
 
 * Golis. 
 
HYDROPS. 337 
 
 nausea or vomiting, — sometimes a dry, florid tongue, though 
 more generally moist and partially coated, — hot skin, flushed face, 
 acute headache, or pain and stiffness in the nape of the neck, 
 or aches of the joints, or soreness in the hands and feet, or the 
 whole together, — throbbing of the temporal arteries, — strange 
 sensations or noises in the ears, as the rushing of wind, or the 
 falling of water, or the ringing of bells, with aversion to light 
 and to sounds, — dry nostrils, picking of the nose, and moanings, 
 or startings, or screamings, and grinding of the teeth in sleep. 
 The fever is remittent, abating in the morning, with a sensible 
 exacerbation at night, when the pulse acquires considerable 
 activity. 
 
 Continuing in this way for a few days, we shall discover, with 
 less general excitement, the approach of heaviness, attended by 
 a knitting of the brows and a scowling expression of counte- 
 nance. The pupil of one or both eyes is dilated or contracted, the 
 first more commonly, and the pulse becomes slower, and some- 
 times intermits. Generally, the bowels are constipated, though 
 occasionally disordered, and then the stools watery or of a gela- 
 tinous consistence, clay-coloured, mixed with green scybalas, 
 the surface of them being covered by an oily-like slime, and 
 the urine is still deficient. For a time, — though the sleep seems 
 to be profound, it is liable to be interrupted as previously de- 
 scribed, — and on arousing the child, there is, at the moment^ 
 partial delirium, denoted by a wild, distracted eye, incoherent 
 mutterings, — unusual behaviour, or quite irrational conduct,— 
 and when raised up, sickness, with a tendency to syncope ,. is 
 very apt to be manifested. Now, or at an earlier period, a dry, 
 teazing cough arises, seemingly from nervous irritation. 
 
 This state of things advances on to the stage of oppression, 
 owing, probably, to effusions. The pulse at first slow, strug- 
 gling, and, perhaps, intermittent, becomes weaker, smaller and 
 more accelerated, till it is thready and can hardly be counted, 
 accompanied by squinting, more widely dilated or contracted 
 pupils, — rolling of the head, — automatic or unmeaning tossings 
 of the hands, low delirium, or profound stupor, convulsions, or 
 spasms, usually of one arm or leg, or both, or of the muscles of the 
 face. No inconsiderable difficulty of deglutition also exists, — 
 and the respiration is frequent and laborious, with a lengthened 
 pause between each inspiration, and not unfrequently, invohm- 
 29 
 
33S HYDROPS. 
 
 tary alvine and urinary discharges, the latter prodigiously copious 
 and mostly pellucid. 
 
 During this period of collapse, and particularly at the com- 
 mencement of it, efforts of reaction are made, which, however, 
 are transitory, followed by a relapse of even still greater depres- 
 sion and in a condition nearly insensible, the child may lie for 
 days. Emaciated considerably, in some instances, though not 
 much, where the case is rapid, its aspect is still more altered by 
 the effects of its sufferings. The face is pale, the eyes are sunken, 
 though half open, with a film on the surface, the temples hollow, 
 — the nose contracted, the forehead glazed or moistened by a 
 cold, dewy perspiration, with occasionally small vesicles on the 
 neck and breast, as if produced by the sprinkling of boiling water. 
 
 This is the tenour of the disease, which, however, may be diver- 
 sified, as well in the mode of its approach as its career and 
 eventuation. Cases occur, some of which I have seen, without 
 any, or very slight premonition, ending fatally in two or three 
 days or even hours. The child apparently well, is seized with 
 ardent fever, attended by gastric or cerebral distress, or both, 
 soon becomes comatose and dies, convulsed. These are the apo- 
 plexies, hydrocephala of Cullen, and subsequently called water 
 strokes, by Golis, from the rapidity of the effusion. On the 
 contrary, we meet with it more frequently in subjects of weakly 
 constitutions and lymphatic temperaments, where it proceeds 
 slowly, and though presenting the leading characteristics of the 
 affection, these are less prominently developed, and at no time 
 betraying any activity of inflammation, either by the general 
 circulation or local excitement. 
 
 Moreover, as the final incident to many febrile diseases which 
 often takes place, all the preliminary stages are characterized by 
 the symptoms of these, and till it actually bursts forth there may 
 be scarcely any thing in the case to denote its approach. 
 
 It would be easy to multiply to nearly any extent, descriptions 
 of the various guises and aspects exhibited by hydrencephalus, 
 were details of this kind consistent with my design, which aims 
 at a concise view of the subject. 
 
 To one other variety of it I cannot, however, forbear to advert, 
 which heretofore, I think, has not attracted sufficient regard. 
 My allusion is to hydrencephalus from metastasis. On a former 
 
HYDROPS. 339 
 
 occasion I endeavoured an explanation of this phenomenon to 
 which I must be content to refer. Of its existence in grown 
 persons I have seen several instances. Thus induced, the case 
 is peculiar in its nature, consisting in a mere transposition in 
 the fluid, from some other part to the brain, and usually happens 
 very suddenly. 
 
 Diversified as the disease is, its duration must be very different, 
 sometimes terminating in twelve* or twenty-four hours, by con- 
 vulsions, in other instances running on for three or more weeks, 
 though, perhaps, the average period is from ten to fifteen days. 
 
 Children between two and five years old are mostly liable to 
 the disease, and, according to Morgagni, girls more than boys, 
 though the contrary is affirmed by Golis, a highly respectable 
 writer. 
 
 As occurring mostly in early life, there must be some pecu- 
 liarity in the physical constitution at this period to create such 
 a predisposition. To the disproportioned size of the head, as 
 well as the greater laxity or softness and vascularity of the brain 
 inviting or retaining an undue amount of blood, has it been 
 ascribed. But I am inclined to believe, as previously intimated, 
 that what in them tends particularly to hydropic effusion, is the 
 extreme tenuity and delicacy of the arachnoid membrane render- 
 ing it less capable to take on and sustain any intensity of inflam- 
 mation. An injury here, which may lead to an irritation pro- 
 ductive of serous elimination, will, at a maturer age, end rather 
 in the extravasation of lymph or the secretion of pus. 
 
 Not uncommonly do we meet with susceptibility to the dis- 
 ease, in an increased degree, and in some families so predominant 
 is it, that I have known several children to be attacked — and 
 Cheyne informs us of his having heard of one where as many as 
 eleven fell successively victims to it. This predisposition, in 
 some instances, seems to be influenced by a certain external con- 
 formation of the head, which is preternaturally large or irregu- 
 larly protuberant — though by no means uniformly, having seen 
 it with the most perfect configuration. Generally, perhaps, it is 
 found in connection with the strumous, or some other cachectic 
 diathesis, to which, however, there are also numerous exceptions. 
 Children florid, and apparently robust, frequently betray the 
 same affectability. 
 
 * Golis. 
 
340 HYDROPS. 
 
 As promotive of the disease in early life, it has been suggested 
 by Golis, that the custom of rocking the infant in the cradle, 
 pitching it backwards and forwards, holding it with its head 
 downwards, and other bodily agitations, may have this effect 
 — and also certain amusements, especially in boys — such as 
 standing on the head, hanging by the feet, &c. Be this as it may, 
 dentition is a less equivocal cause. Cerebral irritation from this 
 process is very considerable, evinced among other ways, by 
 the convulsions so often occasioned by it, and is very apt to lead 
 to hydropic effusion. The same effect is sometimes induced by 
 the suppression or repulsion of crusta lactea, tinea capitis, or 
 those discharges behind the ears attendant on teething, as 
 well as by other acute or chronic eruptions. Blows on the head 
 are a prolific source of the disease. May not this be one reason 
 why children are more subject to hydrencephalus ? Consequent 
 on the want of the symmetry or just proportion just alluded to, 
 it is to be remarked that they are top heavy, and hence, in their 
 tumbles, are very apt to strike the head. Thus excited, it 
 deserves recollection, that in many instances it is not manifested 
 for a long period, weeks, months, or even years. Many or per- 
 haps all the chronic lesions of the brain may conduce to effusions, 
 as will presently more clearly appear. 
 
 Conceding the share of these circumstances in predisposing to, 
 or exciting the disease, I am inclined to impute a vast deal, also, 
 to a certain condition of the chylopoietic viscera, which lays the 
 foundation of many of the morbid affections in childhood. That 
 there are causes of hydrencephalus acting directly on the brain, 
 or indirectly through the digestive and collatitious organs, is, at 
 all events, determined. The latter seem mainly to consist of the 
 irritations from lodgments of food or from worms, or sordes of 
 different kinds, or habitual constipation, or whatever else induces 
 gastro-enteric disturbance. Between the mucous and arachnoid 
 tissues, there is a ready interchange of affections owing to the 
 intimate consent of parts. But disorder of any of the abdominal 
 viscera may occasion it, and particularly the liver, which has the 
 same sort of sympathy. Every disease, in fine, expending much 
 of its force on the brain, immediately or mediately may end in 
 such effusions. The late pathologists, on this account, ceasing, 
 for the most part, to consider k as an idiopathic or distinct affec- 
 tion, have come to the conclusion that it is nearly always, if not 
 
HYDROPS. 341 
 
 uniformly, an effect merely of some pre-existent disorder, having 
 this ultimate tendency. 
 
 Confessedly, it is very difficult to distinguish this disease from 
 others which have a close resemblance to it, in their external 
 physiognomy. To enable us to do it, we must take a very 
 minute survey of the case, noting carefully its prominent appear- 
 ances in connection with its previous history. The symptoms to 
 be attended to, as most characteristic of hydrencephalus, are the 
 inclinations to vomit, the constipation, or the aspect of the stools 
 when procured, the state of the urinary discharge, the aversion 
 to light or noises, the strange sounds in the ears, the dilatation or 
 contraction of the pupils, the strabismus, the stupor, the slow 
 irregular pulse, the rolling of the head, the tossing of the hands, 
 or the spasmodic jerkings of the arm and leg of the same side, the 
 impeded deglutition, and interrupted or embarrassed respiration. 
 There is another circumstance very peculiar. Children can bear 
 only the recumbent posture, — taken up, they are disposed to 
 faint or to be sick, and cry or scream, as if from some sudden 
 increase of suffering. 
 
 Even, however, after this careful percentation, and with all the 
 lights derived from the elaborate and minute investigations of 
 this point, contained in some of the recent treatises on the disease, 
 every candid physician will acknowledge, that any near approxi- 
 mation to uniform certainty is unattainable. Though in many 
 instances the diagnosis may be verified by a diligent and skilful 
 study of the case, we shall still be often disappointed, meeting 
 with precisely the same group of symptoms, which on one 
 occasion may be attended by copious effusions, — on another, 
 with a very different state of the brain, — on a third with lesions 
 of other parts only, — and on a fourth with nothing whatever to 
 explain the disease. Dissection has abundantly demonstrated 
 the truth of this statement. .Not to cite other illustrations of it, 
 I had lately under my care, w^ith Professor Hodge, the child of a 
 medical friend, with supposed hydrencephalus, as strongly desig- 
 nated in its several stages as could possibly be, in whom every 
 organ and portion of structure exhibited a perfectly normal and 
 sound condition. 
 
 Great use is it, in a practical view, to be able to decide whether 
 the case be a primary or secondary affection of the brain, and 
 
 29* 
 
342 HYDROPS. 
 
 here the same scrutiny is demanded and the same uncertainty 
 prevails. Of cerebral origin, it will, however, be found, for the 
 most part, to have commenced with sensorial disturbance, and 
 proceeding from the chylopoietic viscera, that these were previ- 
 ously disordered. 
 
 To determine the separate and independent existence of the 
 affection in the arachnoid tissue, or in complication with the 
 cerebral substance has been attempted. The most distinctive 
 features, according to Lallemand, of the former, are extreme 
 inquietude and restlessness, with delirium — a tendency to con- 
 vulsions, and finally, great diminution of sensibility — while the 
 latter is mainly to be recognized by rigidity or spasms of the 
 limbs, or absolute paralysis, and confusion or decay of the intel- 
 lectual faculties. This, however, is a very imperfect discrimina- 
 tion of the two states, and I am not aware that a more satisfac- 
 tory one can be made, or of its practical importance could it be, 
 as whatever may be its character, essentially similar measures 
 are to be pursued in the cure. 
 
 Of more consequence is it, at least in reference to the treatment, 
 to ascertain the existence of effusion. But this is also exceed- 
 ingly difficult, and no one symptom, or collection of symptoms, 
 can be implicitly trusted. Cases are numerously recorded where 
 somnolency, even coma, dilatation or contraction of the pupil 
 or immobility of it, or strabismus, or blindness, or convulsions, or 
 partial paralysis, has existed without effusion. But above all, 
 our duty requires us to understand the nature, and to be watchful 
 of the preliminary symptoms, so as to arrest an attack, this being 
 the only period when we can interpose our efforts with any con- 
 fidence of success. These, I hope, have been detailed with 
 sufficient perspicuity to be intelligible. 
 
 Forming our decision of the probable issue of an attack of 
 hydrencephalus, we should be not a little controlled by our con- 
 viction of the manner of its production, and the state of the 
 system with which it is associated. Excited by irritation of the 
 chylopoietic viscera, it will caeleris paribus prove more manage- 
 able than when originally seated in the brain, and where the case 
 is acute and inflammatory, occurring in sound, robust children, 
 than the reverse or the slow and lingering, in habits feeble and 
 disordered, which latter, indeed, is scarcely medicable. 
 
 Equally is it intractable, when the result of some other disease, 
 
HYDROPS. 343 
 
 fever or otherwise, thus terminating in effusion. Even, however, 
 in its acute and most active form, the event is greatly influenced 
 by the simplicity or complication of the case. The cerebral mass 
 being involved, the symptoms are more violent, the progress of 
 the attack more rapid, and the cure more difficult, and, indeed, 
 is very seldom accomplished. These are what are denominated 
 water strokes. Moreover, under all circumstances, much de- 
 pends on the stage of the case. By timely management, it may 
 often be cured antecedently to the effusion, and scarcely ever 
 after this has taken place. Doubtless it is owing to their referring 
 to these different stages of the disease, that we find such opposite 
 reports, among practitioners, of the degree of its curability. Thus, 
 Monro avows his utter inability to do it, and Rush, his distin- 
 guished success. Both are right, in relation to the distinctions 
 mentioned. The signs which least equivocally denote recovery 
 are the subsidence of vascular irritation and the cerebral affections, 
 composure of stomach, very bilious or more natural evacuations, 
 healthy urine or an approach to it, or heavy deposits in it, with soft 
 perspirable skin, and, above all, derluxions from the nostrils. This 
 last is the earliest and most certain harbinger of an auspicious 
 change, proclaiming the restoration of natural secretory action. 
 
 The unfavourable indications are, of course, in some degree, 
 the reverse of the preceding. 
 
 Certain symptoms, however, I have observed to be especially 
 of bad import. They are, constant nausea and great disinclina- 
 tion to be raised, with an inability to sit up, from giddiness and 
 confusion of head, and particularly when attended by tinnitus 
 aurium or other sounds, or by deafness or blindness. 
 
 Dilatation or contraction of the pupil, or squinting, is unpropi- 
 tious, and so is pain in the neck, much more so than in the head. 
 Coma, convulsions, especially spasmodic jerking of the limbs, or 
 copious discharges of pellucid urine or watery stools, voluntary 
 or otherwise, are usually mortal signs. Cheyne thinks differently 
 as to the urinary discharge. But I am sure he is wrong, such 
 evacuations of urine always denoting decay of cerebral energy. 
 They occur in hysteria, also from frights, and whenever, in short, 
 this state of the brain and nerves is induced. The loss of cerebral 
 energy in these latter cases being only temporary, no serious 
 harm results from it. But in hydrencephalus it is very different. 
 By compression, or otherwise, the vital power of the brain is so 
 
344 HYDROPS. 
 
 greatly and permanently impaired, that the symptom to which I 
 have alluded is one of the most fatal character. The appearance 
 of the vesicular eruption, formerly mentioned, though not noticed 
 by any writer whom I have consulted, is scarcely less so. 
 
 Examinations post mortem exhibit great diversity of appear- 
 ances, to be ascribed, in part, to the number of affections imitat- 
 ive of hydrencephal us, confounded with it, particularly arachnitis 
 of an active character, and not less, perhaps, to its own varieties, 
 as well as the stage at which it terminates. Death early occur- 
 ring in the more acute and violent forms of it, we shall usually 
 have phlogosis in the meninges, particularly in the arachnoid 
 tissue, which may be very minutely injected, and, of course, more 
 or less red — while, in other instances, it is opaque, and, though 
 seldom, slightly thickened. The pia mater sometimes presents a 
 net-work of turgid vessels, with here and there small masses of 
 extravasated blood— and the dura mater floridness, with lymphy 
 extravasations, or even adhesions. Nor does the substance of 
 the brain always escape. Generally, when implicated, retaining 
 its natural texture, there are indications of greater vascularity, 
 and the oozing of blood from numerous points of a cut surface, 
 or more positive congestion or inflammation may be apparent. 
 
 The case, however, having run a protracted course, still less 
 equivocal evidence is exhibited of the effects of the disease. 
 Connected with accretion of the meninges, particularly of the 
 arachnoid tissue and other changes, such as a granulated or 
 tuberculated surface in the latter, there are adhesions, with occa- 
 sionally the brain softened, blanched, fimbriated, and some por- 
 tion of it enlarged or hypertrophied. The lesions are chiefly 
 found at the base of the brain in children, differing, in this 
 respect, from adults, in whom they are oftener met with in the 
 upper and lateral portions of the hemispheres. It is also worthy 
 of remark, that in children, marasmus, or wasting of the fornix, 
 is one of the most frequent events. Differing from all this, it is 
 by no means rare to meet with cases entirely exempt from every 
 description of structural injury — and, indeed, in place of even 
 simple inflammation, to have the aspect of extreme pallor and 
 flabbiness of the brain, in its substance and meninges. Long 
 known and affirmed, this circumstance is now fully established 
 by the careful researches of Bricheteau, Abercrombie, Brechet, 
 and, above all, Andral. As might be supposed, such a state of 
 
HYDROPS. 345 
 
 parts is mainly incident to the atonic forms of the disease occur- 
 ring in weak, lymphatic systems. But I have seen it other- 
 wise, in decidedly febrile cases, where the effusion was early and 
 copious. Effusions of serum are contained in the ventricles, or 
 between the membranes, on the surface or in the convolutions of 
 the brain, or, in all these positions. The cerebral mass itself may 
 be thoroughly infiltrated. G-olis relates a case where the fluid 
 could be pressed out of it as from a sponge, and I have wit- 
 nessed several instances in confirmation of the fact. The fluid 
 differs in quality and quantity— sometimes as thin and pellucid 
 as water, coagulable or not— in other instances, turbid, thick and 
 ropy or bloody, or in place of such effusion, there is an imperfect 
 lymph extravasated or a puruloid secretion. The amount of 
 serum varies from one or two to eight or ten ounces, and some- 
 times it is very inconsiderable. An ounce is deemed necessary 
 to the constitution of dropsy. Duchatelet and Martinet have, 
 however, stated, that out of eighteen cases which they carefully 
 dissected, there were eight with scarcely any effusion. Nothing 
 original or peculiar belongs, however, to this observation, as 
 seems to be claimed. Examples without number of the same 
 kind had been previously reported. Death here probably took 
 place in the congestive or inflammatory stage which precedes 
 effusion, or there may have been merely defective innervation. 
 Tumours of various sorts, scirrhosities, ossifications, abscesses, 
 hydatids, tubercles, indurations or softenings, or other morbid 
 productions or states, have also been remarked. But such, as 
 previously intimated, are more likely mere accidents pre-existing, 
 and, brought at all in connection with the disease, should be 
 considered rather as causes than effects of it. 
 
 Derangement of different kinds frequently prevails in the chy- 
 lopoietic viscera. Cheyne tells us that he has observed the intes- 
 tines to be inflamed and constricted from spasm, and the liver of 
 a bright red colour, abounding in minute vessels, and sometimes 
 extensively adhering to the peritoneum. The stomach also has 
 been found in the same inflamed condition, and we learn from 
 Yeats, that the hepatic apparatus is pretty constantly affected 
 from simple congestion or inflammation, to great structural dis- 
 organization. Equivalent testimony is borne by Abernethy, by 
 Cooke, by Thompson, by Wilson, Philip, &c. Thompson, in- 
 deed, declares, that of eleven cases of the disease which he ox- 
 
346 HYDROPS. 
 
 amined, he detected inflammation in the whole, either in the 
 bowels or liver. My own observations do not go to this extent, 
 nor do I think it is sustained by any weight of authority. Not 
 uncommonly do we meet with worms in the intestines or loads 
 of fasces, or of indigested food or intussusception or other causes 
 of mechanical irritation. Finally, I must repeat, that a condition 
 may exist, completely imitative of hydrencephalus, without a 
 solitary appreciable lesion of the brain elsewhere. 
 
 Considering hydrencephalus proper, as a variety of dropsy, its 
 pathology may be included in those general views of that disease 
 which I have presented, with some allowance for the modifica- 
 tions it receives from the peculiarity of structure in which it is 
 located. As to the circumstances specially influencing the effu- 
 sion, I have nothing to add to the observations previously made. 
 It may be collected from these, that I view it as the result of a 
 weak, diffused phlogosis of the arachnoid membrane chiefly. 
 Lallemand believes that the inflammation may originate in the 
 cerebral substance and extend to this tegument, or conversely, the 
 latter happening more commonly. No reason is there to doubt 
 this, or that it may simultaneously prevail in both structures, 
 more especially, since, on dissection, evidence of such complicated 
 lesions is discoverable. 
 
 In denying the identity of the state leading to effusion and 
 arachnitis, under all circumstances, I differ from many of the 
 pathologists of the present day, whose great defect, in my opin- 
 ion, is an undue proneness to generalization. Not more variant, 
 surely, is pleuritis from hydrothorax or pericarditis from hydro- 
 pericardium, or peritonitis from ascites, in their common character, 
 than arachnitis from hydrencephalus. Each serous tissue may 
 again and again be inflamed, and without the peculiarity hereto- 
 fore pointed out existing, not one drop of hydropic fluid shall 
 escape. Correctly considered, the disease itself we are discussing, 
 as well as every other genuine dropsy, consists in that condition, 
 and the effusion is only one of the proximate effects. 
 
 It has, indeed, been held, that the latter, so far from consti- 
 tuting the disease, or proving the principal or even accessory 
 cause of death in the case, operates, on the contrary, to the pro- 
 traction of life by imparting to the brain a degree of tone which 
 otherwise it would lose under such circumstances. No doubt, 
 as alleged, fluid will remain in the ventricles, or, at least, we have 
 
HYDROPS. 347 
 
 every reason to suspect its existence, in some instances, for 
 weeks, or months, or years, without any serious detriment. But 
 here there is a gradual effusion, and the brain accommodates 
 itself to the distension. The reverse happens, when suddenly 
 induced,— a train of phenomena arising indicative of cerebral 
 oppression. Taken place more slowly, it may often be remarked, 
 that there is such a subsidence of the symptoms as to create an 
 expectation of recovery. This is a treacherous calm. The 
 excited vessels are relieved by effusion, and the case assumes a 
 mitigated aspect. As in other instances of dropsy, however, the 
 extraneous fluid operates as a re-exciting cause, and the disease 
 returns with exasperated force, particularly in regard to the 
 signs of oppression. 
 
 Nevertheless, though I place the proper seat of hydrencephalus 
 in the brain, I am persuaded that in many cases it commences in 
 a disordered state of the stomach, intestines, liver, &c. To this 
 conclusion I am conducted by the well-known association be- 
 tween these parts, and by various considerations which may be 
 deduced from the history of the disease, — some of its causes, the 
 great disorder in the digestive organs, — the tenderness in the 
 regions of the stomach and liver, — the obstinate constipation, the 
 character of the biliary secretion, the peculiarity of the stools, 
 denoting vitiation, all of which sometimes prevail for a long 
 time antecedent to the hydrencephalic appearance, — and, lastly, 
 the phenomena on dissection, proving the existence of no slight 
 derangement in several of the abdominal viscera, and, occasion- 
 ally, little or none in the brain itself. 
 
 Not few are the instances, as well on record as within my own 
 experience, of apoplexy, paralysis and other similar affections 
 of the brain, proceeding apparently from gastric or intestinal dis- 
 order, and which, the hydrencephalic included, were relieved 
 by remedies addressed mainly to the alimentary canal. The 
 ventricular irritation reflected on the brain is probably, at first, 
 productive of neither congestion nor inflammation, though by 
 continuance, these states may ultimately take place, followed by 
 effusion. 
 
 By several of the foreign writers, the secondary nature of 
 hydrencephalus is maintained, and especially by Yeats, who 
 goes further than I have done, deeming it to be the ordinary 
 mode of occurrence. More recently, indeed, Wilson Philip has 
 
348 HYDROPS. 
 
 declared it to be his conviction, that five out of six cases proceed 
 from some disorder of the digestive organs. But the phreno- 
 logist, Spurzheim, while he concedes that the disease may often 
 arise primarily from abdominal irritation, is led to infer from his 
 dissections, that in a still larger number of instances, it is of cere- 
 bral origin, in which view I concur. 
 
 The preceding exposition of the pathology of hydrencephalus 
 has reference to the decidedly inflammatory state of the disease. 
 We shall presently see that it occasionally exhibits a very oppo- 
 site character, and where, most probably, the effusion results 
 from a mere erethism of the arachnoid membrane, or even leak- 
 age of the exhalent vessels. 
 
 Brought now to the treatment of the disease, 1 have to remark 
 that, in order to be appropriate, it must be adapted to the three 
 stages it presents in its more usual inflammatory or febrile cha- 
 racter. 
 
 The disposition to it, whether seated in the brain or abdominal 
 viscera, may generally be removed by those remedies which are 
 most successful in the arrestation of the early movements of fever, 
 consisting of evacuations of the alimentary canal, sometimes by 
 an emetic, where the stomach is much affected, — though princi- 
 pally by purgatives, and preferably the mercurial, aided by a 
 state of rest and quietude, — low abstemious diet and a strict 
 adherence to the antiphlogistic plan in every other respect. An 
 irritation, particularly of the abdominal viscera continuing, small 
 alterative doses of calomel, or the blue pill, occasionally worked 
 off by a mild laxative, should be resorted to, and where any 
 pain or uneasiness in the head, or tenderness of the epigastrium 
 arises, leeehes to the affected part may be most advantageously 
 applied. 
 
 The case, however, having advanced so far as the develop- 
 ment of positive phlogosis, the practice is required to be more 
 energetic and decisive. It might be presumed that venesection 
 is the leading and most important measure. That it is useful 
 cannot be questioned, — though, in this mode, the loss of blood in 
 any considerable quantity, is rarely well borne, and in some in- 
 stances, even with no small activity of the circulation, a single 
 bleeding is followed by considerable exhaustion. Yet it ought 
 not to be concealed, that a very different opinion prevails among 
 some practitioners, and there is a recent writer who urges vene- 
 
HYDROPS. 349 
 
 section, at once, ad deliquium, ascribing the common failure of 
 it in the disease, to inadequate loss of blood. It is Dr. Maxwell 
 of Scotland to whom I allude. He bleeds altogether from the 
 jugular vein, and in a recumbent posture, so as to procure the 
 largest possible quantity of blood, previously to syncope. Two- 
 thirds, of ninety cases, are reported to have been cured by this 
 mode of management. Not to impeach his veracity, I presume 
 that he mistook states of active congestion or phlogosis of the 
 brain for hydropic effusion. 
 
 From all that I have seen, I am quite sure it behooves us to 
 proceed cautiously with the lancet. My remarks on venesection 
 are applicable more pointedly to the cases of children, and to 
 that form of the disease where the arachnoid membrane is 
 alone or chiefly concerned— and here, I must repeat, that the 
 remedy, if not well sustained, and carried to excess,, may, per- 
 haps, induce that very state of things, promotive of effusion. 
 But our notions of hydrencephalus are exceedingly vague, and 
 the diagnosis of the imitative cerebral disorders is so little to be 
 relied upon that the practice cannot possibly be guided by definite 
 rules or principles. It happens that arachnitis, which by itself 
 is nearly always a delicate phlogosis, may be complicated with 
 inflammation of other tissues, or of the substance of the brain, 
 productive of greater intensity of action, and here venesection 
 becomes the most important of measures. Let, therefore, the 
 practitioner be governed, to a certain extent, by all those con- 
 siderations which influence him in other instances, — urging or 
 forbearing the remedy, according to the state of the system and 
 the nature of the case. 
 
 Topical bleeding, on the whole, answers better, and this may 
 and ought to be repeatedly employed. On this point, I deem it of 
 some interest to remark, that the detraction of blood from behind 
 the ears, or the back of the neck, is far more effectual than from the 
 temples or forehead, the parts more commonly selected — to be ex- 
 plained, probably, as coming from nearer the seat of the affection, 
 which we have reason to believe, in children particularly, is 
 about the basis of the brain. There is a further advantage, that 
 when leeches cannot be had cups may be used in these positions, 
 which are very painful, and perhaps somewhat injurious from 
 the shock or jar of the scarificator, applied to the other places. 
 In the preference I have expressed for the local abstraction of 
 30 
 
350 HYDROPS. 
 
 blood, I am supported by nearly the entire authority of the best 
 of the late writers. 
 
 Co-operating to the same end, much will be derived from cold ap- 
 plications to the head, with simultaneously stimulating pediiuvia, 
 or cataplasms to the feet, of the same character, by which the tem- 
 perature and excitement of the one part are directly abated, while 
 the same effect is indirectly attained by revulsion to the extremities. 
 
 As far more effectual than the ordinary cold applications, it is 
 strenuously urged, of late, by some of the English writers, to 
 pour a small stream of cold water on the crown of the head for 
 a few minutes, — then to intermit it, and return again to it when 
 required. But since it is admitted to be so hazardous, as to be 
 practised with circumspection — that it is only exacted in cases of 
 extraordinary cerebral excitement, and must, from the necessary 
 alarm created by it in children, lead to great agitation, I have 
 never ventured on the trial of it. There are some, indeed, as 
 Reeamier of Paris, who, under such circumstances, have resorted 
 to immersion in the cold bath, and though its success is affirmed, 
 I doubt it, and must condemn it as a pernicious and unwarrant- 
 able expedient. 
 
 No measure is more important than purging, on the almost 
 unremitting continuance of which at this stage, much depends. 
 To generalize too closely, or to be led away by analogy, in the 
 practice of-our art, is among the greatest of evils. That there 
 is in this case some peculiarity which renders it more submiss- 
 ive to copious intestinal evacuations than to large detractions of 
 blood, I am entirely persuaded. This is a truth which I wish to 
 impress, as the result of my own observations, sustained by the 
 suffrage of much higher authority. Not many, indeed, what- 
 ever may be their speculative differences as to its pathology, now 
 deny the superior efficacy of this process in the disease. It is 
 called for, as well to reduce the momentum of the circulation as 
 to divert blood from the head, to arouse the torpid condition of 
 the bowels — to remove the foul or irritating accumulations they 
 contain, and rectify the morbid secretions of the liver, which are 
 often most materially affected. To show the propriety of purg- 
 ing, I may state, that in several instances, when a hydrencephalic 
 state was suspected, I have seen the disordered stomach, the 
 comatose tendency, and other alarming symptoms, removed by 
 very free evacuations. Cheyne reports a remarkable case to the 
 
HYDROPS. 351 
 
 same effect, in which relief was immediately afforded by the 
 bringing away " two chamber pots full of the most extraordinary 
 collection of faeces." Calomel alone, or to be worked off by 
 castor oil, is here generally the most appropriate article. But 
 where worms are suspected, an infusion of the spigelia and senna 
 may be substituted, or the two combinations alternated. Even 
 if none such exist, the latter is scarcely less suited. Early in the 
 history of the spigelia, was it remarked, and I have reason to 
 believe, justly, that independently of its vermifuge property, it 
 proves very efficacious in the arrestation of the slow fevers of 
 children, simulating hydrencephalus. By uniting senna with it, 
 we gain the purgative operation, and counteract its narcotic or 
 poisonous effects. 
 
 Emetics have, perhaps, been too much neglected in the disease. 
 An oppressed stomach I have known to bring on symptoms very 
 imitative, at least, of hydrencephalus, and which were promptly 
 removed by puking. This is sufficiently intelligible. But the 
 same sort of affection will occur, or one attended by similar phe- 
 nomena, though there may be nothing in the stomach to which 
 it can be traced. Even under such circumstances, emetics some- 
 times prove useful, probably in the same way that they remove 
 headache, apoplexy, and some other cerebral and nervous affec- 
 tions, which I believe they do, in the first place, on the principle 
 of revulsion, the strong impression on the stomach attracting the 
 blood or excitement to that point, and next, on the reaction of 
 the system, re-establishing a more just distribution of it. To their 
 use I was first attracted, by observing the disposition in the dis- 
 ease alternately to affect the stomach and brain, and when the 
 first was much distressed by nausea or vomiting, the latter be- 
 came relieved. But as in other hydropic states, they probably 
 go further in their salutary influences by changing that state of 
 the secerning vessels which leads to effusion. Between haemor- 
 rhage and dropsy, the close analogy I formerly pointed out, and 
 of the decided efficacy of emetics, in obviating or suppressing the 
 flow of blood, little doubt can longer remain. The late Profes- 
 sors Kuhn and Physick were much addicted to the emetic prac- 
 tice in this disease. 
 
 Not unlikely, it is partly in the same mode, by a constant 
 impression on the stomach, that the antimonials, in small doses, 
 particularly the James's powder, have acquired so much reputa- 
 
352 HYDROPS. 
 
 tion in the diseases of the brain, as apoplexy, and especially 
 hydrencephalus. The transactions of the College of Physicians 
 of Dublin contain a very interesting paper on this subject, by 
 Dr. Stoker, in which it is shown, that the latter article has a 
 tendency, as well to relieve as to prevent these affections, where 
 a predisposition to them is manifested. But, perhaps, something 
 must also be ascribed to their more diffusive action, especially 
 on the skin. Entertaining this notion, the very active diapho- 
 retics have been employed, and to the efficacy of which we 
 have the testimony of many of the eminent Dublin practitioners, 
 Brooke, Cheyne, Crampton and Percival. Even the warm bath 
 has been resorted to by Itard, with a view to the relaxation of 
 the skin and the promotion of perspiration. But, on adequate 
 experience, I suspect it has been rejected, as unduly determining 
 blood to the head, and the application of vapour substituted as a 
 safer process. Deeming all these suggestions rash and inexpe- 
 dient, 1 have never carried any one of them into practice, and 
 cannot advise others to do it. 
 
 Evacuations having been premised, blisters prove serviceable. 
 The application should first be made to the nape of the neck, 
 and afterwards to the cranium, of a sufficient size to embrace 
 the whole of it, from the ears upwards, to remain on for twenty- 
 four or thirty-six hours, or till suppuration of the scalp is in- 
 duced, without which it is comparatively useless. That vesi- 
 cating the head has been opposed by some of the recent writers, 
 I am aware, as tending rather to exasperate than allay irritation. 
 But it is much less painful in this than the other position, where 
 it is recommended, and hence less objectionable. Be this as 
 it may, its utility I was first taught by the late Professor Kuhn, 
 many years ago, and subsequent experience has confirmed it. 
 It will be well, where the delay is admissible, to shave the head, 
 for some time previously to the application, to guard against 
 strangury, so apt to occur from blisters in this position, and 
 which may be thus prevented. Heberden, probably, first ob- 
 served this fact, which has been abundantly corroborated. Mer- 
 riman and others, however, maintain that such an effect is salu- 
 tary, operating as a diverticulum to the head, and for the purpose 
 of inducing it, the tincture of cantharides is given internally — in 
 the propriety of which I cannot concur. From early removing 
 the hair, this advantage is certainly gained, that a larger and 
 
HYDROPS. 353 
 
 better surface for cold applications is commanded — and, perhaps, 
 by the loss of this warm covering of the head, the force of the 
 disease is directly mitigated. Cerebral affections, acute and chro- 
 nic, as in certain fevers, or headaches, &c, it is perfectly ascer- 
 tained, are thus relieved : and why should it not prove useful in 
 the case before us ? 
 
 It sometimes happens, at this stage, just prior, probably, to 
 effusion taking place, in weak, phlegmatic children particularly, 
 that much restlessness and jactitation are manifested, the pulse 
 being very feeble, and the skin cold and clammy. 
 
 No period is more critical in itself, or embarrassing in the 
 management. Depletory, evacuant, and all the other means 
 hitherto enumerated, it is presumable, have been vainly directed, 
 and, indeed, are no longer admissible. Now, general exhaustion 
 exists in which the cerebral and nervous systems deeply partici- 
 pate. Believing it to be a state of collapse of the latter, that 
 occasions the attendant affections, I have acted accordingly. 
 Great reliance do I place on opiates — the carbonate of ammonia, 
 wine whey, or diluted wine, or even ardent spirits, which should 
 be graduated in the use, as the case may seem to require. That 
 these remedies are successful, might be shown by no small mass 
 of cumulative testimony — they operating apparently by the 
 invigoration of sensorial power, and raising up a more healthy 
 excitement, preventive of effusion, or arresting it if already com- 
 menced. But whatever may be the explanation, I have seen, 
 again and again, this very condition superseded in this mode, 
 and which experience had taught me was utterly uncontrollable 
 by any other means known to me. 
 
 Great surprise, I am sensible, has been expressed by some at 
 my adoption of such practice at this conjuncture, so opposite, as 
 is alleged, to the tenour of authority and general usage. Little, 
 however, do I care for the tenour of authority and general usage, 
 when I know they are wrong. Confessedly too often fallacious, 
 it is owing to a blind faith in them that an inconceivable degree 
 of mischief has, and continues to be perpetrated in all the con- 
 cerns of this world. Why not, I demand, resort to remedies 
 here which are the very best adapted to the advanced stages of 
 typhous and other low fevers, where the brain is probably in 
 very much the same condition as in the case before us ? Con- 
 vulsions or spasms occurring, and these are common incidents to 
 
 30* 
 
354 HYDROPS. 
 
 this stage of the disease, opiates, at all events, are indispensable, 
 and may be much earlier and more freely administered in all cere- 
 bral affections than usually supposed. 
 
 Effusion having taken place to any extent, little can be hoped 
 to be accomplished. Granting the existence of absorbents in the 
 brain, it is still true that they act very incompetently in the 
 hydrencephalic affections. Yet, on this account, we should not 
 be discouraged from making the most strenuous exertions. Ex- 
 perience proves that the ordinary means of promoting absorp- 
 tion are here nugatory. An exception, I am aware, has been 
 made in favour of digitalis, and some similar articles, to which I 
 am afraid they are not entitled, though still deserving of trial. 
 Digitalis I have certainly known to be beneficial, rather, however, 
 by calming the circulation, and the nervous system, than by 
 removing the effusion. Mercury holds out the fairest, and, per- 
 haps, the only prospect of advantage. Even though effusion 
 may not have taken place, might it not be serviceable, by chang- 
 ing the state of the secerning vessels, or other pathological con- 
 ditions ? 
 
 Commenced in England by Dobson, in the year 1775, this 
 practice was soon adopted, and there are not a few cases reported 
 of its success. Nevertheless, it must be confessed that for some 
 time it ihas been losing reputation, and is now comparatively 
 little employed, which I am inclined to suspect is owing, in part, 
 to ike timid and incompetent course adopted. Disappointed 
 very often in my expectations from it, I have still seen it of 
 manifest utility, and especially in two instances, the outlines of 
 which I shall give. 
 
 In 1814, I attended, with the late Professor Kuhn, a child of 
 six years of age, who, having passed through the early stages of 
 well-marked hydrencephalus, presented the phenomena of effu- 
 sion. Conformably to his established practice, he resolved, if 
 possible, to attain the specific influence of mercury, and with this 
 view, directed calomel to be freely exhibited, while the whole 
 surface of the body should be rubbed twice a day, with mercurial 
 ointment of double the strength of that of the dispensatories. 
 Not content with this, he had gloves reaching to the arm-pits, 
 stockings up to the groins, a belt around the abdomen, and a cap 
 to the head, smeared with the unguent, kept constantly on, all 
 which was perseveringly done till the fourteenth morning, when, 
 
HYDROPS. 355 
 
 on the appearance of a slight ulceration of the gums, an im- 
 provement conspicuously taking place, it was discontinued, after 
 a consumption of fourteen pounds and a half of the ointment. 
 Convalescence henceforward rapidly advanced, without any fur- 
 ther inconvenience either from the remedy or the disease. 
 
 Not long afterwards I saw, with this distinguished practitioner 
 and the late Professor Wistar, a child nearly of the same age 
 under similar circumstances, in whose case this treatment was 
 pursued, and with an equally happy result. Both patients are 
 now living, and in full health. 
 
 Hardly can it be supposed, after the admission I have made 
 as to the uncertainty of mercury, that these cases are cited to 
 inspire any sanguine hopes in the success of the practice. Nor 
 am I insensible to the danger it involves. But it may sometimes 
 answer, and under circumstances so desperate, what else can be 
 done ? 
 
 SUB-ACUTE HYDRENCEPHALUS. 
 
 Nothing more suggests itself to be said, as to hydrencephalus 
 in its acute and inflammatory form. But the disease occurs occa- 
 sionally in a very opposite state of the system, and is of a more 
 lingering character, approaching, in some instances, the chronic 
 condition. For the most part, it is presented with a dry, husky, 
 pallid, sallow or dingy skin— depraved appetite, imperfect diges- 
 tion, furred tongue, foetid breath, panting respiration on the 
 slightest exertion — torpid or relaxed bowels, the stools being of 
 a clay or slate colour — deficient and loaded urine — tumid abdo- 
 men, and pain or uneasiness in it — much general attenuation of 
 frame, particularly of the lower limbs, with loss of muscular 
 power— dulness of intellect, and fractiousness of temper. No- 
 thing very distinctive of hydrencephalus is evinced by these 
 symptoms. But ultimately, they are succeeded by a slow irrita- 
 tive fever, with cerebral suffering, expressed by headache, extreme 
 fretfulness— morbid vigilance, or undue somnolency, — and hence- 
 forward, such an evolution of the disease takes place as to render 
 its existence no longer equivocal. 
 
 Generally it occurs, I think, at a more advanced period of life 
 than the acute variety of it — and in children of feeble frame, and 
 
356 HYDROPS. 
 
 as is said with heads large, or irregularly shaped. The influence 
 of a strumous habit has also been much insisted on as predis- 
 posing to it. 
 
 By Percivai, it is stated, that out of twenty-two cases, eleven 
 were decidedly thus contaminated, and Mills affirms, that in a 
 large proportion of those which came under his care, such was 
 the fact. The British authorities mostly concur in this opinion. 
 Corroborative of it. we are informed by my friend Dr. Gerhard, in 
 his extensive researches conducted in one of the Parisian hospi- 
 tals appropriated to the accommodation of children, he found the 
 effusion so constantly connected with a tubercular state of the 
 cerebral membranes, deemed of a strumous nature, as to be led 
 to infer, that the former is really the principal cause of the affec- 
 tion. These views are probably true in relation to countries 
 where scrofula is known to pervade the population. But with 
 us. in this respect, it is very different, that disease being com- 
 paratively little prevalent, and I am inclined to believe, from 
 what I have seen, that any condition whatever may predispose 
 to, or excite it — and above all, depravity of the nutritive functions, 
 induced by improper feeding. Two-thirds of the cases are hence 
 found among our negroes, or the poorer and improvident class 
 of emigrants to our country. 
 
 From the acute and phlogistic hyclrencephalus, it is to be dis- 
 tinguished by the circumstances already enumerated, and in 
 regard to the comparative curability of the two affections, I have- 
 only to repeat that it is infinitely less, so that, indeed, I am not 
 aware of having known a recovery from such an attack. 
 
 With many ol the organic lesions incident to the other form of 
 the disease, which I shall not recapitulate, it is here that tuber- 
 cular degenerations, as I have said, are chiefly detected. The 
 credit of determining their very frequent co-existence in the 
 meninges with hydropic effusion, is due to Dr. Gerhard — though 
 they had been previously observed in the brain itself by Laennec, 
 and since fully demonstrated by Green and some other writers. 
 Never, perhaps, are marks of active inflammation to be traced 
 in these cases, — the parts, on the contrary, being pallid, soft, or 
 even flabby, and the fluid copious, thin, pellucid and without the 
 quality of coagulability. Even more than the cerebral structures, 
 however, do the abdominal contents suffer, — meeting nearly al- 
 ways with the chylopoietic apparatus more or less affected, and 
 
HYDROPS. 357 
 
 above all, the mesenteric glands. Not unlikely it is in this state 
 of dropsy that the lymphatic system exhibits the general depravity 
 formerly noticed. 
 
 It is deducible from the preceding considerations, that this is 
 an atonic or passive dropsy, or in which, at least, there is, for the 
 most part, rather a deficiency than any increase of excitement, 
 and sometimes, even none at all, the fluid escaping as a mere 
 leakage from relaxation of the extreme vessels. But while I so 
 far concur in this prevalent pathological view, I must protest 
 against the conclusion to which some have recently arrived, that 
 the effusion is almost exclusively the product of tubercular 
 irritation of the brain or its meninges. Common as the coinci- 
 dence may be in the European hospitals, I am sure it is rare 
 with us, and that our experience goes to show the most prolific 
 source of the affection to be the sort of cachexy brought on by 
 bad nutrition, or what is similar to it, that induced by a residence 
 in miasmatic regions. Dropsies of the same kind in other cavi- 
 ties are well known to be occasioned by various and different 
 lesions of their organs, and no valid reason can I perceive why 
 the present one should form an exception to the general rule. 
 
 Effusion in many of these instances has happened before atten- 
 tion is attracted to the cerebral affection, and we are sensible 
 how deplorable is such a state of things. Even where this result 
 is anticipated, the vigorous remedies are precluded. I have sel- 
 dom seen a case in which venesection could be employed, — 
 though in the early stage a resort may be had to leeches, — and 
 a blister ought to be applied to the cranium. Chief reliance, 
 however, is placed on purging in the beginning, and afterwards, 
 by some, in mercury alone, or in combination with the squill 
 or digitalis. But these remedies prove impotent, and as to 
 mercury, I am afraid that it might be even pernicious in such a 
 bad habit of body. Nor have I greater expectations from any 
 of the preparations of iodine, more recently commended. The 
 case being thus hopeless, it is our duty, when the opportunity is 
 afforded, to do away the condition which may lead to such a 
 catastrophe, by an appropriate treatment. 
 
355 HYDROPS. 
 
 CHRONIC HYDRENCEPHALUS. 
 
 It remains to give a cursory view of what may be deemed 
 another and more confirmed state of chronic hydrencephalus. 
 Mostly, its approach is very gradual, and its subsequent progress 
 slow and retarded. Extreme excitability of the nervous system 
 is among the earliest of its manifestations, which, however, is 
 often preceded by severe headache, morbid vigilance, vertiginous 
 affections, or unusual sounds in the ears. The temper and dis- 
 position are much changed, — sour, fractious and depressed, or 
 good-humoured and hilarious, — sometimes alternately weeping 
 and laughing, as in hysteria. It is not long before the physical 
 sufferings become more clearly evinced. Debility and loss of 
 command over the voluntary muscles take place, and, conse- 
 quently, the gait is staggering, with inability in the movements 
 of the hands. The speech is thick, indistinct, slow and inter- 
 rupted for the want of words, and very often the substitution of 
 one for another in the strangest manner. The face is bloated, 
 with a silly or vacant expression, in the whole, closely resem- 
 bling the state and aspect induced by habitual inebriety. 
 
 It is now that derangements of the intellectual and moral 
 faculties are conspicuously displayed. First the memory is im- 
 paired, then the power of reasoning or of judgment, — the ima- 
 gination being, on the contrary, rather excited. The passions 
 are usually fierce and irascible, and venereal desires vehement 
 in adults, and, in some instances, prematurely developed in mere 
 children. The disease having still further advanced, epilepsy is 
 apt to ensue, and partial palsy, particularly of the mouth, which 
 is drawn to one side or remains open, permitting a constant 
 dribbling of saliva. Deglutition is difficult, though the appetite 
 is voracious, — constipation habitual, — urine deficient, or occa- 
 sionally profuse and limpid, — the respiration embarrassed on any 
 exertion, — the countenance more fatuous, or deformed by squint- 
 ing, — the pupils widely dilated, or contracted, — the pulse irre- 
 gular and intermittent,— somnolency increases to stupor, with 
 sometimes involuntary alvine and urinary discharges. Even in 
 this wretched state, the individual may still be up,— he, indeed, 
 is rarely confined to his bed, and though locomotion is tottering 
 and difficult, or even painful from the vertigo, or confusion of 
 
HYDROPS. 359 
 
 head it occasions, there seems to be an ambition to attempt it. 
 Death, however, not suddenly taking place by convulsions, or a 
 stroke of apoplexy, which is very apt to happen, the state of 
 things henceforward becomes worse, till finally, with extreme 
 impairment of mental and corporeal capacity, existence degene- 
 rates into little else than mere vegetation, and is usually extin- 
 guished in one of the modes just mentioned. The duration of 
 such attacks is very indefinite, from a few weeks to several years. 
 
 Not long ago I had under my care the case of a distinguished 
 physician of this city, which lasted nearly three years. Golis 
 has recorded one of more than three times this period, and others 
 are to be found of a very lengthened continuance. 
 
 Chronic hydrocephalus is incident to every age, though in this 
 shape much more rarely occurring in children, and I think, 
 oftener to be met with after than at the season of maturity or 
 thereabouts. Examples are reported of it even in very advanced 
 life, of which the writer just quoted gives three in persons 
 beyond seventy years. 
 
 Many of the causes of the chronic are the same as of the acute 
 disease, operating more tardily. Those peculiar to the former 
 are intemperance, exposure to the sun, and to certain mechani- 
 cal operations, in which the brain is heated and inflamed, — to 
 which may be added certain moral influences, as intense study, 
 or cares, anxieties and vexations, — attended by lengthened in- 
 somnolency. Yet were I to determine from my own experience, 
 I should say, that it may be most frequently traced to some act 
 of violence, blows or falls on the head. Following an acute 
 attack of the disease, I have never seen an instance. 
 
 For the diagnosis, I must refer generally to what was said 
 under a preceding head. Between the acute and chronic states 
 of the affection there can be no difficulty of discrimination. But 
 very much otherwise is it in relation to some of the other lesions 
 of the brain, softening or induration, or, indeed, any material 
 structural change of it. The whole of these have, in common, 
 a similarity of aspect, marked by little individuality of features. 
 
 As in every affection of gradual formation and long standing, 
 the difficulty of cure in this case is enhanced, and frequently ren- 
 dered utterly so, by either the antecedent or subsequent disor- 
 ganization, the causes or effects of the disease. Except in the 
 
360 HYDROPS. 
 
 early stage of the slightest attacks, we probably have little or 
 no control over this affection. 
 
 Great alterations are usually observable, on an autopsic inspec- 
 tion in the membranes, the consequence of inflammation, and the 
 cerebral mass itself affected by those diversified lesions to which 
 allusions have been made on several preceding occasions. No- 
 thing, in short, of this kind, incident to the encephalon and its ap- 
 pendages, under any circumstances whatever, which has not here 
 been detected. The amount of the effusion is usually much larger 
 than in the acute disease, and is sometimes very considerable. 
 
 Not materially variant is the pathology of the two states of 
 the affection, and the treatment does not much differ. Bleeding, 
 general and local, purging, and other antiphlogistics are used in 
 the early or inflammatory stage, and an alterative course of mer- 
 cury, or by some the iodine preparations, with blisters, issues, 
 setons, as counter-irritants, revulsives or drains, at a subsequent 
 period. The diet should be very abstemious, and rest and qui- 
 etude of body and mind strictly observed. 
 
 Dismissing this part of the subject, I turn to the consideration 
 of a still more decided form of chronic hydrencephalus, appear- 
 ing before, or soon after birth, while the cranial bones are im- 
 perfectly united, and such are sometimes the dimensions of even 
 the foetal head, as seriously to impede, or, indeed, totally to pre- 
 vent delivery, of which, among other instances, a case is related 
 by Blanchard, where four pints of fluid were evacuated. It has 
 hence been truly said, that the moment of birth is the term of 
 existence to many of these ill-fated creatures. Nascentes mori- 
 unter. 
 
 But the disease is generally of more gradual formation, and 
 where death does not speedily happen, which is usual, occasion- 
 ally runs a course of great length, the head attaining an enor- 
 mous magnitude, by an accumulation of water. Golis reports a 
 case of a person who lived twenty-seven years, — Aurevill, a 
 second, who reached forty-five years — Gall, the phrenologist, a 
 third, who died in his fifty-seventh year, and there are some 
 others of still greater longevity, less credibly related. As to 
 the size of the head, Monro gives an instance where, in a girl six 
 years old only, it measured two feet six inches in circumference, 
 and I have seen casts of the head in the anatomical collections of 
 Europe, I think not less. Distinctly do I recollect having heard 
 
HYDROPS. 361 
 
 Gen. Washington say, that he saw a young man, during the 
 revolutionary war, in New Jersey, with the disease, whose head 
 he could not embrace with his pocket handkerchief diagonally 
 folded. These, however, are very extraordinary cases, in each 
 respect, — life being seldom preserved for any length of time, or 
 the size of the head exceeding double the natural magnitude. 
 
 Commonly the visage of such a being is hideous. Less than 
 natural, the face is triangular, gradually widening above the 
 cheeks, and ending in the expansion alluded to, which may be 
 enormous, and irregularly protuberant, — sometimes the forehead 
 immensely projecting, so as to overhang the brows, and the occi- 
 put correspondently pushed back, — sometimes the protrusion is 
 to the sides, and the top of the head becomes broad and flat — 
 sometimes it rises upwards and a conical shape is assumed, and 
 sometimes one part alone may be thus affected. During these 
 changes, the bones of the face remain stationary, or very slowly 
 augment, and hence the utter destruction of all symmetry and 
 just proportion of parts. 
 
 From the want of muscular support, the head falls on the 
 breast or shoulders, — the countenance is devoid of expression, — 
 the intellectual faculties are weak,— the senses, particularly of 
 hearing and seeing, defective, and muscular power little or none. 
 Though the individual may eat adequately, and perform some of 
 the other animal functions tolerably well, he is not nourished, — 
 the growth being slow, — the hue pallid and sickly, — the lower 
 extremities singularly diminutive, while the belly is bloated, and 
 the head, as described, resembling in the whole somewhat the 
 tadpole. 
 
 "Monstrum horrendum informe injens," &c 
 
 Nothing is certainly known of the causes of this monstrosity. 
 That there is, however, a strong proclivity to it in some families 
 is determined. Golis tells us that one had six such children, and 
 Frank knew another who had seven of them successively. I 
 have seen three similar instances in a lady of this city, who had 
 afterwards a number of healthy children by the same husband. 
 
 Coming on after birth, the affection seems to be owing to the 
 same original cause continuing to interfere with the perfecting of 
 organization. 
 
 The affection can never be mistaken. Every other considera- 
 31 
 
362 HYDROPS. 
 
 tion aside, it may always be recognized by the peculiar magni- 
 tude and figure of the head, and the state of the cranial bones. 
 As to the probability of a cure, this will presently more clearly 
 appear, and I shall now only observe, that in contradiction to the 
 statements of several respectable writers of what has been accom- 
 plished in this way, I do not believe the disease, under any cir- 
 cumstances, is susceptible of a radical and permanent removal, 
 by any known process. 
 
 On an autopsic inspection, attention is first attracted to the 
 thinness of the cranial bones— their defective size — irregular 
 shape, and the width of their separation by the sutures. They 
 are usually small, insulated specks of ossification, attached, as it 
 were, to a membranous expanse. The water is found, ordinarily, 
 in the ventricles, which are vastly dilated, and the contiguous 
 cerebral substance denser from compression. But in extreme 
 cases the fluid is contained in the sac of the arachnoid tissue, 
 and then scarcely a vestige of brain sometimes remains. Its con- 
 volutions are unfolded, and it is converted into a membrane, its 
 medullary and cineritious parts can no longer be discriminated, 
 or the portions constituting its base, — the pons varolii and the 
 beginning of the medulla oblongata only existing. 
 
 In some instances, however, the brain appears to have been 
 originally incomplete in its organization, some of its parts de- 
 fective and others totally wanting, and here the space which 
 should have been occupied with cerebral matter, is filled with 
 fluid. Nor is it uncommon, in such cases, to meet with a want, 
 or imperfect development of structures in other portions of the 
 body. The liquid in this approaches nearer to pure water than 
 in any other dropsy, and is wholly uncoagulable. 
 
 Connected with the pathology of the affection, the only point 
 which 1 think requires any elucidation, regards the fact, that in 
 some cases, the possession of the senses, as well as the moral and 
 intellectual faculties, is measurably retained. Monro, and very 
 recently Bright, have, indeed, presented instances where there 
 was scarcely any deficiency in this respect. To the researches of 
 the modern anatomists we owe the solution of this problem, who 
 have shown that the encephalon, somewhat like the peritoneum, 
 is a bag, deriving its compactness and solidity from its being 
 folded up, and compressed, as it were, in the bony case which 
 encloses it. Elaborate dissection has enabled them to draw out 
 
HYDROPS. 363 
 
 the involutions and to make the demonstration stated. Effusion, 
 
 by progressive distension, accomplishes the same thing, and as, 
 under such circumstances, there is ascertained to be no loss of 
 substance in the brain, its functions may be performed. But this 
 supposes an entire cerebral integrity, while, in those more com- 
 mon instances, where an impairment or total loss of the natural 
 endowments is sustained, the reverse has taken place. 
 
 Concerning the treatment I have very little to say. The case 
 proceeding from some primordial defect in the nisus formativus, 
 and no other have I seen, I believe our efforts to cure will prove 
 impotent and nugatory. Nor do I consider it very desirable that 
 we should attain the skill to preserve an existence of idiocy or 
 physical helplessness and deformity. Yet some success has been 
 claimed from the use of the diuretics — counter-irritants to the 
 scalp, and, above all, from an alterative course of mercury dili- 
 gently and long continued. Golis, especially, reports very favour- 
 ably of this plan, of which I do not credit one syllable, having 
 repeatedly tried it without the slightest advantage. 
 
 Medicine here, being so destitute of resources, the case has been 
 resigned to surgery. It is proposed, and there are some facts on 
 record to attest the efficiency of the expedient, to endeavour, by 
 compression of the cranium, to arrest the progress of the case. 
 Bandages have been used, though strips of adhesive plaster are 
 found to answer better. The works of Sir Gilbert Blane contain 
 a full account of this practice with the proofs of its utility. 
 
 I have used it and seen it used, with no encouragement. 
 Never did I witness any diminution of the fluid, or any increased 
 tendency to ossification as promised. Besides, it is a mighty 
 hard matter to keep on bandages or adhesive plasters properly 
 adjusted in children. Especially do I recollect how ineffectual 
 it proved in the case of the grandson of a friend of mine, attended 
 by the late Professors Physick, Dewees and myself, where, de- 
 spite of every effort, it utterly failed. No one now, I suspect, 
 thinks much of this project. 
 
 Tapping the sac so as to let out the water, seems, at least, the 
 preferred alternative. The operation was first performed by Le 
 Cat, a French surgeon, in 1751, and next by Rommet of Eng- 
 land, in 177S. Neither succeeding, the operation fell into abey- 
 ance or neglect till revived by Dr. Physick, who performed it in 
 1794. He told me that for some days the child apparently did 
 
364 HYDROPS. 
 
 well, and then died in a manner which satisfied him of the in- 
 expediency of such attempts. But the operation was subse- 
 quently repeated by my late friend Dr. Glover, of Charleston, 
 South Carolina, by whom it is stated, that a cure would proba- 
 bly have happened, had there not been an interposition of acci- 
 dental and adventitious causes to prevent it. No doubt there 
 are many instances on record of the alleged success of this ope- 
 ration. But how far they were actually so, remains to be deter- 
 mined. Too eagerly do surgeons publish as cures, what turn 
 out to be only partial or temporary relief The 8th volume of 
 the Medico-Chirurgical Transactions contains a case by Mr. Vose 
 as entirely cured. Conquest, an accoucheur of distinction, in 
 London, soon followed in this career, by whom it is declared that 
 he has operated on nineteen children, ten of which perfectly 
 recovered, and I have collected thirteen further instances, distri- 
 buted chiefly through the periodical journals of Europe. An 
 example, too, is given of one that ended favourably by an acci- 
 dental rupture of the sac from a fall, and another, where the 
 fluid spontaneously passed away by urination. But all these 
 testimonies are deficient, as we do not learn whether the cures 
 were permanent or what was the precise condition in which the 
 children were left as to mind or body, or their ultimate fate. 
 On the other hand, the failures have been so numerous and 
 death so often immediately taking place, that the practice is now 
 generally condemned as hazardous and ineffectual. 
 
 The operation consists in a puncture by a small trocar or 
 needle to let out the fluid gradually, and then to compress the 
 head by bandages or strips of adhesive plaster. Lizars, of 
 Edinburgh, tapped the head twenty times in one case, and in 
 another the lateral ventricles were penetrated with safety by 
 Tricleton, of Liverpool. Not much of the fluid should be 
 drawn away at once, from the danger of fatal exhaustion. The 
 whole being evacuated, the sac collapses as an empty balloon, 
 leaving only of the head, the fascial, the lateral and the posterior 
 portions of the cranium, and the aspect is really frightful. Even 
 under circumstances apparently so desperate, ossification some- 
 times commences very rapidly, and we have several authenti- 
 cated instances of its ultimate completion. Yet a cure did not 
 follow, either effusion returning, or convulsions, or some other 
 
HYDROPS. 365 
 
 intractable affection supervening, the result of an anormal state 
 of the brain and its tissues. 
 
 An inquiry has been suggested to determine how far it might 
 be proper to extend this operation to acute and other forms of 
 hydrencephalus. Of course it should be reserved only for in- 
 stances where an accumulation of water is as clearly manifested 
 as the nature of the case allows, and the usual remedies had 
 failed. 
 
 On the principle that a desperate is preferable to no remedy, 
 it might, perhaps, be justifiable. Effusion having occurred, there 
 is often, in the acute variety especially, till it excites a reaction, 
 a remission in the disease, and this is the time at which the 
 attempt should be made. 
 
 No great danger would probably be incurred from thus punc- 
 turing the brain, since injuries of a more extensive and serious 
 character to that organ are often followed by no bad conse- 
 quences. Experiments on it, with other views, show it abun- 
 dantly, and we have just seen that the ventricles, in the chronic 
 state of the disease, were harmlessly punctured. 
 
 Nevertheless, even admitting the practicability and safety of 
 the expedient, I think we are not to calculate too confidently on 
 its success. As in other dropsies, the removal of the water here, I 
 am afraid, would very seldom produce a cure. The pathological 
 condition occasioning the effusion, probably still endures, and 
 this is the " hoc opus," the great obstacle we have left to en- 
 counter. The place and best mode of performing the operation 
 I leave to the surgeons to decide. 
 
 ANASARCA. 
 
 The dropsies of which I have treated are of the serous mem- 
 brane. But the cellular tissue may also effuse so copiously as 
 to constitute a dropsy, local or more general, the first of which 
 receives the title of oedema, and the second that of anasarca, each 
 term, however, from its derivation having the same meaning. 
 Not to enter again on ground over which I have so recently 
 travelled, I shall pass by all that has been incidentally noticed in 
 reference to this variety of dropsy in the preceding discussions of 
 the disease, and now address my remarks exclusively to it. 
 
 31* 
 
366 HYDROPS. 
 
 Brought on suddenly in a previously healthy system, cellular 
 dropsy has a very different aspect from that in one shattered or 
 vitiated by diverse organic lesions, and also as it may be simple 
 or complicated with other dropsies, or, indeed, any disease. Ex- 
 hibited in the first of these modes, it resembles an acute febrile 
 condition, sometimes attended by much local affection, and espe- 
 cially of the lungs, — sharp or dull pain, and oppressed, or other- 
 wise disordered respiration, soon followed, in many instances, by 
 effusion. I have seen the latter to take place even in a few 
 hours, and widely pervade at once the superficies of the body. 
 Mostly, however, the disease shows itself gradually by swelling 
 of the feet and ankles towards evening, which, for a time, dis- 
 appears by the morning. The intumescence is soft and inelastic, 
 and pressed upon by the finger, pits, which indentations continue 
 for some seconds, — the skin becoming at these points much paler 
 than usual. By degrees the swelling ascends and may occupy 
 the legs, the thighs, the trunk and at last the face and eyelids 
 particularly, or conversely, though rarely, beginning above, pro- 
 gressively descends. The bowels are nearly always constipated, 
 — the urine scanty and high-coloured, and the skin dry, or with- 
 out perspiration, — the pulse active, tense and corded, with a 
 coated tongue and urgent thirst. In these latter particulars, 
 however, there is sometimes great difference. Destitute of all 
 evidence of undue excitement, we have, on the contrary, the 
 indications of the extremest debility, — cold surface, — feeble cir- 
 culation, scanty, turbid or thick urine, — emaciation and the 
 general appearance of cachexy. Towards the close of the case, 
 whatever may have been its primitive character, much torpor 
 and heaviness are betrayed, with a low, indistinct fever, the skin 
 still colder and of a waxy pallor,— the distension being so con- 
 siderable as to force the fluid in some places through the cuta- 
 neous pores, and in others, where the tegument is more dense, 
 vesicles or blisters form, which bursting, are followed occasion- 
 ally by gangrene and mortification. 
 
 Effusion, however, may take place, also, in the internal cellular 
 membrane, or there appearing originally, extend itself to the ex- 
 ternal portions of this texture. (Edema of the lungs is the most 
 common, perhaps, of such affections, though scarcely an organ 
 or structure is entirely exempt. But since we have no satisfac- 
 tory signs by which it is to be distinguished, not even the pul- 
 
HYDROPS. 367 
 
 monary in^ltration, much as it has recently been attended to, or 
 exacts any specific treatment, I shall pretermit the further con- 
 sideration of it. Cornplicated as anasarca is, in its wide distribu- 
 tions, with hydrothorax and ascites, we have, then, as I have 
 said, universal dropsy, constituting a state of things as afflictive 
 as it is hopeless of cure. 
 
 (Edema is occasioned by some local irritation of the skin, pene- 
 trating to the sub-celiular tissue, or by that arising from an inter- 
 ruption of the circulation, as in the swelling of the feet and legs, 
 in advanced pregnancy, from uterine pressure on the crural ves- 
 sels, or by a tight ligature, around a limb. But it is symptomatic, 
 also, of pulmonary and other diseases of exhaustion, or may be 
 a part of other dropsies by gravitation of the fluid or otherwise. 
 An anasarca or more general effusion proceeds from essentially the 
 same causes as of the thoracic, and abdominal affections of the 
 kind, and, indeed, in many instances, is only a part of these, — the 
 dropsies of the two tissues, as we have seen, reciprocally induc- 
 ing each other by extension. Exposure to cold especially, when 
 the body has been overheated — the irritation left after the erup- 
 tive fevers, and, above all, scarlatina and rubeola, or the retroces- 
 sion of these, or other cutaneous eruptions, acute or chronic, — an 
 excessive plethoric or exsanguineous state, or impoverishment, 
 or other vitiations of the blood itself, and, in short, the whole of 
 the directly debilitating influences, are, however, more apt, in their 
 primary operation, to affect, in this mode, the cellular, than any 
 other membrane. 
 
 Conspicuously marked as this dropsy is, even to the eye, it 
 might be passed over without a word relative to the discrimina- 
 tive signs. The only cases bearing any similitude to it are some 
 other intumescences. Common diffusive inflammation of the 
 cellular membrane, as well as that more peculiar species of it, de- 
 nominated phlegmasia dolens, might most readily be confounded 
 with it. But here, independently of other circumstances, acute 
 pain exists and other evidence of more active phlogosis, and 
 there is wanting the peculiarity of the indentations, on pressure, 
 so characteristic of hydropic effusion. 
 
 Generally speaking, it is far more curable than any of its kin- 
 dred affections. It may, indeed, be stated, that when suddenly 
 induced, in a sound constitution, and restricted to the cellular 
 tissue of the external surface, it usually submits, whereas, it' it 
 
368 HYDROPS. 
 
 slowly comes on, occasioned by visceral organic lesibns, or any 
 bad habit of body, or the internal portion of the tissue is in- 
 volved, or it is complicated with any other dropsy, it is the re- 
 verse. 
 
 The anatomical characters are also varied by these contingen- 
 cies. In the simple or purely elementary forms of it, where the 
 membrane alone is concerned, we usually find only the cells en- 
 larged and thickened, or the contrary extremely attenuated, this 
 difference depending probably on the duration of the attack, and 
 the degree of distension. Connected, however, with other drop- 
 sies, or arising from internal causes, the phenomena of course, 
 are such as were enumerated under preceding heads, and consist 
 in every variety of structural lesion. 
 
 It is important to know that when the case has been excited 
 by cold, there is usually the evidence of considerable inflamma- 
 tion in some one part of the pulmonary structure, either in the 
 substance or the membranes of the lungs, separately or combined, 
 and here it is especially, I think, we are most apt to meet with 
 oedema of these organs. The same may be said in regard to the 
 effusions consequent on the eruptive fevers, with this difference 
 only, that the phlogistic action is more wide spread, embracing, 
 also, in many instances, to a considerable extent, the abdominal 
 contents and the brain, or the meninges, or the whole. 
 
 Let it suffice to state as to the pathology of anasarca, that, for 
 the most part, the effusion is the immediate product of a com- 
 paratively slight and diffused inflammation of the cellular mem- 
 brane, the causes enumerated operating to this effect. But though 
 such is the general fact, it is no less true, that in conditions of 
 extreme debility, and more especially when attended with tenuity 
 of the blood, the effusion takes place, independently of any excite- 
 ment, and must be imputed to the escape of the fluid through the 
 relaxed exhalents. 
 
 There is here an analogous state to that in colliquative perspira- 
 tions, the principal difference being, that the fluid in the one case 
 is externally eliminated, and in the other deposited and retained 
 in the cellular tissue. Examples of an interchange of these pro- 
 cesses I have witnessed. Lately I attended, in consultation with 
 Dr. Phillips, of Bristol, such a case, in one of our most distin- 
 guished citizens. For a long period effusion had been going on 
 into the thoracic cavity, when suddenly ceasing, it took the oppo- 
 
HYDROPS. 369 
 
 site direction, and was poured out most copiously from the 
 cutaneous surface. Continuing in this way for a short time, it 
 then issued from each set of vessels simultaneously, and finally 
 becoming restricted to those of the chest exclusively, it proved 
 speedily fatal from excess. The only exception to the doctrine I 
 have presented in regard to this dropsy, is to be found in the 
 instances of its arising from mere percolation of the fluid into the 
 cellular texture from the internal cavities. These are occasioned 
 in a manner so different as not to be embraced in the same 
 category. 
 
 Of the treatment of anasarca, it is to be observed, in the first 
 place, that the same remedies as in the preceding dropsies, are 
 employed in it, with slight exceptions, having a proper regard, in 
 the application of them, to the state of the system. It seems, 
 however, to be conceded, that mercury is here less beneficial, 
 perhaps, in those instances only, where the glandular viscera are 
 not affected, and that venesection and the diaphoretics are de- 
 cidedly of greater efficacy, and particularly when proceeding 
 from cold. The action may be, indeed, so decidedly inflamma- 
 tory, and the pulmonary affection so urgent, that a very large 
 loss of blood is sometimes imperatively demanded. I have de- 
 pleted in this way, as freely as in pleurisy or pneumonia, with 
 a resort to all the other means appropriate to the early stages of 
 these diseases. Not often, however, is such vigorous treatment 
 required, and after moderate sanguineous evacuations, purgatives, 
 diaphoretics, the sorbentia will prove adequate to the removal of 
 the effusions. Nevertheless, I must insist on the indispensability 
 of general blood-letting in the phlogistic forms of this dropsy. 
 Though oftener excited by cold, they, I repeat, also supervene on 
 the exanthematous fevers. Dropsy, I have rarely encountered 
 under either of these circumstances, in which an inflammatory 
 condition was not indicated, and this has been confirmed by 
 numerous dissections. 
 
 Many topical applications are used, especially when the effu- 
 sion is limited, and among these, perhaps the most common is 
 the rubbing of the lower limbs with a view of getting rid of the 
 swelling. But it does little or no good, — the fluid which had 
 thus gravitated into the feet and ankles being mechanically forced 
 upwards, to return again very soon. To soften the skin and ren- 
 der it more perspirable, frictions with warm oil have been pro- 
 
370 HYDROPS. 
 
 posed, and which, or with ardent spirits and laudanum, warmed, 
 I have seen do good, at least, in painful oedema. 
 
 Enveloping the limbs with silk oil cloth sometimes answers 
 very well. No measure more effectually arouses the action of 
 the exhalents of, or changes the general condition of the skin, as 
 is exemplified in the treatment by it of tinea capitis, and other 
 cutaneous affections. An application of wilted cabbage leaves, 
 and still more so, those of the tulip poplar, previously moistened 
 in water, is also useful. 
 
 The natural tendency occasionally shown to throw off the 
 fluid by the skin, is more frequently exerted in anasarca than 
 any other dropsy. Cases are related by Bartholet, Quarin and 
 other writers, and some even of complete cures, one, of not the 
 least interesting of which, is given by Tissot of a Russian noble- 
 man, who, nearly in extremity, was entirely relieved by a sweat 
 breaking out from his feet, that continued for a great length of 
 time. 
 
 I have more than once remarked, that I had known cures in 
 the same mode, by an exudation from other parts of the body, 
 and also, by letting off the water by puncturing the skin. The 
 latter, I presume, were of the kind induced by percolation of the 
 fluid from the great cavities. But at all times, when the limbs 
 are painfully distended, temporary relief, at least, may be afforded 
 by the operation, and it should be practised. The punctures 
 are to be made by a very sharp-pointed lancet or needle, and 
 care taken that these do not penetrate too deeply, since erysipe- 
 latous inflammation and gangrene may be the result. While I 
 am on this point, it is proper to observe, that we are frequently 
 called to encounter these very affections in cellular dropsies. 
 Either in the manner mentioned, or by excessive distension or 
 pressure on particular parts, the vitality of the integuments is 
 destroyed, or so much impaired as to occasion gangrene. The 
 most frightful sphacelus in some of these cases I have witnessed. 
 It is sometimes preceded by erysipelas of a very malignant cha- 
 racter, in which the mild applications do not succeed. The best I 
 have ever tried is Kentish's ointment, that is so effectual in scalds 
 and burns. But opodeldoc, the volatile liniment, and such like 
 articles, sometimes answer very well. Much, too, has been said 
 of a strong solution of the nitrate of silver, thirty grains to an 
 ounce of water, applied with a small brush to the surface, and 
 
HYDROPS. 371 
 
 also of the lunar caustic itself, on the margin of the healthy integu- 
 ment, contiguous to the affected part, with a view to the arresta- 
 tion of its further progress. But I confess that my expectations 
 have not been realized from the remedy. 
 
 The treatment of the gangrene is exceedingly embarrassing. 
 Blisters, so serviceable in other instances, can here be made of 
 no general use. They are, indeed, at times, the cause of the very 
 mischief we would wish them to redress. Compression of the 
 limb, above and below the affected part with a flannel roller, I 
 have found useful. The principle on which this contrivance 
 acts is very intelligible. Neither action nor temperature exists 
 in the limb at the time, and by the roller enough of each is 
 restored to enable it to resist the further encroachments of this 
 fatal process. As far as I know, this is a discovery of my own, 
 and the efficacy of which has been fairly tested. 
 
 Nitrate of silver has likewise been recommended in this state, 
 — the common fermenting poultice is still more used — though of 
 late, lotions of the chlorates of lime or soda have nearly super- 
 seded every thing else. Notwithstanding what I have said 
 against the use of blisters, they may be sometimes admissible. 
 Two or three cases have come under my observation, where 
 they proved eminently serviceable in checking the gangrene of 
 dropsy. Many years ago, I attended, in consultation with the 
 late Professor Wistar, an elderly gentleman with a rapidly spread- 
 ing gangrene of both legs from anasarca, which they speedily 
 arrested, — and I saw another in the practice of the late Professor 
 Physick, pretty much under similar circumstances, in which their 
 beneficial effects were signally displayed. Employed at all, they 
 ought not to remain on longer than to excite merely a rubescence 
 of the surface. By a more protracted action, they enfeeble or 
 extinguish the vitality of the part, frustrative of the end in view. 
 
 Finally, I must say a few words chiefly on the regimen to be 
 observed in dropsy, and the remarks I am to deliver will apply 
 more particularly to effusions in the thoracic and abdominal 
 cavities and those of the cellular membrane. 
 
 As to diet, this, of course, will depend much on the particular 
 circumstances of the case. In the active or febrile forms of the 
 disease, it should be very low, and even total abstinence for a 
 season has proved, we are told, of utility. Not the least, inte- 
 resting case to such purport, in every view, is that of the cele- 
 
372 HYDROPS. 
 
 brated Dr. Johnson, the lexicographer. Being heavily oppressed 
 and no relief afforded by medicine, he resolved, in order to pro- 
 pitiate Heaven, rigorously to fast for twenty-four hours, at the 
 end of which time copious diuresis ensued, with the happiest 
 results. His piety, which was remarkably tinctured with super- 
 stition, led him to ascribe his recovery to the efficacy of this 
 "mortification of the flesh," not recollecting that: 
 
 " Nee deus intersit, nisi dignus vindice nodus 
 Incident." 
 
 "Never presume to make a god appear, 
 But for a business worthy of a god." 
 
 Roscommon. 
 
 Conformably to this canon it would appear wrong to invoke the 
 gods on small occasions. But whether it be so or not, they sel- 
 dom obey the call. No rule, at least, is safer in philosophizing 
 than never to refer a phenomenon to supernatural interference, 
 where it is explicable by common physical agency. What 
 medical man can doubt the modus operandi of abstinence under 
 such circumstances ? The force of the circulation and the amount 
 of blood are diminished by inanition, and it is a law fully recog- 
 nized that, in proportion to these effects, are the powers of ab- 
 sorption invigorated. 
 
 Dropsy of less or no activity demands an opposite course. 
 To sustain and corroborate the system by a more nutritious and 
 generous diet, is here proper. Eggs, or oysters, or jellies, or 
 some other article containing much nutriment in small bulk, so 
 that the stomach may not be oppressed, should be preferred. 
 The effects of diet, however, are to be carefully watched, since 
 the filling up of the vessels is followed sometimes by a very 
 manifest increase of effusion, and when this happens, the food 
 must be reduced, as well in quantity as quality. 
 
 Greater difference of opinion prevails as to drinks. These, 
 instead of passing off by the natural emunctories, are sometimes 
 thrown into one of the cavities of the body or cellular membrane. 
 
 " Cressit indulgens sibi divus hydrops." 
 
 Then it is that this maxim of Horace only applies, — the fatal 
 dropsy increasing by the indulgence of drink. An apprehension 
 
HYDROPS. 373 
 
 consequently has so strongly prevailed with some as to lead them 
 to enjoin, as much as possible, a forbearance from drinking, and 
 it is alleged, that it has in some instances effected cures. Facts 
 of the kind, however, are of rare occurrence, and the numerous 
 examples of the total failure of the practice have led finally to 
 its abandonment. Difficult and painful, indeed, is it to resist the 
 vehement thirst that often attends, and by the continuance of 
 which such a degree of irritation is induced as to excite or exa- 
 cerbate fever. More generally now do we endeavour to pro- 
 mote the action of the sorbentia by the liberal use of beverages. 
 
 Common water may answer the. purpose, though water im- 
 pregnated with the carbonate of soda, or the tartrate of potash, 
 or the vegetable acids, particularly, will be found more agreeable, 
 and of superior efficacy. Cider and water is a very pleasant 
 beverage of this nature. The juniper-berry tea, however, is still 
 more effectual, and so is an infusion of the buds of the silver 
 pine, or the scabious,* or of the root or seed of parsley. Gin, or 
 whisky and water, are allowable in weak states, and especially, 
 where such liquors were formerly used to excess. Drinks alone 
 have cured dropsy on the authority of Cullen, Sir George Baker, 
 and Sir Francis Milman, not to mention other names of nearly 
 equal respectability. The propriety, indeed, of indulging the 
 patient, in this respect, is so incontestably settled, by the con- 
 current approbation of the ablest practitioners, that it would be 
 superfluous to attempt to enforce it by any theoretical deduc- 
 tions, or by a recurrence to additional authorities. 
 
 Granting that the practice proves occasionally prejudicial, such 
 instances can be deemed exceptions only to a very general rule, 
 and the mischief is so easily detected, as to be at once guarded 
 against or arrested. Drinks, when instead of answering the 
 purpose of their administration, by taking a wrong direction, 
 serving only to increase effusion, and enlarging distension, will, 
 by every practitioner of any sagacity, be timely discontinued or 
 restrained. 
 
 My views of the management of dropsy have now been de- 
 livered. But in taking leave of the subject, I cannot forbear, 
 from the importance I attach to the consideration, once more to 
 draw attention to those lesions, which very frequently still con- 
 
 * The Erigeron Heterophillum. 
 32 
 
374 HYDROPS. 
 
 tinue uncured. Not more absurd would it be to suppose, that a 
 vessel decayed throughout her structure, were repaired merely 
 by emptying the water in her hold, than that dropsy, connected 
 with its usual disorganizations, ceased to be further an object of 
 care, on the removal of the accumulated fluid. It is alike re- 
 quired, and indeed the common practice, when rid of this impe- 
 diment, to institute a rigid scrutiny, or overhaul, as it were, the 
 economy in either case, to detect its defects and apply the means 
 of rectification, so as to make again all sound and durable, or as 
 far as may be, attainable. 
 
 Much of the early treatment of dropsy, when well conducted, 
 is certainly calculated to conduce to this end, or, in other words, 
 to reinstate the order of health. Being, however, neglected, or 
 our efforts not entirely succeeding, what remains to de done is no 
 longer to be postponed, and, perhaps, from a clearer apprehen- 
 sion of the nature of the lesion, on the evacuation of the fluid, it 
 may be treated with greater skill and efficiency. Nevertheless, 
 the derangements of the viscera and tissues involved in dropsy, 
 having been erected into distinct, substantive affections, claiming 
 as such, a separate and ample examination, it would be anticipat- 
 ing my future design, or a recapitulation of what has been pre- 
 viously said, to indulge in any details regarding them at present. 
 
 But independently of such positive lesions, or any that are 
 appreciable, a very lively predisposition sometimes endures, and 
 consequently, no little liability to relapses. The causes most apt 
 to re-excite the disease in this state of system, are exposures to 
 cold, indiscretions in eating, the abuse of spirituous liquors or 
 other stimulating drinks, and similar influences, the avoidance 
 of all which is hence to be forcibly impressed and faithfully ob- 
 served. 
 
 No latent phlogosis existing, tonics may be advantageously 
 prescribed, to renovate strength, by an improvement of the di- 
 gestive and nutritive functions, as the vegetable bitters alone, or 
 combined with the martial preparations, the sulphate or tartarate, 
 the muriated tincture, and particularly the phosphate of iron. 
 During this course, should any tendency to effusion be manifested, 
 it will be right occasionally to interpose a purgative, or the sor- 
 bentia, and here the carbonate of potash, with the bitters, is 
 adopted. 
 
 Cold bathing, when it agrees well, the test of which is exciting 
 
HYDROPS. 375 
 
 a glow on the surface, is said to be serviceable, sometimes so in 
 ascites, though more particularly in pure anasarca. Dashing the 
 water on the extremities, to be followed by frictions with the 
 hand or flesh-brush, are likewise so, in the latter case. Bandag- 
 ing to support the integuments has been practised with utility in 
 anasarca and ascites. To hydrothorax I should think the applica- 
 tion of cold, under all circumstances, to be utterly inappropriate, 
 no disease of the chest bearing its impression, in whatever way 
 employed. The practice, in any of its applications, strikes me as 
 hazardous, and should never be adopted except where the con- 
 stitution is vigorous and sound. Disorganizations of the viscera 
 existing, which so often happen, I should think it could scarcely 
 fail to do harm. The warm saline bath, on the contrary, with 
 frictions, is both safer and more effectual, operating as well to 
 restore the functions of the skin, so essential to a perfect cure, as 
 in various other modes. 
 
 Exercise is eminently calculated to obviate relapses and has 
 been found, in some rare instances, to cure the disease itself. 
 As an illustration of its value, the late Professor Rush was in the 
 habit of relating the fact of a poor man, who, despairing of being 
 relieved at home of an inveterate dropsy, determined to seek his 
 advice, and for this purpose travelled on foot several hundred 
 miles. Encumbered by the disease and exceedingly weakened, 
 he, at first, could walk only a very short distance. But as he 
 proceeded, the effusion diminished and his strength returned, so 
 that he was enabled to complete the arduous undertaking, and 
 presented himself on his arrival, perfectly recovered. From this 
 anecdote may be deduced the efficacy of exercise in one instance 
 of the disease, at least, — the value of diffusive professional repu- 
 tation, and the extent to which it was enjoyed by the great phy- 
 sician from whom it was derived. Commencing with such 
 modes of exercise as are adapted to the chamber or house, the 
 external may next be resorted to as walking, riding, sailing, &c. 
 
 Let it be managed, however, as it may by all the resources of 
 our art, under the most skilful direction and with our amended 
 pathology of it, dropsy, in most of its shapes, is a very intracta- 
 ble and fatal disease, to be referred, I repeat, not so much to the 
 difficulty of removing the fluid, which indeed, is comparatively 
 easy, as the eradication of those lesions inducing the effusion. 
 Of the three leading forms, hydrothorax is held to be the least 
 
376 HYDROPS. 
 
 medicable, ascites next, and anasarca the most submissive to me- 
 dical discipline. Hydrencephalus, from its peculiarities, I do not 
 here include, its greater fatality being sufficiently known. This 
 estimate on a large scale is, perhaps, substantially correct, though 
 I have no data by which the point is to be absolutely determined. 
 My own experience tells me that, as to the dropsies of the two 
 great cavities, there is no material difference : on the whole, I 
 think, I have been less successful in ascites than hydrothorax. 
 
 The reports of some of the hospitals abroad, several years ago, 
 enable us to judge of the fatality then of this disease in the 
 aggregate, the several varieties not being designated. In Lon- 
 don, it is stated that one in three of all the cases admitted die, 
 and in Dublin, the proportion is as two to seven. Even this 
 success, which is ascribed to improved modes of treatment, I 
 find to be a subject of congratulation, the mortality being for- 
 merly much larger. What would be the result of a comparison 
 of the preceding statements with those of our own institutions I 
 have no means of precisely ascertaining. But I do know that 
 we have not a great deal to boast, and that our reports, candidly 
 given, would show a frightful mortality, though undoubtedly not 
 so considerable as within my recollection. In private practice, 
 and among a class of people the integrity of whose constitutions 
 is not impaired by the vicious habits that so abundantly replenish 
 hospitals with such cases, we seldom meet with dropsy, and 
 called to encounter it under these circumstances, find the disease 
 to be of a miLder character and infinitelv more curable. 
 
ON SOME OF THE 
 
 DISEASES OF THE MUSCULAR 
 
 OH FIBROUS SYSTEM. 
 
 This system comprehends the muscles and their appendages 
 or immediate connections, the tendons fasciae, aponeuroses liga- 
 ments and the muco and sero-fibrous tissues, especially those 
 entering into the composition of the articulations. The most 
 interesting of its affections is, perhaps, 
 
 ARTHRITIS OR GOUT. 
 
 Both of these terms are very objectionable, and, were it prac- 
 ticable, should, be repudiated. As it plainly imports, from its 
 derivation, arthritis means simply an inflammation of a joint, 
 and in this general sense, without discrimination, was used till 
 modern times. To a disease so pervading and peculiarly liable 
 to fluctuation, — occupying in turn every part of the system, the 
 exterior as well as the interior, and presenting the most striking 
 modifications, it is, indeed, utterly inapplicable. The other ap- 
 pellation has been still more unhappily selected. Derived from 
 the Latin gutta, a drop, or perhaps more directly from the French, 
 goutte, it was adopted during the prevalence of the false patho- 
 logy, which supposed the disease to be owing to some acrid or 
 peccant humour dropped into the joint, creative of the irritation or 
 phlogosis, — and such was the general adoption of the hypothesis, 
 that synonymes of the term gout are to be found in all the Euro- 
 pean languages. 
 
 32* 
 
378 DISEASES OF THE 
 
 To compensate, however, for the meanness and vulgarity of 
 this bad epithet, we have had applied to the subdivisions of the 
 disease a set of titles full of sound and dignity, coming imme- 
 diately out of the classical fountain of the Greek. When in the 
 foot it is called podagra, — in the hand, chiragra, — in the 
 elbow, onagra or pechyagra, — in the knee, genagra, — in the 
 clavicles, cliesagra, — in the humerus, omagra, — in the spine, 
 rachisagra, — in the teeth, dent a gr a, — in the tendons, tenon ta- 
 gra, &c. Excepting podagra, which has been rendered familiar, 
 and consecrated by long and general usage, it were mere pe- 
 dantry to retain any other of these jaw-breakers. 
 
 Gout, as I apprehend we must continue to call it, is one of 
 those diseases of the remotest antiquity. The Greeks and the 
 Romans appear to have been perfectly familiar with it, and while 
 formally described by their medical writers, is occasionally sport- 
 ingly alluded to, especially by their poets, more in the spirit of 
 reproach than sympathy, it being believed then, as very much at 
 present, to be the just punishment, rarely endangering life, of 
 habits to be ridiculed, or more gravely reprobated. 
 
 Nosologists usually divide the disease into tonic and atonic, 
 or regular and irregular gout, with some distinctions hereafter 
 to be noticed. 
 
 The paroxysm of regular acute gout sometimes comes on 
 without any decisive warning. Twice I have seen it attack 
 with the suddenness of an electric shock. In 1826, 1 was visiting 
 a patient for supposed dyspepsia, who, in the act of putting on his 
 coat, was seized with such poignant arthritic pain in the elbow, 
 that he became excessively alarmed lest a dislocation had taken 
 place. Conversing some time afterwards with a valetudinary 
 lady, on her general health, she, without any previous admoni- 
 tion, screamed out from a similar affection of her foot. The late 
 Professor Physick told me of the case of a gentleman to whom 
 he was hurried, from an apprehension of some dislocation of 
 the bones of the foot, while walking in the street, and of another 
 for a supposed rupture of the great tendon of the leg in ascend- 
 ing the steps at the entrance of his house, — both of which he 
 found to be gout. Examples of the same kind are numerously 
 recorded. We learn from Van Swieten that he saw a robust man 
 so stricken with gout in descending from his coach, that he thought 
 he had luxated his ankle, and Guilbert tells us, that in the retreat 
 
MUSCULAR OR FIBROUS SYSTEM. 379 
 
 of some French troops across a bridge, he witnessed an officer 
 so violently assailed by the disease, that at once all power of 
 motion was lost. Even, however, in these very cases, and cer- 
 tainly in the two which came under my own observation, there 
 may have been some precursory disorder of health, and per- 
 haps the pointed indications of the approach of the disease which 
 I am now to mention. 
 
 Commonly connected with a coated tongue, the appetite is 
 diminished, or sometimes anormal, depraved or craving, just 
 before an attack, — the stomach is vexed with acidities, flatulency, 
 and other symptoms of indigestion, — attended by a sense of 
 weight and tension in the abdomen, costive or occasionally dis- 
 ordered bowels, — copious and pallid, though more generally very 
 high-coloured and scanty urine, with, in some instances, an irri- 
 table bladder, or, as has been noticed, a blennorrhoeal discharge, 
 and an urgency of the venereal propensity. There are, also, 
 yawning and stretching of the limbs, drowsiness, much lassitude 
 and fatigue, itching of the skin, and, in short, a very pervading, 
 and, in some manner, indescribable derangement of diverse func- 
 tions. 
 
 Nor does the mind escape this distempered condition. Not 
 unusually its operations are dull, confused and inefficient, — some- 
 times so much so that it cannot be applied to any purpose of 
 study or business. The temper, too, is apt to be irritable, sour, 
 petulant or irascible, and I have seen the spirits depressed into 
 moping melancholy, productive of the darkest views of life. 
 For many years, I attended a friend, one of the most wealthy 
 and substantial merchants of this city, who was always thus 
 affected previously to an attack, conceiting every sort of disaster 
 to his fortunes and reputation, which illusion it was vain to 
 endeavour to dispel, — though instantly on the disease fixing itself 
 on a joint, his natural gaiety returned with increased hilarity, 
 like that of incipient inebriation. Frequently, in this fine frenzy, 
 did he exclaim to me, on entering his room, "I feel inspired, and 
 am only fitted to write poetry!" 
 
 As more immediately prelusive of a paroxysm, an unusual 
 coldness of the feet and legs, a suppression of perspiration in 
 them, numbness or a sense of pricking along the whole of one 
 or both of the lower extremities, or cramps of the muscles, are 
 to be remarked. 
 
380 DISEASES OF THE 
 
 Indisposed in some of the modes noticed, the individual goes to 
 bed, and after a few hours of disturbed sleep, is awakened by the 
 severity of the pain, at first fluctuating, though oftener in some 
 joint, and particularly that of the great toe, or in the heel, instep, 
 or in the whole foot, which, becoming at length more violent, is 
 succeeded by throbbing or gnawing in the part. This becomes 
 inflamed, swollen and intensely florid, — the veins being turgid, 
 and such exquisite tenderness exists, that the slightest pressure, 
 even that of the bed-clothes, cannot be borne, and any agitation 
 of, or an attempt to move the limb, is productive of agony. 
 
 . The local affection is not independent of constitutional par- 
 ticipation. Chills or rigors, anticipatory, simultaneously or sub- 
 sequently take place, leading to fever. The degree of reaction, 
 however, is very different, — being sometimes moderate, while in 
 other cases it is very considerably marked by a strong, voluminous 
 pulse, hot, dry surface, loaded tongue, more or less cerebral dis- 
 turbance, the temper singularly worried, — fractious and impatient, 
 with excessive jactitation and inquietude. Towards morning, 
 however, he usually falls asleep, and a gentle vapoury perspira- 
 tion breaking out abates the paroxysm. Yet it may be other- 
 wise, or it may continue unremittingly for an indefinite period. 
 Even when most mitigated there is not entire relief. During 
 the day, still considerable harassment continues, and towards 
 evening an exacerbation takes place. It is this succession of 
 paroxysms which constitutes what is familiarly called a fit of 
 the gout. These, however, gradually prove milder, till the dis- 
 ease goes off, and frequently by critical discharges from the skin, 
 kidneys or bowels, while at the same time the oedematous inflam- 
 mation of the joint subsides, — the cuticle partially desquamates, 
 and, excepting some itching, rigidity and lameness, there is resto- 
 ration to a state of health, very often even better than that pre- 
 ceding the attack. Many are the occasions, indeed, where a regu- 
 lar fit of the gout has operated to disperse a series of the most 
 diversified affections, so that its salutary tendency has become a 
 very popular notion. That it may supplant other diseases is not 
 improbable, though, mostly, its beneficial effects are to be ascribed 
 to the transposition of itself from the interior, where it had vexed 
 and deranged various organs, to the exterior, fixing on some one 
 or more joints on which it wastes its force. 
 
 Different is the result, however, when the metastasis is incom- 
 
MUSCULAR OR FIBROUS SYSTEM. 381 
 
 plete, or any degree of the original irritation within continues. 
 The cure, under such circumstances, necessarily partial, is fol- 
 lowed by manifestations of lingering disorder of diverse struc- 
 tures, particularly of the alimentary canal, the liver and ner- 
 vous system, and hence indigestion, constipation, vertigo, biliary 
 and other vitiated secretions, depression of spirits, with general 
 wretchedness, or violent headache, or wandering pains through- 
 out the body, which condition sometimes suddenly terminates in 
 a stroke of apoplexy or palsy. 
 
 The duration of a fit of the gout will be longer or shorter, 
 according to circumstances. Being the first attack, it seldom 
 exceeds a few days, and, on each repetition, the continuance is 
 lengthened, till ultimately weeks elapse before convalescence is 
 established. It may happen, too, that after the disease has sub- 
 sided in one joint, it seizes on some other, perhaps the opposite 
 one, and runs the same lingering course. 
 
 An attack, at first, recurs generally at some distant interval, 
 perhaps once in two or three years. Then it comes on annually, 
 or semi-annually, spring and fall, at length more frequently, and 
 is of longer duration, each succeeding fit, till, in some instances, 
 there is scarcely any exemption from it, except, perhaps, in the 
 middle of summer. 
 
 Degenerating ultimately into the chronic state, to which, in its 
 progress, it is prone, it varies materially from the acute form, as 
 well in the constitutional as the local affections. Much pravity 
 of system is exhibited, and especially of the primse viae and 
 biliary organs, in the shape of obstinate dyspepsia, torpid bowels, 
 or occasional diarrhoea, the stools denoting a want of bile — de- 
 ficient, turbid, or loaded urine or gravelly deposits — dry, harsh, 
 sallow or dingy skin — petulant, morose, irresolute temper — and, 
 sometimes, confirmed hypochondriacism. 
 
 Nor do the contents of the thoracic cavity escape. There are 
 often very enduring irritations of the mucous membrane of the 
 lungs, from simple bronchitis to asthma or the most oppressive 
 dyspnoea ; no inconsiderable cardiac disorder, and hydropic effu- 
 sions may take place. 
 
 Connected with this impaired or ruined state of the constitu- 
 tion, there is usually less acute suffering in the paroxysm. 
 Moderate during the day, it is exacerbated at night, though 
 even then, more of a teasing ache than positive pain, and the 
 
382 DISEASES OF THE 
 
 part is pale, or purplish, rather than red, and with greater osdema. 
 But the pain may be otherwise, and I have seen it as violent as 
 in an acute attack. 
 
 The disease is very apt to fluctuate, transitions rapidly taking 
 place. No great fever prevails, and it is more irritative than 
 inflammatory. Commonly the joints lose their strength and 
 flexibility, and become so stiff sometimes as to be deprived of 
 motion. 
 
 Little indurated swellings may arise in the articulations of the 
 fingers, to which Haggarth has applied the title of nodosities. 
 Concretions, of a chalky appearance, are likewise formed upon the 
 joints, and calculous affections occur from a deposit of the same 
 kind of matter, the lithate of soda, in the kidneys or bladder, 
 which, though fluid at first, become dry and firm, at last, as a 
 stone. 
 
 This is an outline of the symptomatology of gout in its more 
 ordinary and regular form, acute and chronic. But, as already 
 remarked, it presents occasionally several varieties, arising chief- 
 ly from difference of location, which hereafter will be noticed. 
 
 Gout selects as subjects of attack, and chiefly out of the aris- 
 tocracy, men of robust frame, of full and corpulent habits, and 
 of a phlogistic diathesis. The physical constitution predisposing 
 to it has been more minutely described, as consisting in a large 
 head, very capacious chest, gross and heavy body, soft, solids 
 full, distended veins, thick skin and big bones. Numerous are 
 the exceptions, however, to this rule, and I have known it in 
 directly the reverse, or in the feeble and attenuated, — frequently 
 in women, and once in a boy of thirteen years of age. The 
 latter is denied by Sydenham, Heberdenj and the writers very 
 generally. On this point the language of Hippocrates, which I 
 take from the Latin version of his works, is very strong: 
 
 " Puer non labored non podagra ante veneris usum" 
 
 It may be affirmed that it is very seldom to be met with before 
 the age of puberty, more generally commencing beyond the 
 meridian of life, and, in its regular forms, is chiefly restricted to 
 the male sex. Eunuchs, according to Hippocrates, do not have 
 it, which, however, is denied by Richter and some other modern 
 authorities. This is, thank God, a point that I have no compe- 
 
MUSCULAR OR FIBROUS SYSTEM. 383 
 
 tency to decide, such mutilated beings not belonging to our own 
 enlightened country. 
 
 Gout is thought to be mainly an inheritance, the sins of the 
 father being visited upon his children to the third and fourth 
 generations, and especially on those who neglect or despise the 
 precepts of sobriety and temperance. To use the language of a 
 late writer, it is as regularly transmitted in this way from the 
 parent to his progeny, in many instances, as any species of pro- 
 perty. But it may also be acquired, or, as Shakspeare has said 
 of honours, some acquire gout and some have gout thrust upon 
 them. Come, however, as it may, even 
 
 " With the boast of heraldry or pomp of power," 
 
 it is a most unwelcome guest. 
 
 Nevertheless, the estimate of its hereditary nature appears not 
 to be founded to the extent commonly received. To this point 
 a diligent inquiry has been directed by Scudamore, the result of 
 which is, that the hereditary exceed only about one-third the 
 acquired cases. 
 
 As so large a portion of attacks may be generated, it is right 
 that the causes producing the disease should be pointed out with 
 some particularity, and the more so, since, by the avoidance of 
 them, the origination as well as the development of the disease, 
 when hereditary, can, at least sometimes, be prevented. 
 
 Of these, by far the most prolific is an excess in drinking and 
 eating, aided by sedentary habits. No drink seems to be so 
 pernicious in this respect as wine. It is said, that while ardent 
 spirits derange more directly the hepatic apparatus in various 
 ways, wine has the effect of exciting the arthritic affections. 
 But some wines do this more than others. An opinion is very 
 generally entertained in Great Britain, and in which we mostly 
 concur in this country, that claret and other light ascetic wines 
 are particularly pernicious. Yet the French, the Spaniards, the 
 Italians and the people of the north of Europe, who chiefly use 
 such wines, are comparatively exempt from the disease, — while, 
 in Britain, where they are much less consumed, it prevails, per- 
 haps, more than in any section of the world. 
 
 That port, the principal wine of the people of that country, 
 is the most unwholesome of all wines, even in a state of purity, 
 I have no doubt whatever, as well from its peculiar qualities as 
 
384 DISEASES OF THE 
 
 from actual experience of its effects in those who use it freely. 
 Factitious and adulterated, however, as nearly the whole of it 
 is confessedly in Britain, it must, h priori, prove exceedingly mis- 
 chievous, and is probably one of the chief causes of the wide- 
 spread prevalence there of arthritic affection. 
 
 Not many years ago I read a review of a report of a com- 
 mittee of the British House of Commons on the subject of wines, 
 with a view to a commercial treaty with France, in which it 
 was stated that scarcely any genuine port existed in that country. 
 Among other startling facts, it is mentioned that nearly the 
 whole of it, previously to its being vended, undergoes a process 
 of mixture with some other ingredients, some of which are 
 actually deleterious. In the island of Guernsey there is a large 
 manufactory for the purpose, and out of six hundred tons of 
 wine imported annually on an average of three years, six thou- 
 sand were exported, it being converted into ten times the original 
 quantity. The liquor substituted is cider, or the cheap common 
 wines of France, which are drugged to give the colour and other 
 qualities of port. The same process is practised at Southamp- 
 ton, in England, and at Leith, in Scotland, in the great manu- 
 factories in those places of a similar kind. 
 
 Contradictory statements also prevail as to malt liquors. By 
 some, as Sydenham, Van Swieten, Linnaeus, &c, they are sup- 
 posed to be rather preventive in their effects. Yet the prepon- 
 derance of authority is on the other side, — and certain it is, that 
 the disease has augmented in England since the common con- 
 sumption of these beverages. 
 
 Of cider, the denunciation of its use is nearly universal, in 
 relation to gout. But here, too, there are some opposing facts 
 adduced, among which is, that cider is the popular drink of New 
 England, where the disease is of rare occurrence, — whereas, in 
 the southern states, it is far more general, though, in place of this 
 beverage, ardent spirits and Madeira wine are usually consumed. 
 The circumstance, however, has not been adverted to by those 
 who urge this against the common opinion of the properties of 
 the liquor, that it is hard cider, which our Eastern people only 
 use, a very peculiar preparation of which is really efficacious in 
 the prevention as well as the cure of certain stomachic disorders, 
 and hence may be anti-arthritic in its tendencies. 
 
 More pernicious than any I have mentioned, according to my 
 
MUSCULAR OR FIBROUS SYSTEM. 385 
 
 observations, is the habitual use of punch or lemonade, or any- 
 other drink prepared from citric acid, though it may be safest to 
 infer, on the whole, that the abuse of any of these articles is, by 
 disordering the digestive organs, productive, in a greater or less 
 degree, of this disease. 
 
 Not less operative, in the same way, is an improper indulgence 
 in eating. By some of our highest authorities it is held to be even 
 more so, in the case of either an enormous consumption of ordi- 
 nary food, or of that moderately, — high-seasoned and stimulating, 
 habitually taken, and which is sufficiently probable, when we 
 advert to its ultimately debilitating and deranging effects on the 
 stomach and its connections. 
 
 Of the dependence of gout on the habits of living, no stronger 
 proof can probably be supplied than from the annals of this city. 
 When I commenced my professional career, the disease abounded 
 in the higher circles, and then it was the practice to drink punch 
 in the forenoon, to continue it at dinner, or to resort to ardent or 
 malt liquors, followed by a liberal use of diverse wines, closing 
 the evening with substantial suppers and stimulating potations. 
 But, in this respect, within the last thirty years, a signal change 
 has taken place. No punch or distilled spirits, and comparatively 
 little malt liquor, has been consumed, and the custom of supping 
 is nearly extinct. Temperance has superseded debauchery or 
 excess, and gout thus deprived of its aliment is fast perishing 
 away. My opportunities have enabled me to ascertain the fact, 
 that so late as the commencement of the present century, a hun- 
 dred cases of the disease existed in this community where one is 
 now to be met with, and with few exceptions, these are the rem- 
 nants of other days, serving as memorials of a state of society, 
 of which there are scarcely any other traces to be recognized. 
 Literally is it true, as expressed by May, one of the oldest of the 
 English dramatists: — 
 
 "From our tables now, no painful surfeits, 
 No fed diseases grow, to strangle nature, 
 And suffocate the active brain. No levers, 
 No apoplexies, no palsies, no gouts 
 Are here." 
 
 Contemplating this happy reformation, who can forbear to 
 exclaim with the fair poetess, — 
 
 "'Tis to thy rules, O temperance ! that we owe 
 All pleasures which from health and strength can flow; 
 
 33 
 
386 DISEASES OF THE 
 
 Vigour of body, purity of mind, 
 Unclouded reason, sentiments refin'd, 
 Unmixt, untainted joys, without remorse, 
 Th' intemperate sinner's never-failing curse." 
 
 To the causes of gout must, as previously intimated, be added 
 sedentary, indolent, or intensely studious habits. 
 
 It is well known, that in the common orders of life, the disease 
 hardly exists, and infinitely less among the higher classes who 
 pursue occupations of active industry. Neglect of the exercise of 
 walking has particularly an effect, and among other evidence of 
 it which we learn is, that while the people of Edinburgh, who, 
 from the location of their trade at Leith, the seaport town, a mile 
 or more distant, usually ride, are very liable to the disease ; — 
 those of Glasgow, the practice of whom is different, are nearly 
 exempt from it.* 
 
 Not doubting the influence of this custom, to a certain extent, 
 I am still inclined to impute more to a wider difference in the 
 character and habits of the inhabitants, in other respects, of these 
 two cities. Edinburgh is the abode of the opulent, the noble, the 
 learned, and also the refuge of nearly every veteran of Scotland, 
 of the military, naval, or civil service, who returns from the per- 
 formance of arduous and lengthened duties, in distant and sickly 
 climes, with shattered constitutions, to enjoy at home iuxurious 
 ease. The one city has claims to the highest intellectual society, 
 though voluptuous, and even grossly dissipated, at least it was so 
 in my time, and the other the reverse, or that marked conspicu- 
 ously by economical prudence and active, stirring, money-making 
 industry. Thus contrasted, can the disparity, as to the relative 
 prevalence of the disease in the two places, be a matter of sur- 
 prise ? 
 
 Equally is it determined that men of great mental endowments 
 or application and distinction, have been singularly prone to it, of 
 which examples might be cited from the history of all agss. 
 
 Treating of gout, Sydenham, who was a martyr to it, says, 
 "What is a consolation to me, and may be so to other gouty per- 
 sons of small fortune and slender abilities, is, that kings, princes, 
 generals, admirals, philosophers, and several other great men 
 have thus lived and died : in short, it may, in a more especial 
 
 * Scudamore on Gout. 
 
MUSCULAR OR FIBROUS SYSTEM. 387 
 
 manner, be affirmed of this disease, that it destroys more rich than 
 poor, more wise men than fools, and, which seems to demonstrate 
 the justice and strict impartiality of Providence, who abundantly 
 supplies those that want some of the conveniences of life with 
 other advantages, and tempers its profusion to others, with equal 
 mixture of good and evil, so adapted to our weakness and perish- 
 able condition, as is, perhaps, admirably suited to the present 
 state." 
 
 From this train of reflection many seem to have derived con- 
 solation or comfort. Few are ashamed of having gout, however 
 acquired, and there are some who affect it, as denoting antiquity 
 of blood, elevation of rank, the temperament of talent, the dig- 
 nity of association, or even an intemperate addiction to wine as 
 the exclusive drink of the high-born, the polite and accomplished. 
 
 Concerned in the predisposition to the disease, climate ought 
 to be mentioned. Gout is rarer in the tropical and hyperborean, 
 than the temperate regions, and especially where the latter are 
 humid and austere. Much depends, undoubtedly, on the habits 
 of the people, though it is affirmed, that, cseteris paribus, there is 
 a material difference. Certainly, in this city, the seasons of the 
 most frequent occurrence of the disease are early in the spring 
 and late in the fall, when the weather is damp and chilly. 
 
 An hereditary or acquired tendency to it existing, the paroxysm 
 may be readily excited by numerous circumstances, such as grief, 
 vexation, or any anxiety or trouble of mind, — the indulgence 
 of violent passion, particularly the rage of anger, which, indeed, 
 is quaintly called by an old writer " the midwife of gout," from 
 its so frequently bringing it forth. Farther, by inordinate vene- 
 ry, fatigue, and the loss of sleep, cold feet, or compression of 
 these by tight boots or shoes — and, also, a contusion or strain of 
 a joint, the sudden change from a full to an exceedingly low diet, 
 or the converse, and above all, by particular articles of food or 
 drink. The acescent flatulent vegetables or fruits will often in- 
 duce an attack very promptly, and still more so the sour beverages. 
 Lemonade will sometimes do it in a few minutes : in one of my 
 friends a single glass of claret or champagne had the same effect, 
 and another informed me, that even the odour of cider had 
 brought it on in him. This, indeed, so often happened by merely 
 entering the repositories of the liquor in a state of fermentation, 
 
38S DISEASES OF THE 
 
 of which he was a large manufacturer, that he had been com- 
 pelled to desist from the practice. 
 
 Gout may be so faintly, or ambiguously exhibited, even in its 
 regular or articular form, as not to be readily recognized. It is 
 to be mistaken for any phlogosis or irritation of a joint, and can 
 only be discriminated by a careful perquisition into the case. 
 Not a little may be learned from the precursory symptoms — 
 sometimes from the existing appearances, and particularly from 
 the affection being permanent or otherwise. Gout is nearly 
 always changeable, while the imitative lesions, with the excep- 
 tion of the rheumatic, are the reverse, or fixed till their subsi- 
 dence. 
 
 It is rheumatism, under all circumstances, which bears the 
 closest affinity to it. Coming, however, to the history of that dis- 
 ease, we shall find they vary so materially, that they seldom need 
 be confounded. 
 
 The leading particulars in which they differ, I shall now only 
 mention. Gout belongs chiefly to the higher class of society, is 
 the result of a series of habits which vitiates the nutritive pro- 
 cesses, or is received as an inheritance without sometimes any 
 obvious excitements, and once occurring, is apt to be repeated 
 throughout life at certain intervals, with considerable regularity. 
 On the contrary, rheumatism is met with almost as exclusively 
 among labouring people, and seems to have as an only cause, the 
 influence of cold in some mode of application. The former is 
 pretty uniformly preceded by derangement of health, and the 
 latter not, and is wanting in the same liability to stated recur- 
 rences. The common seat of the one is in the smaller, and of the 
 other in the larger joints, — and though, in each instance, swell- 
 ing takes place, with great suffering, these incidents are not 
 identical, gouty inflammation being far more bright, florid and 
 polished, with a greater proneness to oedema, and subsequent de- 
 squamation, and the pain is peculiarly gnawing or lacerating and 
 deep seated. Gout, moreover, seizes on a single joint, and rheu- 
 matism on several, as a general rule. The fever in the one is 
 unsteady, alternately very high or low, or scarcely any, in quick 
 succession, with little perspiration, and in the other is continued 
 or remittent at long intervals, and attended pretty constantly by 
 copious sweats. The distinction, however, on which more reli- 
 ance may be reposed, is, that gout always originates internally, 
 
MUSCULAR OR FIBROUS SYSTEM. 389 
 
 and rheumatism very seldom. Nevertheless, there is a compound 
 form of the disease exceedingly perplexing, induced by rheuma- 
 tism falling on joints, previously weakened by arthritic attacks, 
 causing what might be properly called rheumatic gout. 
 
 In its regular form, gout is rarely, or, perhaps, never imme- 
 diately fatal. As I have said, its tendencies, indeed, are mostly 
 salutary, clearing away other affections, and re-establishing, for a 
 time, the order of health. Death occurring from it, an im- 
 portant vital part becomes affected, or the constitution is gradu- 
 ally undermined, and some one of various lesions as its conse- 
 quences, is induced, ending mortally. 
 
 The issue of an attack, therefore, may be presumed to be favour- 
 able, when the constitution is sound, particularly the viscera, 
 and where the disease, entirely quitting the interior, becomes im- 
 movably fastened on the extremities. Convalescence is ordinarily 
 denoted by the tongue becoming clean, with a return of appetite 
 and good digestion — the stools more natural, lateritious deposits 
 in the urine, the skin relaxed or moistened, and, — with these a 
 subsidence of vascular and nervous irritations, and of the local 
 inflammation, and intumescence. 
 
 The adverse circumstances are, a decayed system, weakness 
 of the primse vise, or an imperfect translation of the disease out- 
 wardly, or fluctuation in the seat of it, or proneness to recede 
 from the joints to the internal organs, attended by irritative fever, 
 and much nervous and mental disquietude. 
 
 With some accuracy the anatomical characters in gout might be 
 inferred from the preceding account. Death seldom taking place 
 in the acute stage of it, except by a metastasis to vital organs, 
 by which the joint is relieved, of course we know little of the 
 articular appearances. In the more recent attacks, however, 
 inflammation, with a peculiar albuminous sort of exudation, or 
 serous effusions, have been noticed in the joints. Chronic cases 
 present every variety of structural lesions. The synovial mem- 
 brane is essentially altered, the bursas mucosae enlarged and in- 
 durated, the cartilages absorbed, the exposed surfaces of bone 
 smooth and polished, or where such destruction has not occurred, 
 a firm anchylosis, wasting of the ligaments or the reverse, thick- 
 ening of them, and throughout the articulation, deposits of 
 earthy or saline matter, generally the lithate of soda. These are 
 among the products of the more violent and inveterate attaeks. 
 
 33* 
 
390 DISEASES OP THE 
 
 Correspondently less are such as appertain to the inferior grades 
 of the disease. As regards the internal lesions, it may be enough 
 to state, that the stomach and bowels, the liver, the kidney, lungs, 
 heart and brain, are occasionally met with in various degrees of 
 inflammation, engorgement or disorganization. 
 
 That I should enter, to any extent, into the controversy which 
 has so long prevailed relative to the pathology of this disease can 
 hardly be expected. Till the time of Cullen, who satisfactorily 
 refuted the hypothesis, it was, with scarcely an exception, regard- 
 ed as originating in some morbid condition of the blood, by 
 which a humour, with an acid or an alkaline property, or some 
 acrid salt, was generated and dropped into the affected part. The 
 very term gout, as we have seen, expresses such a notion. These 
 suggestions of a crude pathology are so completely set aside, 
 that I shall dismiss them without further animadversion. 
 
 My own conviction is, that it is primarily an affection of 
 the digestive and assimilative organs, intimately connected with 
 lithiasis. Both conditions are induced by a train of similar causes, 
 and are prevented or palliated by similar means. It has also 
 been shown, by the analysis of the chemists, that the calculous 
 concretions in the kidney or bladder, and those which form 
 in the joints, called chalk-stones, are sometimes identical, being 
 mostly urates of soda. Not unlikely, the same diathesis is com- 
 mon to the two diseases, and the product of it may be thrown 
 off by the kidneys, or the skin, in confirmation of which, we 
 learn that the urine and perspiration in each case, have an excess 
 of acid, the uric or phosphoric, most generally. These emunc- 
 tories not adequately performing their offices in this respect, an 
 accumulation of the acid results, and calculous formations take 
 place in the kidneys, bladder or articulations, or in each, as may 
 happen. The latter, however, is not a common event, and I 
 have rarely or never seen a coincidence of this state in the differ- 
 ent emunctories. Generally, the kidneys and skin are vicarious 
 in their operations, and where the powers of the one fail, those 
 of the other are correspondently invigorated, on which account 
 it is that they so seldom act concurrently in this case. Let it 
 not, however, be supposed, from the views here presented, that 
 any countenance is lent to the notion formerly alluded to, of the 
 dependence of the gouty paroxysm on such deposits in the joints. 
 These must be deemed the effect, not the cause of the disease, 
 
MUSCULAR OR FIBROUS SYSTEM. 391 
 
 which is shown to be true, independently of other considerations, 
 by the fact, that they occur at the close, not at the commence- 
 ment of an attack, and for the most part, are altogether wanting. 
 
 As previously intimated, gout has its origin in a vitiation of 
 the digestive organs, and whatever subsequently arises, is to be 
 traced up and assigned to this starting point, as the "fons et origo 
 mali." Thus, the local affection of the joints, as well as the 
 excitation and fulness of the vascular system, so frequently con- 
 comitants of gout as to be considered by some as really consti- 
 tuting the disease itself, I hold to be merely secondary and 
 subordinate. 
 
 Of the precise nature of this primary lesion we are imperfect- 
 ly informed. The advocates of the hypothesis have, with a sin- 
 gle exception, offered no explanations of it. Broussais, to whom 
 I now allude, in conformity with his dominant propensity to 
 generalize, declares it to be an inflammation of the gastro-enteric 
 mucous surface, to which, indeed, he seems to impute all things. 
 That such a condition sometimes ultimately takes place, we are 
 not permitted to doubt, — though it is equally true, that more fre- 
 quently, it is merely a functional derangement, very analogous in 
 its leading features to certain forms of dyspepsia. Brown, in- 
 deed, calls it " the indigestion of the luxurious." It is hence very 
 probable that, in common with the more normal dyspeptic affec- 
 tion, the inception of gout is to be referred to the centre of the gan- 
 glionic nerves, and which disturbance exercises a very material 
 influence over the case throughout its whole career. Looking at 
 the causes of the disease— the phenomena of its rise and progress, 
 and in some respects, the method of cure, the conclusion can 
 scarcely be resisted. 
 
 On the extremities becoming affected, the internal irritation is 
 mostly relieved, and as happens in the exanthemata, such is the 
 natural process of cure. This opinion differs from that of some 
 of the modern pathologists, who maintain the topical affection to 
 be primary, leading to constitutional derangement, and also, that 
 of others who think it is merely a symptom, excited and kept up 
 by the persistence of the irritation in the internal tissues. These 
 hypotheses, partially applied, are correct. Denying the origin- 
 ality of the local lesion, it is yet not unreasonable to suppose 
 that it may operate to the aggravation of the general disturbance 
 of the system, and it is more apparent, that there are cases of an 
 
392 DISEASES OF THE 
 
 occasional occurrence, where the disease, still lingering in a de- 
 gree in its primary position, may have the effect imputed to it. 
 Conceding this, my views remain unin validated as having refer- 
 ence only to those instances of the disease where the metastasis 
 is complete. 
 
 The seat of the local affection being among the parts directly 
 subservient to the articulation of the joints, it has many of the 
 characteristics of the inflammation of the fibrous textures. What- 
 ever may be its violence, genuine arthritic action, strictly con- 
 fined to these textures, never ends as common phlogosis in the 
 effusion of serum or lymph, in the secretion of pus. These 
 taking place, the inflammation has invaded other tissues, the sur- 
 rounding cellular or the serous synovial membranes. Its proper 
 terminations are such as previously noticed. Yet it must be con- 
 fessed, that there are very striking singularities in gouty action, 
 and that the whole subject is not without obscurity. Located in 
 precisely the same parts as rheumatism and various other inflam- 
 matory affections, it is so far from having an identity with them, 
 that usually it may be at once discriminated. As an attempt 
 merely at an explanation of these differences, I shall offer the 
 conjecture, that the idiosyncrasy in question is owing to the 
 peculiarity of the cause of gout, it being determined that in the 
 modification of morbid action, the cause of it has no less influ- 
 ence than the structure which it may occupy, and that these 
 two circumstances, taken in connection with the existing diathe- 
 sis, produce mainly the peculiarities of the disease. Not satisfied, 
 however, with this exegesis, it has been advanced by some that 
 the whole of the affection is purely neuritis or neuralgia. That 
 the nerves may be implicated, I have admitted, and I will now 
 add, probably to a greater extent than in any of the phlegmasia, 
 not excepting rheumatism. To this circumstance, among other 
 features of the disease, I suspect the extraordinary disposition to 
 metastasis to be assignable. But to refer the entire disease to 
 such a state were surely a hasty conclusion from a very super- 
 ficial examination, warranted neither by the prominent symp- 
 toms, the phenomena on dissection, nor the mode of cure. 
 
 Consulting most of the writers on the subject, it will be per- 
 ceived that very little is prescribed in the paroxysm of gout, 
 and that it has become too much the practice everywhere to let 
 it spontaneously expend itself. To envelop the limb in flannel 
 
MUSCULAR OR FIBROUS SYSTEM. 393 
 
 and to urge a patient endurance of the pain and confinement, 
 constitute, indeed, proverbially, what is chiefly done in podagra. 
 That a system so inert could only have arisen from the want of 
 confidence in the known remedies, or to a conviction of the 
 injurious effects of intermeddling at all with the case is apparent. 
 As long ago as the time of Ovid, and from the same causes, such 
 an opinion seems to have been entertained. The poet, at least, 
 declares, 
 
 " Tollere nodosam nescit medicina podagram." 
 
 Experience, however, has taught me, that much can be effected 
 in the paroxysm, and that we are called upon to use remedies as 
 unhesitatingly in it as in any other acute inflammatory affection. 
 To this state of the disease, I am, in the first place, to address 
 my remarks. 
 
 Of all the means I have tried, the most decidedly efficacious 
 is active purging. This is a very ancient practice, having pre- 
 vailed, with no interruption, from the earliest times, till it was 
 prohibited by Sydenham, on purely theoretical grounds, — it being, 
 he observes, " an invariable law of nature that the peccant matter 
 of the disease should be thrown out by the extremities — emetics 
 and cathartics will have no other effect than that of counteracting 
 this design. 7 ' 
 
 Need I observe that the example of Sydenham in this case 
 has been highly pernicious, having led to the desertion of a 
 practice which, if judiciously applied, is safe, and particularly 
 calculated to overcome this most distressing disease. 
 
 I have before stated that gout is intimately connected with 
 depraved conditions of the alimentary canal. Whether this 
 opinion be correct or not, it may be confidently affirmed that the 
 practice it dictates is sound and fully warranted. 
 
 For forty years I have habitually employed purgatives in the 
 paroxysms of gout, and with unequivocal advantage. Not con- 
 tent with simply opening the bowels, I completely evacuate, by 
 purging, the entire alimentary canal, which being accomplished, 
 the distressing sensations of the stomach are usually removed — 
 the pain and inflammation of the limb gradually subside, and the 
 paroxysm, thus broken, speedily passes away. To effect these 
 purposes, however, it is often necessary to recur to the remedy 
 repeatedly. As to the particular purgative, this will depend on 
 
394 DISEASES OF THE 
 
 circumstances. Considerable depravation existing in the chylo- 
 poietic viscera, I prefer a dose of calomel or the blue pill, to be 
 hastened in its operation by magnesia alone, or with Epsom salts. 
 The mercurial purge is seldom again required, and the bowels 
 may be kept freely open by any of the milder laxatives. Gene- 
 rally, however, the most effectual of this class of articles, and 
 especially with a view to the immediate reduction of the topi- 
 cal affection, is the following mixture, a tablespoonful of which 
 should be given every hour, till it purges copiously.* 
 
 Eminently beneficial as an evacuant undoubtedly is, I do not 
 think that all its effects are ascribable to this mode of operation. 
 Colchicum has a peculiar property to which some of the credit 
 must be assigned. Given alone, it is less serviceable, and hence, 
 we are to seek in a combined influence, for the salutary tenden- 
 cies of the mixture. 
 
 My practice with regard to purging in gout, differing materially 
 from the prevalent one, it may, perhaps, be expected, or at least 
 desired, that I should justify it on other grounds than my own 
 declaration of its efficacy. To its defence I can bring both reason 
 and authority. 
 
 Granting the disease to be preceded or accompanied with those 
 symptoms of depraved stomach and bowels which I have no- 
 ticed, no one can doubt, for a single moment, of the propriety of 
 resorting to the use of purging. There is here, indeed, exactly 
 that group of affections, which the common observation of prac- 
 titioners has taught is most readily removed by the thorough 
 evacuation of the alimentary canal. 
 
 Why we should adopt a different course in gout, and refuse 
 the remedies we have found so efficacious under nearly similar 
 circumstances, in other diseases, is a question I suspect that can- 
 not be very satisfactorily answered. Further may it be urged, 
 in support of the purgative plan, that the paroxysm is always 
 abated, if not removed, by the coming on of diarrhoea or dysen- 
 tery or cholera morbus. This interesting fact did not escape the 
 notice of Hippocrates, who tells us that the disease is never cured 
 where the bowels are constipated, except by the providential 
 occurrence of a dysentery, by which he seems to mean any 
 
 * It. — Magnes. calc, 3j. ; Sulph. magnes., gij.; Tinct. colch., giss.; Aq. cin- 
 nam. simp., ^iij.,ft. sol. 
 
MUSCULAR OR FIBROUS SYSTEM. 395 
 
 spontaneous purging, — and adds, that he had witnessed the best 
 effects from the profuse discharges he emphatically calls a "melt- 
 ing down of the bowels." 
 
 Musgrave, too, one of the earliest and best of the professed 
 writers on gout, declares that, " during the paroxysm, a diarrhosa 
 often takes place, which carries off the tumefaction and pain." 
 " Cures effected in this way," he also remarks, " have this advan- 
 tage, that they do not return for a long time afterwards." 
 
 The confession, on this subject, of Sydenham himself is ex- 
 ceedingly curious. Treating of gout, suspended by diarrhoea, he 
 advises, as the only means of restoring the paroxysm, deemed by 
 him essential to health, to give certain medicines to check the 
 discharge from the bowels, which, he says, when completely 
 stopped, the gout comes " thundering back on the extremities." 
 
 Nothing can be more conclusive of the efficacy of diarrhoea, 
 and hence consequently to be inferred of purging, in removing 
 the arthritic paroxysm, than this acknowledgment. 
 
 The treatment of gout by purgatives, I repeat, is not a new 
 practice. My limits, however, will not allow me, at present, to 
 offer, in detail, a retrospective history of what has been done in 
 this way. It may, perhaps, be sufficient to state, what I have 
 before done in some degree, that, commencing with Hippocrates, 
 the practice continued till put down by the proscription of Syden- 
 ham. During this long period, it was pursued successively by 
 the physicians of Greece, of Rome, of the school of Egypt, and 
 of modern Europe after the revival of letters. Nearly the whole 
 of them concur in the propriety of the practice, and some, in 
 speaking of its success, use, if not the language of enthusiasm, 
 certainly the tone of entire confidence. 
 
 Nor is it unworthy of recollection, that the purging, in these 
 cases, must have been exceedingly active, as, anterior to the era 
 when the Arabians cultivated medicine, the cathartics in use 
 were exclusively of the most drastic kind. Nevertheless, we do 
 not perceive, in scarcely any one work which has descended to 
 us, any of those dangerous consequences pointed out or alluded 
 to that have so much alarmed modern practitioners and deterred 
 them from the employment of purgatives. 
 
 Great, however, as was the homage paid to the opinion of 
 Sydenham, it did not prevent occasional dissents from it. Turn- 
 ing over some of the treatises on this disease, hi reference to the 
 
396 DISEASES OP THE 
 
 present inquiry, I was surprised to find how many writers there 
 are, who, contemning his authority, had adopted the ancient prac- 
 tice. Cheyne, one of the most distinguished of the age, acquaints 
 us that, in his time, " some eminent physicians had so little regard 
 for the opinion of Sydenham in this matter, that, in the fit of the 
 gout itself, they never scrupled to drive it off, both in themselves 
 and others, by strong, quick and active purges." 
 
 Even Sydenham himself admits, notwithstanding all his theo- 
 retical prejudices, that, during the operation of purgatives, the 
 patient feels no pain, or at least very little, and that, if the ca- 
 tharsis were kept up for several days, he would most probably 
 be cured. It is, moreover, an interesting circumstance, and one 
 which strikingly illustrates the propriety of the course for which 
 I am contending, that almost all the remedies of any reputation, 
 whether they be the preparations of regular bred physicians, or of 
 empirics, act powerfully on the bowels and contain, for the most 
 part, as a basis, the hermodactylus or the extract of scammony. 
 Especially does it appear, that during the prosecution of the ex- 
 periments made in Europe some years ago, with different sub- 
 stances, for the purpose of detecting the leading ingredients of 
 the Eau Medicinale, an article of which I am subsequently 
 to speak, by a resemblance in effects, that several of the more 
 drastic cathartics, as the elaterium and white hellebore, were 
 employed. Though among the most harsh and violent of all our 
 purgatives, these are still represented as having evinced such con- 
 siderable powers in certain cases, as very generally to be con- 
 sidered, at the time, as the chief constituents in the French nos- 
 trum. Nor does it less appear, that formerly, the gamboge, a 
 purge violently distressing to the bowels, had acquired so much 
 repute, that, on this account, the title of " gutta ad podagrarn" 
 was conferred upon it. Taking the whole of what I have said 
 on this point into consideration, I think we are entitled to con- 
 clude, that purgatives may be safely and efficaciously employed, 
 and that they have hitherto been strangely and inconsiderately 
 neglected or repudiated. 
 
 Cathartics being so beneficial in gout, it is reasonable to sup- 
 pose, from analogy, that emetics might likewise be so. In the 
 practice of antiquity, as well as of more recent times, they were, 
 indeed, made a part of the treatment, and came to be excluded 
 with the other evacuants, pretty much through the influence of 
 
MUSCULAR OR FIBROUS SYSTEM. 397 
 
 Sydenham. The most conspicuous of those by whom the use 
 of them is commended, are Celsus, Callus, Aurelianus, Deme- 
 trius and several of the Arabian school, to which may be added, 
 among the modern authorities, Fabricius, Hildanus, Gesner, Stoll 
 and Scudamore, &c. No one, however, seems so strenuously 
 to have endeavoured the revival of the practice as Small, the 
 author of a very good paper on gout.* He urges it as affording 
 prompt relief of the pain and inflammation of the paroxysm. 
 Considering the nature of the case and the properties of the 
 remedy, such an effect is probable, though I confess my expe- 
 rience is not sufficiently extensive with it to lead to any very 
 decided confirmation of its utility. It is found so in all painful 
 affections where the nerves are deeply concerned, as odontalgia, 
 paronychia and neuralgia, which it wonderfully controls, and 
 these striking analogies lend no slight support to the facts pre- 
 viously adduced. Emetics, however, at all times are much re- 
 sisted in the higher classes of society, where chiefly we meet 
 with the disease, and this, and not any apprehension of mischief, 
 has prevented my using them. Yet there are cases, as where 
 the stomach is greatly disordered and the tongue loaded, in 
 which I have prescribed them with advantage. Gout, moreover, 
 may be acquired in miasmatic districts, and connected, as it 
 sometimes is, with intermittent fever, and a very oppressed state 
 of stomach, emetics I have found, in some instances, indispensable 
 to the cure. Especially do I recollect the case of a gentleman 
 of this city, who was compelled annually to visit, in the autumn. 
 a large estate he owned on the banks of the Susquehanna, 
 which he was endeavouring to reclaim by drains and embank- 
 ments. Never, on these occasions, did he escape a combined 
 attack of the two diseases, and I uniformly found that without 
 an emetic every thing else proved ineffectual. 
 
 Estimating, as I do, evacuations of the alimentary canal in 
 gout, I have seen too much of the practice of my profession to 
 confide exclusively in any one curative process in a disease 
 which presents so many diversities. As in all other instances, 
 the remedies here are to be accommodated to circumstances, — 
 and, hence, I sometimes call into requisition, in the different 
 stages or forms of gout, every variety of treatment. 
 
 * Med. Ob., vol. i. 
 34 
 
398 DISEASES OF THE 
 
 It will be necessary to resort to the lancet where it is indicated 
 by a strong febrile pulse or irregular determinations of blood, or 
 to relieve intense local pblogosis, and such conditions existing, it 
 should precede the use of evacuants of the alimentary tube, as 
 well as all other measures. Cases have come under my care in 
 which I have bled very freely and with decisive utility. But 
 these do not ordinarily happen, and since I have relied so much 
 on purging, the necessity of the lancet has been infinitely less. 
 Not the least, of the great advantages of it in this disease, is that 
 the increased pulse, the temperature, and other febrile symptoms 
 as well as the topical affections, are removed. It has been 
 remarked, too, very generally, that venesection is not productive 
 of as much benefit in gout, from its peculiar nature, as in other 
 phlegmasia, and which I believe to be true. Nevertheless, such 
 is its importance as to be indispensable under the circumstances 
 previously stated, — and though condemned by some of the Euro- 
 pean writers, is sustained by a host of the very highest of our 
 own authorities, from an early period down to the present day. 
 No other foundation than an idle prejudice has the objection to 
 the practice, on account of its tendency to induce retrocessions of 
 the disease. Frequently as I have employed it, none such, at 
 least, have I observed, and in this opinion I know that I am well 
 sustained. 
 
 From a conviction that it is one of those diseases dependent on 
 morbific matter, and that the skin is a natural emunctory for its 
 discharge, many of the disciples of the humoral pathology in- 
 dulged in the very free use of diaphoretics in gout. As sub- 
 ordinate means, these, unquestionably, are sometimes of service. 
 Nature, whose intimations ought always to be consulted, and 
 which frequently may be trusted, clearly points to their use. The 
 paroxysms of regular arthritis, when spontaneously cured, go off 
 commonly with diarrhoea, diaphoresis or diuresis. I have shown 
 how efficient is an imitation of the first of these natural attempts 
 by purging, and hence, that of the others may be analogically 
 inferred, independently of any more positive testimony. But 
 there is a time or state of the disease in which diaphoretics are 
 proper only. It is, after the reduction of the force of an acute 
 attack, or earlier in those less active cases, arising out of an 
 originally feeble frame, or one broken down by a course of 
 vicious indulgences. The cordial and stimulating articles in the 
 
MUSCULAR OR FIBROUS SYSTEM. 399 
 
 latter state are mostly to be preferred. Combinations of the 
 carbonate of ammonia with laudanum, aided by wine whey, are 
 admirably adapted. The Dover's powder, also, when the sto- 
 mach is not irritable, may sometimes be employed advantage- 
 ously. 
 
 Discharges of urine, as just remarked, are also often critical 
 in this disease, and which proclivity should be promoted. The 
 dulcified spirits of nitre is well suited to the occasion, and I have 
 witnessed, in some instances, great utility from a union of the 
 tincture of colchicnm with it. But on the whole, perhaps, I 
 have seen the most signal advantage from an infusion of digitalis, 
 sometimes alone, and on other occasions in combination with the 
 preceding articles. Like colchicum, however, there is a property 
 in digitalis displayed in gout of a salutary tendency, independ- 
 ently of any of its ordinary sensible effects. The urinary and 
 perspiratory processes are productive of nearly the same effect in 
 the cure of many diseases, and the one or the other should be 
 encouraged as nature seems to indicate. 
 
 Completing, as I have now done, the regular treatment of gout, 
 I must next say a word or two of a nostrum, of too much 
 repute in this disease to be overlooked. To the eau medicinale 
 I allude, an article originally invented in France, which, at one 
 time, had acquired immense celebrity throughout Europe. It 
 also crept partially into use in this country, and I have had 
 several opportunities of witnessing its astonishing powers in 
 different shapes of arthritic affections. Of its composition we 
 have ascertained nothing with certainty, — though there are 
 various conjectures on the subject, the most probable of which 
 is, that it is essentially colchicum. Distinctly marked are its 
 effects on the system. As a purgative it operates actively, and 
 sometimes vomits violently, producing, at the same time, copi- 
 ous perspiration or diuresis, with extreme nervous distress and 
 prostration of muscular power. During the operation, however, 
 the pain and swelling of the joint so rapidly subside, that it is 
 not unusual for the person to be perfectly relieved. 
 
 This medicine is very differently appreciated by practitioners: 
 while, by many, it is most highly extolled, there are others who 
 condemn it as both useless and pernicious. By some of those 
 who admit its immediate utility, it is, however, dreaded lest it 
 might eventually injure the constitution. Examples are cited 
 
400 DISEASES OF THE 
 
 by Ring, Powell, Gregory, and other respectable authorities, of 
 its suddenly extinguishing life by causing apoplexy. But such 
 were rather coincidences than effects, I am inclined to believe, 
 as well from what I have seen myself, as that we are possessed 
 of the most abundant evidence of the older writers of the safety 
 of the hermodactylus, the colchicum itself, or a very active 
 species of it. Colchicum surely cannot be deemed dangerous if 
 not abased, — and when displaying any baneful effects, they are 
 rather on the primse viae, or skin and nerves, than on the brain. 
 Nausea, vomiting, purging, sweating, with nervous distress, &c, 
 take place, and never, so far as I have observed, any cerebral 
 affection of the kind alleged. From the use of the eau medicinale 
 I was first restrained by the enormous price of the article, and 
 afterwards abandoned it by having found a very efficient sub- 
 stitute for it in the tincture of colchicum, administered in the 
 same manner. 
 
 Of the latter having the powers ascribed to it, the medical men 
 of ancient times were so confidently persuaded that the title of 
 anima articulorum, the soul of the joints, was conferred on it, 
 and, as lending additional confirmation of this view, it may not 
 be uninteresting to mention that I have seen some instances of 
 the most agonizing neuralgia, particularly of the spine and head, 
 an affection in some respects not dissimilar to gout, the same 
 prompt relief from it. But though large doses are required of 
 these articles to command their full effects in the height of the 
 disease, they may be given much more moderately in cases 
 originally mild, or subdued by previous remedies, say twenty 
 drops of either twice or thrice a day, and which is one of the 
 most common and not the least useful applications of colchicum. 
 
 Of the thousand other nostrums which, at different periods, 
 have been proclaimed, and for a season secured more or less 
 attention, the only ones that at present maintain any repute are 
 Wilson's tincture and Reynold's specific, each probably being 
 composed of colchicum and some opiate preparation. Neither 
 have I ever employed. Lartigues' pills, so called after a distin- 
 guished apothecary of Paris, by whom they were contrived, and 
 the annexed formula,* liberally promulgated, have recently ac- 
 
 * R. Extract, colocynth. comp., gr. iv.; Rad. colch., gr. i.; Fol. digital., gr. ss.; 
 Mucil. gum. Arab., qt. s. ft. pill, i. Two of these pills to be taken morning and 
 night. 
 
MUSCULAR OR FIBROUS SYSTEM. 401 
 
 quired, and I suspect, deservedly, considerable reputation in this 
 city. It will be perceived that they contain colchicum and digi- 
 talis, two articles of which I have already spoken highly, and an 
 active purgative, thus from their properties well calculated to do 
 good, according to my views of the pathology and treatment of 
 the disease. But whatever may be the merits of this or any 
 other single prescription, it can only be useful by a proper adapta- 
 tion to certain stages or conditions of gout, and employed to the 
 neglect of that general management of the disease which I have 
 so fully pointed out, must prove, as all catholicons have hitherto 
 done, the curse of scientific and successful practice, — the pro- 
 moter of quackery and the agent of death ! 
 
 These are the general remedies in regular gout, and which, for 
 the most part, correspondency relieve the local affection. Yet 
 sometimes the agony of the latter is so intense, that the vehement 
 calls for additional succour can scarcely be resisted, and I shall 
 proceed to notice the best palliatives. 
 
 Much might be expected from opiates, under such circum- 
 stances. In the height of the paroxysm, however, it seems now 
 to be sufficiently ascertained, that they have a tendency to aggra- 
 vate it, by inducing constipation, and increasing the fever, and 
 restlessness. But a course very different was recommended by 
 Brown, and pursued by himself and his disciples. Deeming gout 
 to be always connected with an asthenic state, he maintained 
 that it should be treated by stimulants, and, among these, that 
 none was more efficacious than opium. 
 
 That this is mere theory, refuted by ample experience, I 
 need not say. Brown was destined to illustrate, in his own in- 
 stance, the pernicious nature of his practice. To a large dose of 
 opium, taken in a paroxysm of podagra, that brought on apo- 
 plexy, it is said his death was owing. 
 
 Nevertheless, the force of action being abated by proper evacua- 
 tions, we may then direct opiates with advantage, and especially 
 with a diaphoretic, as in Dover's powder. To this limitation of 
 opiates, there is an exception. Cases sometimes occur, where, 
 even in the early stage, the pain seems to proceed more from 
 extreme nervous irritation than proper arthritic inflammation, 
 in which the circulation, though accelerated, is not full or dis- 
 turbed by the febrile movement that is benefited by it. 
 
 Leeches afford the most prompt relief to the local affection, 
 
 34* 
 
402 DISEASES OF THE 
 
 when intensely inflamed, and, in contradiction to some writers, 
 may be freely and unhesitatingly employed. These not being to 
 be procured, or, after the trial of them, ineffectual, fomentations 
 are to be directed, made of poppy heads, or the hop, or chamo- 
 mile, or elder flowers. 
 
 As somewhat analogous, I may also mention the application 
 of a piece of raw fresh meat, a beef-steak, particularly. Lu- 
 dicrous as this very homely means may seem, I have really 
 known it to prove an excellent lenitive. It should be renewed 
 whenever it becomes dry. This, I presume, is a relic of an old 
 custom of soothing wounds and other injuries by putting to them 
 portions of recently killed animals, while still warm, or what, 
 perhaps, was oftener prescribed, a pigeon split open. The prac- 
 tice, indeed, in a modified shape, appears to have been continued 
 to our times. Baron Larrey, at least, I am told, was in the 
 habit of enveloping the whole person in the fresh skin of a calf, 
 as a cure for the muscular rigidity caused by cold, as well as a 
 preventive of traumatic tetanus. But to return to our subject. 
 By steaming the inflamed joint, relief is sometimes speedily ob- 
 tained, and a very convenient machine for the purpose is now 
 used. 
 
 Covering the part with flannel, or cotton, or wool, over which 
 a piece of medicated oil silk is to be bound, operates, to a certain 
 extent, in the same way, and, while it assuages suffering, is well 
 calculated to obviate the retrocession of the disease. By Scuda- 
 more, a mixture is strongly recommended, consisting of three 
 parts of camphorated spirit and one of alcohol, applied warm, 
 from which, however, I have seen no benefit. 
 
 Blistering has been proposed, and since it is so useful in the 
 other phlegmasia, with great plausibility of its efficacy. By 
 Stedman, a writer of good repute, in a treatise on the disease in 
 which he adopts as a motto " dolor est medecinas doloris," it is, 
 indeed, affirmed that it never fails to do good. Yet, it is at pre- 
 sent very generally abandoned, and by some, from an apprehen- 
 sion of its tendency to repel the disease internally. We know, 
 however, that sinapisms and blisters are the best means to invite 
 and fasten it down on the extremities, and I can have no idea 
 of the same remedy producing such opposite effects. My own 
 experience with blisters, in their appropriation to this painful 
 affection, is too limited to decide confidently on the matter. But, 
 
MUSCULAR OR FIBROUS SYSTEM. 403 
 
 from analogy, as well on account of what I have seen of their 
 operation, I presume that after a partial reduction of the phlo- 
 gosis, they would be serviceable — which opinion is strengthened 
 by the consideration, that counter-irritation, by some means, 
 seems always to have been a favourite practice in such cases. 
 Burning the part with flax is the suggestion of Hippocrates — 
 with moxa, is adopted among the Chinese — and urtication in 
 some of the countries of Europe. Deeming counter-irritation of 
 importance, the common epispastic I should prefer. The cata- 
 logue of topical applications, professional and popular, which 
 have been employed in the disease is boundless in number and 
 variety. An idea may be formed of the extent of such means 
 even in early times, and they have since been greatly multi- 
 plied, from the ensuing often-quoted passage from Lucian. 
 
 "Terunt plantagines, et apia 
 
 Et folia lactucarum et sylvestrem portulacam. 
 
 Alii marrubium ; alii potamoge'itonem ; 
 
 Alii urticas terunt; alii Symphytum ; 
 
 Alii lentes adferunt ex palustribas lectas ; 
 
 Alii pastinacam coctam ; alii folia persicorum, 
 
 Hyoscyamum, papaver, cepas agrestes, mali punici cortices, 
 
 Psyllium, thus, radicem ellebori, nitrum, 
 
 Foenum grsecum cum vino, gyrinum, collamphacum, 
 
 Cyparissinam gallam, pollen hordeaceum, 
 
 Brassicse decoctse folia, gypsum ex garo, 
 
 Stercora montansg caprse, humanum oletum, 
 
 Farinas fabarum, florem asii lapidis: 
 
 Coquunt rubetas, mares-araneos, lacertas, feles, 
 
 Ranas, hysenas, tragelaphos, vulpeculas. 
 
 Quale metallum non exploratum est mortalibus ? 
 
 Quis non succus? Qualis non arborum lacryma'? 
 
 Animalium quorum vis ossa,nervi, pelles, 
 
 Adeps, sanguis, medulla, stercus, lac. 
 
 Bibunt alii numero quaterno pharmacum: 
 
 Alii octono; sed septeno plures. 
 
 Alius vero bibens hieram purgatur: 
 
 Alius incantamentis impostorum deluditur," &c. 
 
 Every measure of a stimulating or heating character, however, 
 is condemned by some practitioners, and particularly by Kinlake, 
 a respectable writer on gout, who maintains that, instead of aug- 
 menting the temperature or excitement of the part, already too 
 high, by such applications, we should do directly the reverse. 
 His theory of the disease is as fallacious as the practice deduced 
 
404 DISEASES OP THE 
 
 from it proves hazardous. Contemplating the local affection as 
 primary, and the general disturbance of the system to be of a 
 secondary and sympathetic nature it is inferred that, by curing 
 the first, the other of course must subside. 
 
 That the application of cold to the part will mitigate the phlo- 
 gosis, has been shown, from the time of Hippocrates, with whom 
 the practice originated, to the present day. Yet that it is a peril- 
 ous expedient, by repelling the disease, is equally clear, and is 
 now discarded by discreet practitioners. The only case in which 
 it is admissible at all, is where the individual is of sound and 
 vigorous constitution, of which the illustrious discoverer of the 
 circulation, by whom the practice was tried, in regard to himself, 
 ultimately became convinced. Early in life, when robust, he 
 resorted to it safely and usefully. But, as soon as the feebleness 
 of age began to approach, he was admonished to desist, from the 
 injury he received. The same was experienced, I recollect, by 
 the great financier of our Revolution, the late Robert Morris. 
 Like Harvey, he was long in the habit, he told me, of immersing 
 his feet in cold water, deriving immediate relief from it, till, de- 
 terred from its further use, by having, on one occasion, a sudden 
 and nearly fatal translation of the disease to the brain. Three 
 cases are mentioned by Parry where paralysis speedily followed 
 from it, and I have no doubt that others might be collected of 
 this or some other disastrous consequence. 
 
 Even under the most propitious circumstances, it will be pru- 
 dent to fortify the stomach by the previous exhibition of some 
 cordial or stimulant, as, a dose of the carbonate of ammonia or 
 camphor, or ether or laudanum. 
 
 Cold water, applied as a pediluvium, I should think, in any 
 case, too hazardous to be ventured. Merely sponging the in- 
 flamed part is greatly to be preferred. Covering it with cabbage 
 leaves, and still more with those of the tulip poplar, I have known 
 to be productive of ease. They are prepared and operate, how- 
 ever, differently, the one being welted by heat, and used as a 
 fomentation, and the other in the natural state, lowering tempe- 
 rature by occasioning the most copious cold dewy-like exhalation. 
 
 The course of treatment, now detailed, has reference mainly to 
 the more violent states of gout. It often, however, assumes a 
 mitigated shape, or appears in the aged or otherwise infirm, and 
 here the measures are to be tempered accordingly. 
 
MUSCULAR OR FIBROUS SYSTEM. 405 
 
 On the subsidence of the paroxysm, little is commonly required 
 to be done, where the integrity of the constitution is preserved. 
 Moderately nutritious diet, with a glass or two daily of pure Ma- 
 deira or Sherry wine, and some attention to the bowels, are all 
 that is usually exacted to secure a perfect convalescence. The 
 joints, however, may continue swollen and stiff, to remove which, 
 frictions, with a stimulating liniment, and a flannel roller, when 
 an oedematous state exists, are the most effectual. 
 
 CHRONIC GOUT. 
 
 In the inveterate states of gout, not much can be done towards 
 a cure, and, for the most part, our efforts are limited merely to a 
 palliation of urgent affections. The remedies here are nearly the 
 same as in the acute disease, though none of them can be urged 
 to any extent. As the management, on the whole, is very simi- 
 lar to that of some of the forms of atonic gout, I shall postpone 
 the details of it till I arrive at the consideration of that division 
 of the subject. In many instances, the animal machine becomes 
 so broken and out of order, by the ravages of the disease, that 
 no skill can repair it. But, less injured, some encouragement is 
 afforded, and endeavours should be made toward its rectification. 
 As preliminary to any such attempts, the entire economy is care- 
 fully to be surveyed, with a view to the detection of the principal 
 lesions. Nearly always, it will be found, that the abdominal 
 viscera are materially in fault, the stomach, bowels and liver 
 especially. Great advantages are sometimes derived, in such 
 cases, from the cautious use of the blue pill and the taraxicum 
 mixture, to be followed, ultimately, by a course of the mildest 
 preparations of steel, and a properly regulated regimen. As 
 pains, nervous inquietude, and the want of sleep, are pretty uni- 
 form attendants on this condition, worrying and exhausting, 
 these must be mitigated by lenitives, among the best of which is 
 henbane, or an opiate in combination with a gentle diaphoretic, 
 at night. Confidence is, however, reposed by some, at this con- 
 juncture, in the compound syrup of sarsaparilla, volatile tincture 
 of guaiacum, the terebinthinates, the savin, and similar articles. 
 But, so far as I have seen, these are very equivocal remedies, 
 and ordinarily prove so offensive to the stomach, that they arc at 
 
406 DISEASES OF THE 
 
 once rejected, or cannot be continued to any efficient end. The 
 savin, however, when tolerated for a considerable length of time, 
 I have known, in several instances, to remove the extraneous 
 matter in the joints, and thereby to restore freedom in their 
 movements. This is the most useful property of the article, in 
 its application to gout. But, in relation to the articular derange- 
 ments, I prefer treating of them fully under the head of chronic 
 rheumatism, in which they more frequently occur. I have now 
 only to add, that, whenever practicable, individuals with chronic 
 gout should make a fair trial of the Thermal and other Springs 
 of Virginia, which often do more than all other means. 
 
 RETROCEDENT, RETROGRADE, OR DISPLACED GOUT. 
 
 Gout, though apparently fixed in one of the extremities, is 
 prone to shift its position, and seize on some internal or vital part, 
 creating, sometimes, the most imminent danger. This is the form 
 of it which receives the above titles. 
 
 It may locate itself in any one of the organs of the great cavi- 
 ties, though, most commonly, in the stomach, causing nausea, 
 vomiting, and violent spasms, which, if not expeditiously relieved, 
 will often prove fatal. Gastric affections of this nature require 
 a very opposite mode of treatment, in their several stages. It is 
 usual to commence with the diffusible stimulants and antispas- 
 modics, such as opium, ether, musk, carbonate of ammonia, the 
 spirit of turpentine, spiced wine or ardent spirits, either pure or 
 converted into hot toddy. The stomach here loses its suscepti- 
 bility, in a very considerable degree, and hence, in prescribing 
 any of the articles mentioned, the dose must be very much in- 
 creased. This remark applies, perhaps, with peculiar force to 
 opium and its preparations, which, in some instances, may be 
 given in three or four, or five times the ordinary quantity. As 
 co-operating means, hot fomentations to the epigastric region are 
 not to be overlooked in the more vehement of these attacks. 
 They contribute to mitigate pain, and sometimes so far tran- 
 quillize the stomach as to check the puking, and thus prepare the 
 way for the exhibition of medicines. 
 
 This is the customary mode of managing the early stage of 
 retrocedent gout in the stomach. Not succeeding, it will be 
 
MUSCULAR OR FIBROUS SYSTEM. 407 
 
 proper to take away some blood. Leeches or cups over the epi- 
 gastrium prove very effectual. Cases, however, occur of such 
 urgency, as not to admit of so slow a process, and venesection 
 must be substituted. Yet, as regards the latter, care and discri- 
 mination are to be exercised. The pulse here scarcely can be 
 trusted as a guide, being frequently weak, or depressed in the 
 more violent attacks, and when, perhaps, the loss of blood is im- 
 peratively demanded. In making up our decision on this point, 
 we should take into view the strength of the patient, the intens- 
 ity of the pain, the state of temperature on the surface, and, in 
 fine, the degree of probability, as to the power of the system to 
 react on depletion. It is well to bear in mind that, mostly, where 
 there is apparently depression of the vital forces, suddenly in- 
 duced, the existence of acute pain is a pretty certain sign of the 
 propriety of such practice. 
 
 Notwithstanding all the monitory suggestions against it, in 
 many of the European writers, bleeding, and very copious bleed- 
 ing, too, is habitually directed by me, and other practitioners of 
 this city in gout of the stomach, and with great success. It is the 
 best and most certain antispasmodic, and if inflammation exists, 
 holds out the only chance of cure. 
 
 These are cases to be managed essentially in the same manner 
 as common colic. Being spasmodic in the beginning, whatever 
 is calculated to resolve the spasm will be useful. But phlogosis 
 having taken place, and which sometimes happens even at an 
 early stage, all stimulating articles are to be abandoned, and 
 measures of a directly opposite tendency resorted to, as general 
 and topical bleeding, a blister to the epigastrium, and opiates. 
 
 Nearly a similar course should be adopted, when it attacks the 
 bowels, which it is almost as apt to do by violent cramps and 
 obstinate constipation. 
 
 The kidneys are also very liable to be assailed, and with the 
 symptoms of ordinary nephritis, which sometimes may be relieved 
 by fomentations or the warm bath. But when obstinate, general 
 or topical bleeding, a blister over the affected part, and an opiate, 
 — the latter answering best as an enema, are required. Lingering 
 cases, I have found singularly benefited by the use of colchicum. 
 Equally is this treatment suited to an attack of the urinary blad- 
 der and of the uterus, which is usually betrayed by severe spas- 
 modic pain. 
 
408 DISEASES OF THE 
 
 Translated to the lungs, gout produces a state sometimes imi- 
 tative of pneumonic or pleuritic inflammation ; — and, in other 
 instances, of bronchitis or of asthma. The treatment in each 
 instance is very much the same as if the attacks had proceeded 
 from the vicissitudes of weather, or any other of the ordinary 
 causes of such complaints. 
 
 Cardiac affections from the same cause are characterized by 
 violent spasms of the heart, or by inflammation of it, or a state 
 resembling syncope, or by an immediate extinction of life, from 
 suppression of the circulation. 
 
 As may be supposed, this affection is calculated always, 
 whether it be violent or not, to create great solicitude and appre- 
 hension. Without, indeed, the attack be slight, we are often 
 precluded altogether even from the hope of doing good, by the 
 suddenness of death. Two of the cases which I have met with, 
 terminated almost immediately. Time, however, being allowed 
 to interpose our efforts, venesection, and then topical bleeding 
 and blistering with an opiate, constitute the proper means, to be 
 followed up by the use of colchicum or digitalis. 
 
 Much of the preceding treatment is equally applicable to gout, 
 when it seizes on the brain, in which position it is chiefly betrayed 
 by violent cerebral excitement, with delirium, or by apoplexy, 
 palsy, stupor or lethargy. Conforming the practice to the state of 
 the system, we should bleed generally or locally, or both, vesicate 
 the nape of the neck, purge copiously, and do whatever else is 
 called for in these states otherwise induced. 
 
 In relation to retrocedent gout, there is one precept of univer- 
 sal application, which, in practice, must be kept in mind. It is 
 steadily to endeavour to invite or restore the disease to the 
 joints, and, with this view, a resort is to be had to a stimulating 
 pediluvium, and next to sinapisms or blisters to the lower ex- 
 tremities, as the most effectual measures. 
 
 ATONIC, IRREGULAR OR MISPLACED GOUT. 
 
 In the ordinary acceptation of the former of these terms, is 
 meant that state of the disease where, though the arthritic diathe- 
 sis prevails, there is not vigour enough to induce the inflammatory 
 affection of the limbs, or, if it take place, it is slight or transitory, 
 
MUSCULAR OR FIBROUS SYSTEM. 409 
 
 continuing only for a very short time, and then reverting to some 
 inward structure. 
 
 Commonly, the individual is persecuted by a group of affec- 
 tions, which appears chiefly in the stomach, such as loss of appe- 
 tite, nausea, vomiting, acrid and sour eructations, cardialgia, 
 pyrosis, &c. These, with pains and cramps, like those of flatu- 
 lent colic, are sometimes relieved by a discharge of wind. Con- 
 stipation usually predominates, though alternated by purging, 
 which may be attended by tormina and tenesmus. The urine, 
 as well as the other secretions, is scanty and vitiated, the tongue 
 foul, — the skin very dry — the breath heavy and offensive, and 
 great depression of spirits, amounting to melancholy, often pre- 
 vails with a constant and anxious attention to the slightest 
 feelings, much aggravated by disturbed imaginations and idle 
 fears, to which may be added, palpitations of the heart, or angina 
 pectoris, or asthma, or headache, vertigo, &c. &c. Fever can 
 scarcely be said to exist, though the pulse may be quickened and 
 irritated. 
 
 Considering the articulations as the proper seat of the disease, 
 when it primarily appears in any other part, it receives the title 
 of misplaced gout. Disposed to wander about the system, as it 
 is very apt to do, then it is denominated erratic gout, and some 
 instances of it are remarkably distinguished by the suddenness 
 and capriciousness of its fluctuations. Generally incident to an 
 atonic state of the system, we, however, sometimes meet with 
 this variety of it, most decidedly otherwise, or actively inflamma- 
 tory. Misplaced gout, of the latter description, may occupy any 
 position, the head, the heart, the lungs, or any one or more of the 
 abdominal viscera. Frequently, too, it attacks the testicles, and 
 I knew an elderly man, who had it repeatedly in the penis, 
 causing very painful priapisms. The skin is, moreover, some- 
 times assailed by it, manifested by an irritation, resembling 
 prurigo formicans, or by some eruption, particularly on the peri- 
 naeum or about the anus or vagina. No part of the body has, in 
 short, an immunity from its attacks, which present every diversity 
 of aspect, simulating all other diseases. Thus occurring, it some- 
 times bears a very close resemblance to retrocedent gout in the 
 same positions. 
 
 The causes of these two varieties of the disease are the same 
 as of regular gout. Men of originally delicate constitutions, or 
 35 
 
410 DISEASES OF THE 
 
 rendered so by depraved indulgences, or in any way, are mainly 
 exposed to such aggressions. Even still more, perhaps, are 
 women, especially after the cessation of the menses, under the 
 guise of some one of those numerous and anomalous affections 
 which they are apt to exhibit at that period. 
 
 To discriminate between the real gouty and other conditions, 
 which, though apparently similar, are essentially different, is often 
 a matter of considerable perplexity. Chief reliance must be 
 placed, under circumstances of such embarrassment, on an inquiry 
 into the history of the individual, whether there is reason to sus- 
 pect an hereditary taint, or from certain habits, it may have been 
 acquired, on a careful comparison of the symptoms themselves, 
 and particularly, on the proneness to metastasis. 
 
 Generally, irregular gout is exceedingly troublesome in the 
 management, owing to its disguises, fluctuations and proteiform 
 shapes. Concentrated, and fixed in a part, as a phlegmasia, it 
 is least so, though immediately more alarming. But oftener 
 otherwise, it preys upon the constitution, involving organ after 
 organ, till ultimately a general cachexy is induced. The result, 
 on the whole, will depend materially on the condition of the indi- 
 vidual, the integrity of his economy, the simplicity or complica- 
 tion of the case, its duration, the organ or organs affected, and the 
 kind and degree of lesion or lesions. 
 
 Of the anatomical characters, little seems to be accurately 
 known. We have, however, evidence, though not definitely 
 given, of the existence of spasm and inflammation, acute and 
 chronic, with every sort of disorganization, as the case may have 
 been. Yet the disease sometimes long endures, and with consi- 
 derable severity, without leaving behind any appreciable signs. 
 
 In approaching the pathological consideration, the question 
 which I am first to advert to is, whether these internal affections 
 are really gouty, or of a distinct character, superinduced on that 
 peculiar diathesis. Each view may possibly be correct, or, at 
 least, that a totally different affection shall sometimes become thus 
 engrafted. Nevertheless, I think the susceptibility of the internal 
 structures to gout cannot be doubted on solid grounds, nor that 
 a very large proportion of such instances are of this nature. Be- 
 lieving, indeed, that both propositions are sufficiently established, 
 I shall dismiss them without further inquiry. 
 
 Between misplaced and atonic gout, I take the only, or at all 
 
MUSCULAR OR FIBROUS SYSTEM. 411 
 
 events, the chief difference to consist in the former being more 
 fully developed and inflammatory, though in error loci, while 
 the latter is a feeble, ill-defined and rather an irritative state of the 
 same affection. Even this distinction must be received with 
 limitations. 
 
 Concerning the treatment of misplaced gout, I have to observe, 
 that we are to be governed by the same principles, and to resort 
 to the remedies which were detailed in delivering the history of 
 the retrocedent variety of the disease. Let it be here recollected 
 as a guide to practice, that instead of an inflammatory attack in 
 an extremity, some internal organ is suffering in a similar man- 
 ner, and requires to be managed accordingly. 
 
 In regard to the atonic states of the disease, though the general 
 characteristics may be that of debility and depravation of system, 
 in which there is more of an irritative than inflammatory condi- 
 tion, I think it is often otherwise, or that some lurking phlegmasia 
 exists, disguised by the pervading weakness. It is, at least, very 
 important in the treatment, to advert to the possibility of the fact, 
 and to endeavour its determination. Not unfrequently will a 
 very careful examination reveal chronic gastro-enteritis alone, or 
 united with functional or other lesions of the liver or kidneys 
 especially, where none was suspected or prominently displayed. 
 
 Can tonics, or cordial stimulants, the customary remedies 
 employed, avail, or rather, would they not be the most inapt or 
 mischievous which could be selected? Common sense, indeed, 
 dictates an opposite course, or the entire removal of these patho- 
 logical states prior to an appeal to such means. This design 
 having been accomplished and the restoration of tone seemingly 
 demanded, or in a case originally with this defect only, then may 
 the plan of invigoration be properly entered upon, and with 
 some rational expectation of advantage. But it still more fre- 
 quently happens that the chylopoietic organs without phlogosis 
 are functionally disordered, showing great derangement in the 
 digestive and nutritive apparatus, resembling ordinary dyspepsia 
 with its sympathetic disturbances. These several conditions, 
 however, having been amply discussed and disposed of under 
 the head of the gastric diseases, I shall be content to re tor to 
 what was said on that occasion for the details of the course 
 as being applicable to the cases now before us. It may. indeed . 
 be enough now to remark, that on the re ctification of the organs 
 
412 DISEASES OF THE 
 
 concerned by the means formerly mentioned, little else remains 
 to be done in atonic gout by medicine than to obviate consti- 
 pation by magnesia, rhubarb or sulphur, occasionally directed, 
 and the use of tonics. Of the latter, the chalybeates alone, or 
 with bark, are much commended. Crude bark, however, I have 
 found to disagree with the stomach, the aromatic decoction or 
 infusion sometimes to answer, and still oftener the tincture, united 
 with one of the martial preparations, though, perhaps, the sul- 
 phate of quinine is to be preferred, and certainly as an adjunct 
 to the steel. 
 
 Yet there is a writer who winds up an eulogium on the pro- 
 perties of the bark itself, with the following enthusiastic expres- 
 sion: 
 
 "Uno verbo, cortex Peruvianus, in podagra divinium est remedium" 
 
 Nearly all of the best authorities, however, seem to unite in 
 denouncing the protracted use of bitters. By invigorating the 
 stomach, they are for a time undoubtedly beneficial, — though a 
 persistence in them, it is alleged, is apt to produce the most per- 
 nicious consequences. The power of the system to throw the 
 disease on the extremities is greatly impaired, and the individual 
 rendered miserable by all the irregular arthritic affections, or 
 he is suddenly destroyed by apoplexy, or has entailed on him 
 palsy, asthma, dropsy, &c., which ultimately prove fatal. 
 
 Of the Portland powder every one has heard. This, so called 
 from the Duke of Portland, who gave it celebrity, is composed of 
 several of the vegetable bitters, no one of which has much 
 activity.* Yet it is declared by Cullen, by Murray, the author 
 of the Apparatus Medicaminum, by Darwin, and, in short, by 
 many of our authorities, that this nostrum has proved most 
 hurtful in the mode I have just mentioned. Exactly the same 
 is said by Galen and other of the old writers of nearly a similar 
 compound, which was in vogue in their time. Bitters long con- 
 tinued, operate here by inducing debility of stomach from over 
 stimulation. 
 
 To relieve at the moment, as well as to prevent a recurrence 
 
 * It is composed of the roots of the gentian, and birthwort, and of the tops 
 and leaves of centaury, ground pine, and germander of equal weight, well dried 
 and pulverized, of which a drachm is to be taken every morning fasting, for 
 months, then omitted for a time and renewed in less quantity. 
 
MUSCULAR OR FIBROUS SYSTEM. 413 
 
 of some of the more harassing affections incident to the disease, 
 as spasms of the alimentary canal, flatulence, palpitations, &c, 
 I have found the volatile tincture of guaiacum, or, the carbon- 
 ate of ammonia, by itself, very serviceable. The Warner's gout 
 cordial which is an aromatic, carminative tincture of senna and 
 rhubarb, is also deserving of attention. These articles are further 
 calculated to throw the disease on the extremities, an indication 
 never to be lost sight of, or failed to be promoted. By such a trans- 
 lation, when perfect, immediate relief is afforded, however great 
 the previous distress may have been, provided no essential struc- 
 tural lesions have taken place. Directed by this view, a small 
 wineglassful of Warner's cordial, especially, should be taken at 
 night, with a copious draught of hot wine whey, a stimulating 
 pediluvium having been previously used. More active revul- 
 sives, as sinapisms or blisters, may also be tried, and I have 
 known, in two instances, the wearing of tight boots to prove 
 effectual. 
 
 Not less important than medicines, is a duly regulated regimen, 
 concerning which, however, I have little to add to what was 
 said on this point in regard to the stomach affections. It differs 
 chiefly in the food, requiring, in some instances, to be more stimu- 
 lating, and in a freer use of wine. 
 
 The gout having been allured to a joint, it will hardly be pru- 
 dent to attempt any means to lessen the pain or inflammation ; — 
 but, on the contrary, our aim should be so to establish it as to 
 let it pass through all the stages regularly, without the least mo- 
 lestation. This is a case which may be properly committed " to 
 flannel and patient endurance," with the exception, that should 
 it show a disposition to recede, such an event must be obviated 
 by pretty much the same means employed to bring it to the ex- 
 tremity. We may, however, be compelled to direct wine itself, 
 and more liberally — and also to resort to opiates, or the carbon- 
 ate of ammonia, or musk, which last article, though less pre- 
 scribed, is, when of good quality, one of the most efficient reme- 
 dies with which I am conversant. 
 
 Closing this part of my subject, I cannot forbear again to urge 
 the value of our mineral and thermal springs, in their relations to 
 every modification of gout. Those of Europe, of a similar kind, 
 have immemoriably had an indisputable reputation in this re- 
 spect, and to which I have reason to believe our own are still 
 
 35* 
 
414 DISEASES OF THE 
 
 more entitled, from greater efficacy. The waters of Bedford In 
 this state, of Saratoga, in New York, and of the White Sul- 
 phur Springs, in Virginia, are eminently calculated to repair the 
 derangement of the primae vias, the liver and kidneys, incident 
 to the disease, and the warm and hot baths in the same neigh- 
 bourhood as the last, are not less so, to re-establish a healthy con- 
 dition of the skin, very frequently dry and harsh, with a feeble 
 capillary circulation, — to invigorate the nervous system, nearly 
 always out of order, and, above all, perhaps, are they serviceable 
 in the cure of muscular weakness of the lower limbs, and the 
 chronic swellings, rigidities and other injuries of the articulations, 
 The first is to be preferred in reference to the general affections 
 named, and the second, to relieve the topical lesions, especially 
 when applied as douches, followed by frictions and champooing. 
 Nothing need be said of the influence of the long journey to 
 reach these springs, or of the delicious climate of the locality, 
 or of the charms of the society by which they are distinguished. 
 
 Though the complete eradication of gout, in any of its forms, 
 when fully established, is perhaps hardly to be expected, still, by 
 care in the avoidance of the exciting causes, the interval between 
 the paroxysms may be procrastinated, — and when they occur, 
 greatly abated. Cullen's directions on this point are so sound, 
 that I cannot forbear to recommend them to general perusal, and 
 most particular regard. 
 
 As indispensable, let me insist on a strict, undeviating adher- 
 ence to a moderate diet. Medical authority, however, differs as 
 to the kind of food. By Redi, Starke, Lobb, &c, the exclusive 
 use of vegetables is strenuously advised, while Brown and his 
 disciples as strongly urge the reverse. Both are wrong. The 
 lowest and most abstemious diet will sometimes be exacted, 
 and on other occasions, the cordial and generous. Limitation in 
 quantity is, perhaps, of as much consequence as the quality of 
 the nutriment. Discrimination is no less to be made in relation 
 to drinks. To some, water alone should be allowed, and others 
 will require a small portion of wine, or of ardent spirits. The 
 great purpose is to preserve soundness of the digestive and assimi- 
 lative functions, and the course of living must be accommodated 
 accordingly. 
 
 Equally important is it, that habits of indolence, or even of too 
 intense application to study, or any other sedentary occupation, 
 
MUSCULAR OR FIBROUS SYSTEM. 415 
 
 be exchanged for those of activity and exercise. Many, says 
 Hoffman, " have lost their gout with their fortune," by turning, 
 no doubt, at the same time, from luxury and lazy enjoyments 
 to laborious pursuits. The eccentric Mr. Abernethy being asked 
 by a nobleman, what would prevent gout, he replied, in his usual 
 sententious manner : " My lord, live on sixpence a-day, and earn 
 it." These are aphorisms, which, though uttered with some 
 exaggeration, contain a vast deal of wisdom, and might be 
 adopted, with proper qualifications, as rules of life, in reference 
 to the object in view. 
 
 By one of the sages of our profession, gout has been pro- 
 nounced as proceeding mainly from " vexation of spirit." Not 
 agreeing entirely with him, the immense influence of moral 
 causes in the origination and maintenance of the disease, seems 
 to be universally admitted. Every emotion or passion, whether 
 of tempestuous excitement, or the reverse, depressive, or worry- 
 ing and irritative, has such an effect. Equanimity is hence to be 
 cultivated, and which will be most successfully done, by resorting 
 to those sentinels which philosophy places over us, to protect 
 against the invasions of the evil dispositions by which the soul 
 becomes agitated or disturbed. Nourished by unresistance, a 
 fretted or exasperated temper is held to be especially baneful, 
 and hence, above all, the injunction of the wisest of mortals 
 should be remembered : " Let not the sun go down on thy 
 wrath." 
 
 Yet, admonished as they may be, we shall find our patients, 
 for the most part, reckless of advice, and our preachings, like 
 those of the divine or moralist, too often leave only an evanescent 
 impression. The victims of gout are, also, usually the votaries 
 of sensual gratifications. By the ancients, who, under the shadow 
 of an allegory, often conveyed a truth, the disease was held to be 
 the progeny of the divinities of love and debauchery. To such 
 persons as I have alluded to, we shall in vain hold the language 
 of remonstrance, or deliver injunctions to reformation, when 
 opposed by the attractions of the festive board, the seductions 
 of luxurious ease and the other fascinations and enjoyments of 
 sense and appetite. Ease, in such cases, retracts the vows made 
 in pain, and exclaims, with the voluptuous poet of antiquity, 
 " Vitam faciunt balnea vina Venus." To such individuals 
 existence has no other charms. "Dum vivimus, vivamus," is 
 
416 DISEASES OF THE 
 
 their motto, to live while we live in every animal and gross enjoy- 
 ment. Differently and more justly, however, has this most per- 
 nicious maxim, which, in the wantonness of folly has, and con- 
 tinues to produce inconceivable mischief, been rendered by a 
 pious divine : 
 
 "'Live while we live,' the Epicure would say, 
 'And seize the pleasure of the present day;' 
 'Live while we live,' the sacred preacher cries, 
 'And give to God each moment as it flies :' 
 Lord in our views let both united be, 
 We live in pleasure, when we live in thee !" 
 
 It remains only to add, that in gout, the paroxysm may be 
 sometimes warded off, if, on the first signs of its approach, a 
 purge be taken. The same good effect I have also known from 
 repeated doses of alkalies or magnesia, the prepared oyster-shell, 
 or other antacids, and also by the use of colchicum. 
 
 I have already referred to the denunciation of the latter article 
 under any circumstances, and more especially to any thing like 
 an habitual employment of it. But these apprehensions, I must 
 think, are unfounded, and certainly to the extent to which they 
 have been expressed by some of the European writers. Much as 
 I have prescribed it, never have I known any pernicious effects 
 from it, and, I believe, that it may be always so regulated as to 
 prove a perfectly safe remedy. There are, within the compass 
 of my own experience, several individuals who were formerly 
 harassed by floating gout, or frequently repeated regular attacks 
 of it, from which their constitutions suffered materially, that have 
 obviated the paroxysms and greatly improved in health, by a 
 pretty constant resort to this medicine, even for a term of years. 
 It is generally taken in the small dose of ten or twenty drops 
 daily, morning and evening, when any slight indications of gout 
 exist, increasing the quantity considerably on a stronger mani- 
 festation of an attack. 
 
 In recurring to the whole of what has been delivered, it will be 
 perceived that I have suggested little very peculiar in the manage- 
 ment of gout. Too long, indeed, have we been accustomed to 
 view it with a sort of superstitious awe. We have been afraid 
 to touch it. Ever since the time of Sydenham, with some few 
 exceptions, the approach of practitioners to this disease has been 
 singularly marked by timidity, and encumbered with doubt and 
 
MUSCULAR OR FIBROUS SYSTEM. 417 
 
 irresolution. The first step towards a correct investigation of 
 its pathology, and, of course, a more successful practice, is to 
 discard such apprehensions and to contemplate it pretty much 
 as ordinary disease, to be cured, for the most part, by common 
 remedies. 
 
 RHEUMATISMUS, OR RHEUMATISM. 
 
 It was remarked, on a preceding occasion, that the term arthritis 
 embraced, originally, every inflammation of the joints, however 
 differing in their causes or nature. But in the process of time, it 
 came to be restricted to gout, exclusively, and that of rheumatis- 
 mus or rheumatism was invented to designate another affection, 
 having an analogy to, though not believed to be identical with it, 
 which is now presented for consideration. Exactly the same 
 objection applies to this term as to that of gout, each proceeding 
 from a crude and erroneous pathological view. The derivation 
 of the former has been given, and the latter comes from rheuma, 
 a peculiar sort of humour, which, as was thought, being distilled 
 into the joints, irritated them into inflammation. Exposed to the 
 " peltings of the pitiless storm," old Lear, among other infirmities, 
 is made to complain of "joint- racking rheums." The credit of 
 separating the two diseases, as specifically different, has been 
 generally accorded to Sydenham, though without justice. Ex- 
 pressive of a morbid state of action, contradistinguished from that 
 of arthritis, the term rheumatismus first occurs in Ballonius's 
 treatise, " De Rheumatismo, et Pleuridite Dorsali," printed in 
 1642. 
 
 Like gout, this disease exhibits great variety of aspects. The 
 common nosological division of it is into acute and chronic, these 
 being its leading and conspicuous states : and from its appearing, 
 either in the joints or muscles, it has lately been subdivided into 
 articular and muscular. Not embracing, however, the whole of 
 the fibrous tissue, the term articular is defective. The disease, 
 too, attacks the interior as well as the exterior of the body, no 
 one of the contents of the great cavities, indeed, escaping. An 
 adequate exposition of the disease, therefore, requires it to be 
 presented in all these views, and each designated by some appro- 
 priate title. By far a better arrangement than any hitherto sug- 
 
418 DISEASES OF THE 
 
 gested, would be into fibrous and muscular rheumatism, each of 
 which species to be considered in its acute, subacute and chronic 
 states, it being easy to bring under these heads every modifica- 
 tion of the disease. 
 
 Of the varieties of rheumatism, the artieulo-nbrous is the most 
 common, and its principal seats are the large joints, one or more 
 simultaneously affected, the shoulder, elbow, wrist, the knee and 
 ankle, the fingers and toes being rarely implicated, though I have 
 met with such instances. 
 
 By an accurate observer, we are told that, of an hundred and 
 seventy cases of the disease, which he had noticed, only nine 
 were exclusively muscular, and in thirty-three more, the muscles 
 were engaged with the joints.* 
 
 An attack of acute inflammatory rheumatism may come on 
 very suddenly, or more slowly, with a general soreness or rigidity, 
 or directly by a chill, followed by the usual symptoms of fever, a 
 very full, strong, round, or bounding pulse, hot skin, dry fauces, 
 slightly furred tongue, and considerable thirst. The local affec- 
 tion, in some instances, anticipates the fever, and, perhaps, most 
 commonly, such is the course of the disease. It may then be 
 remarked, that the pain is steadily fixed at one point — whereas, 
 when it is preceded by fever, it is fluctuating, attacking at once 
 several joints, or changing very rapidly from place to place. The 
 stomach is little troubled, the bowels are constipated, the urine 
 scanty and very high-coloured, and without any sediment, — 
 which, however, in the progress of the case, deposits lateritious 
 matter, sometimes proving critical and salutary. The tongue 
 ultimately becomes loaded with a thick, brown, tenacious mucus. 
 Generally, with a tense skin, spontaneous clammy perspiration 
 occurs, never from the part affected, however, having a peculiar 
 acid odour, which, copious as it may be, does not mitigate the 
 paroxysm, or in any way conduce to recovery. The fever is 
 remittent. There is, for the most part, considerable alleviation 
 during the day, with an exacerbation in the evening, attended, 
 in some instances, by a vast increase of suffering, and especially 
 if the patient be covered warmly in bed. This, which is the 
 ordinary character of the disease, is sometimes considerably 
 modified. Contracted in a miasmatic region, the influence of 
 
 * Haygarth's Clinical History of Eheumatism. 
 
MUSCULAR OR FIBROUS SYSTEM. 419 
 
 such a position is very discernible. The stomach here is greatly 
 disordered, and copious vomitings of bile are common, the skin 
 and eyes sallow, the tongue early coated with yellowish or 
 brownish fur, the head aches, or is otherwise affected, and the 
 fever is usually of the intermittent type. 
 
 In either case, the articular affection is pretty nearly the same, 
 though perhaps less in the latter variety of the disease. The joint 
 is red, tender and very painful, particularly on motion, and ulti- 
 mately becomes swollen and oedematous, by which very sensible 
 relief is afforded. 
 
 Every other portion of the fibrous membrane, however, may 
 be the seat of an attack, even to the sclerotica of the eye, though 
 it chiefly and most prominently occurs in the periosteum, locally, 
 or more generally diffused. The sensation is that of a dull ache, 
 or an acute, pungent, or darting pain, and, from its depth, is 
 referred to the bone. It very often, too, is to be met with in the 
 pericranium, especially on one side of the head, constituting 
 hemicrania, and occasionally in the neurilema or fibrous integu- 
 ment of the large nerves — the sciatic mostly, where it is recog- 
 nized by singularly sharp pain, pursuing the course of the nerve. 
 
 Much of the preceding account is equally applicable to myo- 
 sitis or muscular rheumatism. It is, however, more apt to come 
 on suddenly, or without any very significant premonition. Lum- 
 bago, especially, I have known to strike, as it were, like an 
 electric shock. Three very remarkable cases of the kind were 
 witnessed by me — the first, in drawing on a boot — the second, 
 from an attempt to mount a horse — the third, from stepping into 
 a carriage, — each individual supposing, at the moment, that his 
 back had been broken by a blow from behind. 
 
 Muscular rheumatism is mostly distinguished by a burning 
 sensation, often severely painful, greatly exasperated by the 
 action of the muscle, with sometimes redness of the integu- 
 ments. The muscles, in any part of the body, may be the seat 
 of it, though those of the back of the neck, of the sides of the 
 thorax, particularly the intercostals. — of the lumbar region and 
 hip, are mostly liable to it, to which are applied respectively the 
 terms, torticollis, pleurodynia, lumbago and sciatica. 
 
 This form of the disease is singularly prone to metastases, 
 either to other muscles, or the joints. But, instead of being con- 
 fined to one or more muscles, it, on some occasions, displays itself 
 
420 DISEASES OF THE 
 
 over a wide surface, seemingly not much deeper than the skin 
 itself, causing a painful degree of heat and soreness. From the 
 supposition of its neuralgic character, the term dermalgia, skin 
 ache, has "been applied to it. But though this may be, in some 
 instances, a correct view of its pathology, I am persuaded it is 
 oftener of a genuine rheumatic nature. Caused in the same 
 manner, I have seen it to alternate with the other forms of the 
 disease. There is, indeed, an eminent personage now living in 
 this city, who was for many years scarcely ever exposed to cold, 
 without incurring an attack of it, marked by the fluctuations 
 mentioned. 
 
 Another modification of muscular rheumatism claims here to 
 "be noticed, though hitherto differently assorted. My allusion is 
 to those cases which so closely resemble tetanus, as to be deemed 
 one of the varieties of that disease. The analogy, in some in- 
 stances, is nearly complete. Commencing very much in the same 
 way, we have ultimately violent spasms of the muscles, together 
 with most of the other symptoms of that affection. But, though 
 sometimes, this similitude is not uniformly presented. More com- 
 monly, perhaps, there is a partial or general rigidity of the exter- 
 nal muscles, attended by a cold, collapsed, insensible surface, 
 exceedingly feeble pulse, haggard countenance, and obtuseness 
 of the senses and intellectual faculties. The condition, in a word, 
 is that of torpor, as well of the body as of the mind. But, on 
 reaction taking place, the sensations are very exquisite, and, with 
 universal soreness of the muscles, tremendous spasms occasion- 
 ally ensue. 
 
 Though these several forms of rheumatism, with the exception 
 of the tetanoid, are generally febrile, there are occasionally acute 
 attacks of the disease, attended by much pain, where vascular 
 excitement, is scarcely discernible. These are merely local affec- 
 tions in which, the general sympathies being quiescent, of course 
 no constitutional disturbance arises. The reverse, however, hap- 
 pens — or the highest and most ardent fever prevails, independ- 
 ently of any outward or ostensible local affection — or, at all 
 events, it is so trivial as not to account for such violent and ex- 
 tensive effects — and this is what is called rheumatic fever. 
 
 It has been usual to consider rheumatism as exclusively a 
 centrifugal disease. True, in the main, it does not universally 
 hold. The viscera, and every other structure, are, occasionally, 
 
MUSCULAR OR FIBROUS SYSTEM. 421 
 
 liable to such attacks. I have witnessed them in the dura mater. 
 
 in the diaphragm, in the stomach and bowels, in the kidneys, in 
 the uterus, and we have abundant proofs of its assailing the very 
 fountain of the circulation. The heart is singularly liable to its 
 aggressions, of which I have seen many instances, and still more 
 are recorded. Bouillaud has, indeed, endeavoured to show a 
 pretty constant coincidence between the articular and the cardiac 
 affection, in its several diversities, of the recognition of which he 
 arrogates the merit to himself. Except, however, as to the extent, 
 which, I suspect, is exaggerated, he has no just claim. The fact 
 had been long determined, and taught by me, ever since my oc- 
 cupation of this chair, especially in tracing the etiology of the 
 diseases of the heart, where it is assigned as a leading or princi- 
 pal cause. 
 
 Located in any of the internal parts, which it may be primarily, 
 though much more commonly, by translation from the exterior, 
 rheumatism bears so close an affinity to misplaced or retrocedent 
 gout, that it will be enough to refer to what was said on this 
 subject. The metastasis is as sudden as in its kindred affection. 
 On one occasion, I saw the translation in a moment, and without 
 any premonition whatever. 
 
 No age, sex or condition, is entirely exempt from rheumatism. 
 But it is mostly to be met with, in the acute form, about the 
 meridian of life, rather in males than females, and especially 
 among the labouring classes, from, perhaps, their greater exposure 
 to its causes — and in the lean or muscular, with a sanguineous 
 temperament, than in the corpulent, nervous or phlegmatic. 
 Even very young children are liable to the disease. Examples 
 of it I have seen so early as within the first year of life, usually 
 in the muscles of the nape of the neck. It seldom occurs in aged 
 persons, these being more subject to the chronic states of it. 
 
 As an inheritance, a predisposition to it would seem sometimes 
 to be received. Evidence is, indeed, given of its having been 
 transmitted through successive generations, with great obscurity 
 as to the temperament or condition by which its propagation is 
 promoted. But a strong tendency to it may also exist, — the dis- 
 ease pervading whole families, where the occasion of it is not 
 assignable to this, nor any obvious constitutional peculiarities 
 As much as to any thing else, perhaps, is a susceptibility to it 
 created by an abuse of mercury, and which is long retained by a 
 36 
 
422 DISEASES OF THE 
 
 system once deeply affected by that article. Nor is it less deter- 
 mined that a previous attack of the disease has a similar effect. 
 
 More immediately, however, does it depend on the sensible 
 qualities of the atmosphere, and hence it is chiefly prevalent in 
 damp, sour, inhospitable or variable climates, and everywhere in 
 the spring and fall, owing to greater and more sudden fluctua- 
 tions of weather. But, at all times, by an exposure to cold, and 
 particularly with moisture, or sleeping in a damp room, or damp 
 sheets, or wearing damp clothes, or being thinly clad, or sitting 
 in a draft of air, or entering ice-houses or damp cellars, or other 
 such places, an attack may be induced, and some of the worst 
 cases I have ever encountered were thus brought on in the 
 midst of summer. Cold, operating on a previously heated sys- 
 tem, is, indeed, so influential in the production of the disease, that 
 the tetanoid variety of it, at least, is almost endemial in the torrid 
 or intertropical climates. The writers of the West and East 
 Indies speak emphatically of its prevalence, caused chiefly by 
 sleeping, subjected to the dews and cool air of the night of those 
 regions. Girdlestone mentions the remarkable fact of several 
 hundred soldiers of a regiment being seized in this way, by 
 lying in the open air, after a long and fatiguing day's march 
 in some portion of India. Examples of the kind I have met 
 -with, chiefly among our vagabond paupers picked up at night 
 in the streets or other exposed places, and brought into our 
 former Almshouse. 
 
 With an unusual proclivity to rheumatism, an attack of it is 
 readily excited by very slight causes, as a strain or other injury 
 to a joint or muscle, or by indulging freely in high-seasoned 
 food, or stimulating drinks, or by almost any indiscretion — and 
 in all instances, the liability to relapses is lively and enduring. 
 
 By Swediaur, Brodie and other writers, rheumatism has been 
 traced to a suppression of the gonorrheal discharge, or, at least, 
 a connection is attempted to be made between the two affections, 
 the one arising as the other declines. That inflammation of a 
 joint has taken place under such circumstances I am not pre- 
 pared to deny. But its origination in gonorrhoea, or its identity 
 with rheumatism remains to be proved, and, at all events, on so 
 imperfect a foundation I am not disposed to erect a new species 
 of the disease. 
 
 Much as rheumatism sometimes resembles gout, the prominent 
 
MUSCULAR OR FIBROUS SYSTEM. 423 
 
 distinctions already given, with a careful comparison of the 
 whole history of the two diseases, can scarcely ever fail to lead 
 to a just diagnosis. 
 
 The leading divisions of the disease itself, the fibrous and 
 muscular, are too clearly designated to be well confounded. It 
 requires sometimes, however, no little attention to be enabled to 
 discriminate, with precision, the modifications of rheumatism 
 occasioned by its several locations. I have merely to state, that 
 a joint being affected, we shall find some marked difference in 
 the symptoms, as the tendons, ligaments and fasciae, or the syno- 
 vial capsule and bursae may be concerned. The pain, in the 
 former, is acute and lancinating, the swelling slowly arises, and 
 never attains to any height — is florid and exquisitely tender, 
 comparatively seldom involving the surrounding textures. It is 
 very much the reverse in the latter, or the pain is dull and 
 steady, the intumescence quickly takes place, and is circum- 
 scribed and elastic, or pulpy, or oedematous from effusion into 
 the adjacent cellular membrane, to which may be added, that 
 the general constitutional disturbance is far greater in the first 
 than second instance, in proportion to the degree of the local 
 affection. In relation to the other cases there is less difficulty, 
 and they are, perhaps, sufficiently cognizable from what was 
 said in the antecedent sketch of them, and I shall, therefore, 
 decline a further prosecution of the inquiry into their peculiarities. 
 
 Certain spinal and neuralgic affections have also a resemblance 
 to some of the rheumatic modifications, and especially to lum- 
 bago and sciatica. Not now to go into any details, I have to 
 observe, that whenever the latter exist, the pain is referable to the 
 muscles and restricted to them, is relieved by rest, and becomes 
 agonizing on the least motion. In the other lesions without 
 these characteristics, the source of the irritation is to be traced 
 to a point in the vertebral column, betrayed by tenderness on 
 pressure, from which emanate acute darting sensations, pursuing 
 the course of a nerve or nerves. Much may also be learned by 
 an inquiry into the causes and mode of production of these dif- 
 ferent affections. 
 
 Managed properly, acute rheumatism, excepting the tetanoid 
 variety, can nearly always be cured, and never proves imme- 
 diately dangerous, unless it be in some important or vital organ. 
 Neglected, however, or feebly treated, and especially whore the 
 
424 DISEASES OF THE 
 
 local inflammation is violent and continues long, it so deranges 
 the structure of the parts as to irritate the system into hectic 
 fever, followed by its wasting and debilitating consequences. 
 Death in this way often happens. But, though such may be one 
 of its ordinary terminations, it is deserving of remark, that cases 
 in which there is slight, or perhaps, no appreciable affection of 
 the joints, called rheumatic fever, are usually very refractory, 
 and certainly still oftener prove fatal. No explanation of this 
 curious fact, so far as I am aware, has heretofore been offered. 
 Writers, in noticing it, pass it over without any attempt of the 
 kind. It has for some time occurred to me, that the violence and 
 intractability of such attacks were owing to some internal lesion 
 or lesions of a rheumatic nature, maintaining this indomitable 
 fever, which is to be deemed merely an effect. Not having had 
 any opportunities of autopsic inspections, I am unable to verify 
 the conjecture by this test. But the tendency of the disease to a 
 centripetal direction is well known. Bouillaud, as we have seen, 
 pretends to have demonstrated, in a very large proportion of 
 instances, the connection of the acute cardiac phlegmasia with 
 articular rheumatism. Even admitting such a co-existence, 
 which, for reasons previously stated, I cannot, to the extent 
 claimed, it would be unsatisfactory in application to the present 
 instance. There is here scarcely ever any sensible affection of 
 the joints, and those of the heart of an acute phlogistic nature, are 
 at ail times so conspicuously displayed that if any really existed, 
 it is presumable they could not be overlooked. Between the 
 two cases, there is, among other differences, this striking one, 
 that in rheumatic fever the pulse is singularly full, strong, volu- 
 minous, bounding, — with high general excitement, and directly 
 the reverse as to cardiac inflammation, either of the substance 
 or membranes of the organ, it being feeble, — the cutaneous sur- 
 face cold, attended by a disposition to syncope. The hypothesis 
 which refers it to arteritis is equally objectionable, as that affec- 
 tion is characterized no less differently. To assign it to some 
 vicious change in the blood, as has also been done, is to pre- 
 suppose some antecedent morbid condition of the solids, which 
 is really begging the question in discussion, and at the same time 
 abandoning the rheumatic nature of the case. Let us rather 
 than adopt such surmises, confess our ignorance, and endeavour 
 after truth by more accurate researches. 
 
MUSCULAR OR FIBROUS SYSTEM. 425 
 
 Rheumatism, however, is, under all circumstances, exceedingly 
 apt, on being confirmed, to run a tedious course of several weeks, 
 and, when life is preserved, then gradually to slide into chronic 
 degenerations, and especially the articular form of it. 
 
 The indications of convalescence are the subsidence of the 
 local pain and inflammation, with abatement or total cessation 
 of fever, a moist, soft, perspirable skin, open bowels, and copious 
 discharges of urine, depositing a pink or lateritious sediment. 
 Much the contrary are the adverse signs, and particularly a con- 
 tinuance of the local affection with indomitable fever, marked 
 in its progress by cerebral and nervous disturbance. Complica- 
 tions of any kind, indeed, are of evil import, and, above all, those 
 of the heart increase the difficulty of cure, and greatly enhance 
 the danger of the ultimate result. 
 
 The phenomena on dissection, in acute rheumatism, are not 
 well understood, — death, as just said, seldom happening to afford 
 the means of inspection. Yet we are not destitute of intelligence 
 on the subject. Examinations have shown that in the articular 
 form, the structure of the joint is uniformly affected in some 
 degree. The synovial membrane, especially, undergoes consi- 
 derable changes, being found injected, red and swollen, with 
 serous or sero-lymphatic, or sero-puruloid, or sanious effusions. 
 Between the theca of the tendons, or rather within the surround- 
 ing cellular membrane, we meet with pretty nearly the same 
 appearances. Extravasations of a peculiar gelatinous fluid are, 
 however, more common events. The latter is the proper pro- 
 duct of fibrous inflammation, which, at least, never ends in sup- 
 puration or gangrene, — and when other results take place in 
 articular rheumatism, they are to be referred to the textures 
 mentioned. 
 
 In the muscular species, scarcely any appreciable alteration is 
 usually discernible. But in very violent attacks, the affected 
 muscle exhibits a reddish-brown colour, and is so softened as 
 readily to be torn, the interstitial membrane containing bloody 
 serum or pus, and sometimes even an abscess. 
 
 Those of the heart excepted, which have been accurately 
 determined, the appearance in the other internal organs I do 
 not know, though it is presumable they are like the lesions of the 
 external structures. The heart itself sometimes exhibits the 
 characteristics of spasm only, where death suddenly happens. 
 
 36* 
 
426 DISEASES OF THE 
 
 But in more lingering cases, we are presented with all the phe- 
 nomena of active phlogosis in its substance, its fibro-serons en- 
 velope, and in the lining of its cavity, the one or the whole 
 being implicated. The great arteries, the aorta especially, have 
 been discovered in similar conditions. 
 
 In many of its features it is so analogous to that of gout, the 
 pathology of rheumatism need not detain us long. Consisting in 
 inflammation of the fibrous or muscular tissue, to this most of its 
 peculiarities may be assigned. That such is true, seems to be 
 proved by the fact, that the disease originating in, or being trans- 
 lated to other parts, these are lost. Thus we see, when seizing 
 on the mucous surface of the bowels or lungs, how strikingly is 
 the difference. The eye affords a further conspicuous illustra- 
 tion to the same purport. Composed of diverse tissues, each 
 phlogosed has its own characteristics, the sclerotica alone, which 
 is fibrous, presenting those of a rheumatic affection. 
 
 Located precisely as gout, there is, however, as I have indi- 
 cated, considerable dissimilarity in the nature of the two diseases, 
 which, I repeat, is partly to be ascribed to a want of identity in 
 the causes whence they proceed, the variations of morbid action 
 being as much influenced by this circumstance as by the position 
 it may occupy. Nor must we fail to advert to an additional con- 
 sideration, which, perhaps, still more determines the discrepancies 
 in these allied affections. Gout has its own distinctive diathesis, 
 and whatever operates on it necessarily gives rise to phenomena 
 sui generis, or changes the affinity to any other condition. 
 
 But other views have been and are entertained of the patho- 
 logy of rheumatism. The idle notions of antiquity regarding it 
 may be pretermitted, and, indeed, the only one I deem worthy 
 of attention, is that recently promulgated, which supposes rheu- 
 matism to be a neuralgic affection, proceeding mainly from 
 spinal irritation. Embarrassed by the peculiarity of the rheu- 
 matic state, having then no precise knowledge of the influence 
 of causes or textures in this respect, pathologists, as long ago as 
 the period when it was so much the habit to seek shelter for 
 ignorance under the term nervous, had refuge in this resource. 
 But of late the hypothesis has been presented in a more defini- 
 tive and attractive shape. Having, in the consideration of neu- 
 ralgia, pointed out the difference between it and rheumatism, I 
 shall not now pass over the same ground of discussion. That 
 
MUSCULAR OR FIBROUS SYSTEM. 427 
 
 neuritis or neuralgia of the great nerves, and especially the sciatic, 
 has been too frequently mistaken for rheumatism of the adjacent 
 muscles, or certain spinal irritations, confounded with lumbago, 
 affections of those of the small of the back, I am not now to be 
 told. But further than this, I cannot admit, and must here recur 
 to a remark formerly made, that no reason can be shown why 
 the fibrous and muscular tissues may not be primarily affected as 
 well as any other of those of the body. Finally, I must protest 
 against the recent and, perhaps, growing notion of the very 
 common coincidence of articular and cardiac rheumatism. Much 
 could be urged in a formal dissent to it. Compressed, however, 
 in a word, my objections to it are,— that it seems scarcely possible 
 that a phenomenon, so constant and prominent as is alleged, 
 could have escaped the close observers of disease for thousands 
 of years, — that though it has commanded my attention, I have 
 seen comparatively little towards its verification, — that did it 
 exist, rheumatism would be a far more fatal affection than war- 
 ranted by fact, — and that it is supported by no adequate authority. 
 Whence originated the dogma, and by whom is it vindicated? 
 From Bouillaud it comes, one of those individuals who seem to 
 me to be always actuated more by the vain desire of acquiring 
 notoriety than establishing philosophic truth. Confident and 
 intrepid as he is in the assertion of his views, they are hardly 
 enunciated before abandoned by himself, and replaced by others 
 often directly the contrary; he ought not to complain if we with- 
 hold from his statements our prompt or entire acquiescence. Ex- 
 actly do I agree with Chomel, that the instances of rheumatism 
 under these circumstances are rare, and exceptional only to a 
 very general rule. 
 
 The treatment of few diseases of so obvious a character is 
 less determined than that of rheumatism. Diametrically oppo- 
 site plans, and the most irreconcilable special remedies, have, and 
 continue to be employed. Especially is this want of uniformity 
 to be remarked among the British writers, many of whom be- 
 lieve that we have little or no control over it, — the cures which 
 happen being the result of the efforts of nature. An eminent 
 practitioner of London having been asked, " what is the best 
 remedy for acute rheumatism," replied, " six weeks," by which 
 he meant to convey the impression of his distrust of all artificial 
 means, and that it might spontaneously subside in that period, 
 
428 DISEASES OF THE 
 
 whatever was done or left undone. Epigrammatic as this answer 
 may be, it is like most pointed sayings, not true. For the most 
 part, the disease proves very manageable when properly attend- 
 ed to in the early stage. 
 
 Differing, however, from me, Mr. Budd, a very recent and 
 authoritative writer, and in which opinion he is supported by 
 many of his cotemporaries, pronounces " that no single remedy is 
 yet known, nor any plan of treatment, which has the power of 
 cutting short the course of acute rheumatism." 
 
 Much of what I should have had to say of the cure of the 
 disease has been anticipated in that of gout. The treatment 
 of it in our own climate, at least, it will be right to commence 
 with copious venesection, which is pointedly called for by the 
 symptoms and by the appearance of the blood, this being, per- 
 haps, more inflammatory than in any other affection. No sub- 
 stitute exists for the lancet in this case. The other remedies will 
 be unproductive of utility, and never should be prescribed, till 
 the intensity of action is overcome by direct depletion. It is my 
 wish to press this precept strongly, since, in most of the writers, 
 bleeding is cautiously advised, and by some altogether interdicted, 
 as nugatory in relation to the cure, calculated to lead to sudden 
 translations of the disease to vital parts, or to run it into the chronic 
 state. These are the objections of theory or ignorance, and must 
 not be listened to, for an instant. Bleeding here, when ade- 
 quately urged, is nearly as effectual in arresting the attack as in 
 the other phlegmasia?, and, instead of promoting, has a contrary 
 effect as to the alleged metastasis. The instances of the kind, 
 amounting to several, which have come under my notice, oc- 
 curred where no blood had been lost. It is an error to suppose 
 that disease is invited to a part by the weakness of it, which seems 
 to be the foundation of the dread of the remedy. The reverse 
 is true, or it is attracted by a pre-existing phlogistic irritation, 
 endowing it with an increased susceptibility, by the removal of 
 which, and bleeding is the best means of doing it, the chance of 
 its happening is diminished. By this mode, a sprain or other 
 injury attracts it, and do we not find the same effect from irritat- 
 ing revulsives, as rubefacients, sinapisms, or blisters, exemplified, 
 especially, in the operation of these applications in retrocedent or 
 misplaced gout? Not less absurd is the supposition that bleeding 
 promotes the transmutation of the disease into the chronic state. 
 
MUSCULAR OR FIBROUS SYSTEM. 429 
 
 It is a rule, to which rheumatism forms no exception, that, pro- 
 portioned to the rapidity with which acute inflammations are 
 reduced, and to this end, surely, the loss of blood is most efficient, 
 is the security against such a result. Nor is any thing more cer- 
 tain to my mind than that the tendency in the disease, which has 
 also been complained of by some, to cerebral disturbance and 
 petechial eruptions, must be ascribed to the premature substitu- 
 tion of a stimulating and tonic, for the antiphlogistic course, and, 
 especially, venesection. 
 
 But very differently is the process appreciated by the writers 
 of nearly every country of Europe. 
 
 To so great an extent has this prejudice against bleeding been 
 carried, by some of the British practitioners especially, that even 
 the Peruvian bark was substituted in its place ! During my 
 attendance in the London hospitals, the use of it was generally 
 adopted, and, undoubtedly, it has received the sanction of several 
 of the highest English authorities, for more than a century. By 
 Morton, the cotemporary of Sydenham, it was probably intro- 
 duced, and claims, subsequently, the distinguished support of 
 Heberden, Fothergill, Saunders, Baker, Fordyce, Haygarth, &c. 
 It is really extraordinary to see the confidence with which the 
 bark is spoken of by Haygarth, who, on the most ample experi- 
 ence with it, says : " Except mercury, in syphilis, there are few, 
 and, perhaps, no examples, where a remedy produces such speedy 
 relief and perfect recovery, in so formidable a disease. For 
 many years, I have been thoroughly convinced that the Peru- 
 vian bark has a much more powerful effect in the rheumatic than 
 in any other fever, and that it does not cure even an ague so cer- 
 tainly or so quickly." 
 
 Nor have the European practitioners become emancipated 
 entirely from the thraldom of this error, even at the present 
 moment. Elliotson and Johnson, Davis and Watson, who are 
 among the most conspicuous of the English, at least, seem to 
 labour under it, and we are told that it almost universally con- 
 tinues with those of France. 
 
 That there is a very egregious fallacy in these statements is 
 obvious. Never did I perceive the least advantage, in any one 
 case of the early stage of the disease, from the practice, and often 
 the most manifest mischief, in which sentiment I am fully sup- 
 ported by the best authorities of our country. Yet, 1 shall pre- 
 
430 DISEASES OF THE 
 
 sently show that, properly applied, the bark is valuable in this 
 disease. 
 
 N01 is it to be supposed, from what I have said, that all the 
 British writers concur in the proscription of bleeding in rheuma- 
 tism. This is very far from the fact, since, among others, it is 
 strenuously recommended by Sydenham, Pringle, Cullen, Scuda- 
 more, &c. 
 
 It is very amusing to us, who have been so long and so 
 thoroughly conversant with this practice, to listen to the igno- 
 rance or presumption of a late French writer, in preferring his 
 pretensions to it as a discovery of his own. Bouiliaud, whom I 
 have previously cited, in a late publication, after harshly censur- 
 ing Louis, Chomel. and others of his cotemporaries, who, he 
 says, pursue an opposite method, proclaims, in a burst of enthusi- 
 asm, the utility of blood-letting in the disease, as a revelation, for 
 the first time, made to himself alone ! 
 
 Next, the bowels ought to be freely evacuated, by a large dose 
 of calomel, worked off by some quicker medicine, and the saline 
 articles are mostly preferred for the purpose. The combination 
 of calcined magnesia, Epsom salts, and the tincture of colchicum, 
 noticed formerly, is, according to my own experience, peculiarly 
 well suited. It empties the bowels adequately, and controls 
 more effectually the rheumatic action. Yet purging by any 
 article is here less serviceable than in the kindred arthritic affec- 
 tion, probably from rheumatism, not, like gout, primarily origi- 
 nating in a depravation of the alimentary canal. My remarks 
 have reference to ordinary rheumatism. The case being modified 
 by miasmatic influence, then purging, and especially by calomel, 
 proves exceedingly efficacious, and under all circumstances does 
 good, on the principle of reducing vascular action and febrile 
 excitement, as well as by preparing the way for the efficient 
 operation of other remedies. 
 
 Emetics have also been directed in rheumatism. Excepting 
 in the form of the disease just indicated, I have no knowledge 
 of them, and must, therefore, advance an opinion diffidently, in 
 relation to their powers. The stomach is here much oppressed 
 and nauseated, and they prove serviceable in a mode which I 
 need not explain. 
 
 As somewhat confirmatory of their efficacy, the fact may be 
 stated, that in this variety of the disease, whenever spontaneous 
 
MUSCULAR OR FIBROUS SYSTEM. 431 
 
 vomiting takes place, there is, for a time, a very marked mitiga- 
 tion of both the general and local affections. 
 
 Evacuations having been thus premised, the treatment, what- 
 ever may be the precise character of the case, is resolved into 
 the use of the febrifuges. Combined in small portions with the 
 nitrate of potash, and sometimes calomel, the tartarized antimony 
 is greatly prescribed. By this preparation, vascular action is 
 further subdued, or kept under, and, what is equally important, 
 the skin may be restored to a more healthy condition. 
 
 It is at this conjunction, or even at an earlier period, that the 
 contra-stimulant plan of the Italian school, consisting of immense 
 doses of emetic tartar, is proposed. What was said of it in rela- 
 tion to pneumonic inflammation is equally pertinent to the pre- 
 sent disease, and I must be content to refer to the criticism on the 
 practice delivered on that occasion. 
 
 Febrile excitement becoming further reduced, a recurrence is 
 usually had to the more direct means of sweating. This is a 
 mode of combating rheumatism, which has long been consecrated 
 to the purpose by the undivided opinions of every description 
 of practitioners, and is too often abused. It is well ascertained 
 that sweating is always pernicious, if practised in the early or 
 phlogistic stage. Even when it comes on spontaneously, it never, 
 as previously stated, affords any relief, and usually aggravates 
 the distress. We commence with the milder diaphoretics, and 
 afterwards employ articles rather more stimulating, of which 
 the most efficacious is the Dover's powder. But it is a popular 
 practice of our country, not without some professional sanction, 
 to treat this state of rheumatism with the Virginia snakeroot, the 
 thorough wort, and, above all, by the pleurisy -root. Each of these 
 articles being very certainly diaphoretic, I have no doubt, when 
 judiciously directed, of their utility. 
 
 To the prohibition of early and active sweating, an exception 
 exists in the torpid or tetanoid variety of the disease. The indi- 
 cation here, at first, is to awaken sensibility, and to bring on a 
 reaction, with which intentions I have found the vapour bath 
 and frictions, aided by the Dover's powder, perse veringly con- 
 tinued, the most effectual. Development of action having taken 
 place, venesection and its auxiliaries may be resorted to with 
 those other means appropriated to the more ordinary forms of 
 the disease in the several stages. 
 
432 DISEASES OF THE 
 
 As in gout, diuretics sometimes prove of immense advantage 
 in rheumatism. Nearly the same articles, as well as the rule for 
 their employment, are suited to both cases. 
 
 Colchicum, in union with the spirits of nitre, is especially wor- 
 thy of trial. Its properties are very peculiar, and it seems, on 
 some occasions, to display a sort of specific agency. But the 
 pipsissewa, the pyrola umbellata of the botanists, has acquired 
 so much repute, as to have had bestowed on it the popular title 
 of rheumatism iveed, and may hence have claims to attention. 
 
 An old practice, with which I was perfectly familiar, of treat- 
 ing this case by the liberal use of the nitrate of potash, an ounce 
 or more, daily, in the freest dilution, has been lately revived by 
 Gendrin, Aran, and other Parisian physicians, and, as usual, with 
 claims to originality, to which they have not the slightest preten- 
 sions. Brocklesby proclaimed its utility in his work, entitled 
 Economical and Medical Observations, printed in 1764 ; not long 
 afterwards it appeared in Macbride's Practice of Physic, and 
 came to be well known among us. Few stomachs will bear the 
 article to such an amount, and, on this account, I presume, it fell 
 into abeyance. More moderately given, it often proves very use- 
 ful, and is one of the most common of our prescriptions. Of the 
 hydriodate of potash, which, of late, has acquired no inconsidera- 
 ble celebrity, I have now only to say, that I believe it is finally 
 admitted to be only adapted to certain states of chronic rheuma- 
 tism, where I shall again speak of it. 
 
 These various remedies failing, and where, especially, evidence 
 arises of a disposition in the case to glide into the chronic state, 
 we should not hesitate to interpose mercury, with a view to a 
 moderate impression, which usually proves a very decisive pro- 
 cess. Having presently occasion to say more of it, I shall now 
 only further remark, that, under the circumstances immediately 
 before us, it will be found often expedient and, particularly if 
 much pain exists, to unite opium, and sometimes ipecacuanha, 
 to the calomel. 
 
 Essentially is this the practice at present so urged by some of 
 the English writers, and the merit of introducing which is 
 assigned to the late Dr. Hope, the author of the work on the dis- 
 eases of the heart. The only difference, indeed, consists in the 
 latter, after one or two bleedings in robust patients, directing ten 
 grains of calomel with a grain and a half of opium every night, 
 
MUSCULAR OR FIBROUS SYSTEM. 433 
 
 and a purge in the morning, so as to procure several openings, — 
 then a saline draught with twenty drops of the tincture of colchi- 
 cum, and five grains of Dover's powder thrice a day, — steadily 
 pursuing this course throughout the case. Certainly there is 
 nothing new in this plan, it being merely a modification of other 
 modes long since employed, and I cannot doubt its inferiority to 
 the one suggested by me. 
 
 In attending to these general indications, the local affection is 
 not to be overlooked. The pain of it, when violent, can hardly 
 be borne, and has, certainly, the effect of keeping up fever. On 
 every account, therefore, we should endeavour to do it away. — 
 But, as in gout, some difference of opinion prevails as to the pro- 
 per measures to be adopted. Cold applications, even snow or 
 ice, have been lately employed. I cannot, however, be persuaded 
 of their general propriety. Granting, for a moment, the utility of 
 them, I should much apprehend a metastasis. Yet I am in pos- 
 session of some evidence in support of this practice, of too much 
 importance to be withheld. By Professor Jackson, of Boston, I 
 have understood, it is constantly pursued, and not less by the 
 physicians of Russia and Spain, and, as is represented, with un- 
 equivocal advantage. Yet I repeat, that my own experience, 
 confirmed by the tenour of medical authority, is against it. 
 
 No great relief is, however, afforded by opposite means or 
 warm fomentations, though I cannot allow that they are utterly 
 destitute of effect. The other expedients enumerated under the 
 head of gout, I will not now repeat. 
 
 The practice of Mr. Balfour has attracted no inconsiderable 
 attention. It consists in bandaging, as tightly as can be endured, 
 the affected part by a flannel roller, with the occasional use of 
 frictions. Whatever may be its utility, in some other applications, 
 of which I am hereafter to speak, I cannot, consider it adapted 
 to an inflamed and sensible condition of the local affection. 
 
 Discarding most of the preceding measures as nugatory, or of 
 inferior efficacy, our main reliance is to be placed on topical bleed- 
 ing by leeches or cups, frequently renewed, — and next on repeated 
 blisters. Governed by those theoretical notions, to which refer- 
 ence was formerly made, these appliances are now directed by 
 some practitioners to the spine. That, on certain occasions, they 
 have thus answered better, I am unwilling to deny, though, at 
 the same time, I must insist, that, where more successful, the 
 37 
 
434 DISEASES OF THE 
 
 cases were not genuine rheumatism. By revulsion, such appli- 
 cations to a distant point may be doubtless serviceable. Yet it is 
 equally true, that they oftener fail, and are generally less effectual 
 than when practised near the affected part. 
 
 In regard to the use of opium, we are governed, very much, 
 as in gout. It seldom fails, according to my experience, to exas- 
 perate acute unsubdued rheumatism. Eveninthe form of Dover's 
 powder, and where it produces perspiration, too, it mostly, with- 
 out abating pain, adds to the heat and restlessness. This fact is 
 particularly entitled to attention, as patients, in extreme anguish, 
 very often demand, in a clamorous manner, a dose of the medicine. 
 
 Different, however, are the notions of some in this respect. 
 Corrigan, of Dublin, especially, whose reputation is distinguished, 
 seems to treat the disease almost exclusively by opium, and, as 
 he declares, with very great success. The ordinary doses of the 
 article, he deems prejudicial, by exasperation of the excitement, 
 and gives two grains of it every three hours, so that the aggre- 
 gate has amounted to sixteen grains in some instances, during a 
 day and night. The sedative effect being thus procured, we are 
 assured by him that the pain is relieved, and complete cures 
 speedily follow. Contradictory as this representation is, to my 
 own experience, I will not discourage a fairer and more extensive 
 trial of the plan than I have made. 
 
 Nor must I deny, though still persuaded that the use of opium 
 generally should be regulated as I have enjoined, that there are 
 cases in which it may be resorted to at a much earlier period 
 than pointed out by me. 
 
 The form of the disease, to which I refer, sometimes succeeds 
 genuine rheumatism, after a few days' continuance. It is, how- 
 ever, more commonly met with as an original state in women, or 
 other persons of weak and irritable habits. There is, here, no 
 force of vascular action, and incomparably more of irritation 
 than inflammation. Either alone, or in conjunction with calomel 
 and ipecacuanha, as has before been mentioned, opium is une- 
 quivocally serviceable. 
 
 Located in the more diffused portions of the fibrous tissue, and, 
 especially, the periosteum, essentially the same course is to be 
 pursued in the disease. What I shall say of the affection of the 
 pericranium, to which my remarks will be confined, may suffice 
 as a general direction. The remedies, here, are steaming, leech- 
 ing, blistering the nape of the neck, and keeping the head warm 
 
MUSCULAR OR FIBROUS SYSTEM. 435 
 
 by an envelope of cotton, or wool, or a flannel or fur cap. Com- 
 bined with these topical means, evacuants of the bowels are ser- 
 viceable; nauseants are likewise so, and vomiting will promptly 
 relieve it, on some occasions. As further means, opiate diapho- 
 retics are deserving of confidence. Many persons, with thin hair, 
 or entirely bald, are very susceptible to such attacks, on the 
 slightest exposure. Wearing a wig by day, and a warm cap at 
 night, I have hardly ever known to fail as preventives. 
 
 We come now more immediately to the muscular form of rheu- 
 matism, or myositis. Being of a febrile or inflammatory charac- 
 ter, the depletory, evacuant, and other general remedies already 
 recited, are here also demanded. As, however, the management 
 of the disease, in its several positions, is somewhat modified, the 
 peculiarities, in this respect, should be indicated, and I shall com- 
 mence with the most simple. 
 
 Confined to the mere superfices of the body, productive of 
 soreness only, the remedies are the warm or vapour bath — fric- 
 tions, with oil and laudanum, and the mild diaphoretics. But 
 when deeper seated in the muscular tissues, a more energetic 
 course is to be pursued. INotthe least distressing of such attacks 
 are those of the muscles of the neck, causing rigidity with acute 
 pain, and by neglect, sometimes ending in permanent deformity. 
 Little else, at first, is usually required than ironing the part 
 repeatedly, and covering it with a pad of cotton or wool. But 
 these means not answering, a resort must be had to steaming it, 
 and ultimately, to leeches and a blister. 
 
 Nearly the same plan may be adopted in regard to pleurodyne — 
 though early applied, a sinapism will generally succeed alone. The 
 muscles of the loins or those about the hip being implicated, from 
 their magnitude, the case presents, in some respects, a more 
 serious character. Connected with extreme agony, on an attempt 
 to rise from a seat, or to turn in bed, there may be a total inability 
 to do either, and I have seen from it even paralysis of the lower 
 extremities to be induced. 
 
 The milder states of the affection are relievable by ironing the 
 surface frequently, or by frictions with Cayenne pepper and 
 brandy, or the essence of mustard, or any other irritating Liniment, 
 or by a sinapism or by pouring a stream of water, as hot as can be 
 borne, on the part, or even by a thick pad of cotton or wool to it. 
 
 It is an interesting fact, that an impression made on the feet by 
 a stimulating pediluvium, or by placing them to the fire, or on hot 
 
436 DISEASES OF THE 
 
 bricks, or any similar article, or by a mustard plaster, will some- 
 times prove more effectual than by a direct application to the seat 
 of the affection. Not availing, these means should be succeeded by 
 a copious loss of blood, especially by cups or leeches to the back, 
 and then vesication. It is very inconvenient to purge, though 
 when it can be done without great suffering, it ought not to be 
 omitted. An anodyne diaphoretic, after free depletion, is de- 
 cidedly useful. 
 
 We are aware that rheumatism occasionally takes an inward 
 direction, assailing some one of the organs of the great cavities. 
 The treatment, however, does not differ from that of gout in the 
 same positions, to recapitulate which cannot be exacted. Enough 
 may it be, to repeat that it consists mainly of the freest loss of 
 blood generally and locally — of epispastics over the suffering part, 
 and then of revulsives, either at the original seat of the affection, 
 or to the lower extremities, as the case may have been metastatic, 
 or primarily in some internal structure. 
 
 More of the affection of the heart should I have said, here, had 
 I not treated of it in another and more appropriate place. 
 
 Lastly, I have to advert to rheumatic fever, or that state of the 
 disease, where, with the highest possible degree of vascular 
 excitement, very trivial, or, perhaps, not any topical lesion is appa- 
 rent, either within or outwardly. Yet such is to be suspected 
 among the interior organs, and as influencing the cure, it ought to 
 be sought out diligently. It is here, a fortiori, that the general 
 remedies already enumerated are to be employed to the greatest 
 extent, especially venesection, — and in the event of the detection 
 of local inflammation, the appropriate means for its removal must 
 be brought into requisition. 
 
 The diet in acute rheumatism of every shape should be abste- 
 mious, and of the lowest description — and the temperature of the 
 chamber so regulated, as equally to avoid an excess of heat or 
 cold, the one exciting fever and restlessness, and the other exacer- 
 bating pain. 
 
 In conducting the cure of this disease, I have proposed the most 
 energetic practice. My conviction is, that when it assumes the 
 character in which it has been presented by me, it is one of the 
 highest grades of inflammatory fever imperatively demanding 
 such a course, and which, though not always capable of arresting 
 its progress, is alone calculated to mitigate its violence, and to 
 prevent those degenerations, so often ending in some sad cata- 
 
MUSCULAR OR FIBROUS SYSTEM. 437 
 
 strophe. But, happily, the tenour of the disease is otherwise, some- 
 times extremely mild, and as its gradations may be, so are the 
 remedies to be tempered and accommodated, from the most active 
 down to the most lenient, or even to the mere regulation of regi- 
 men, or perhaps an entire resignation of the case to the uncon- 
 trolled resources of nature. 
 
 CHRONIC RHEUMATISM. 
 
 By this is usually meant that state of the disease in which there 
 are pains, without inflammation or fever. But this definition, 
 though a common one, does not universally apply. Cases are of 
 frequent occurrence, which would be more correctly denominated 
 subacute rheumatism. It is, indeed, hardly possible to draw the 
 line with exactness, between the several states of it, so shaded 
 are they into each other, at least in many instances. The loca- 
 tions, however, being the same as the acute, it is similarly divided 
 into articular and muscular, though, as I have proposed, it might 
 be, with greater propriety, into fibrous and muscular rheumatism. 
 From the want of precision in our views as to what really consti- 
 tuted the chronic conditions of the disease, these have been ex- 
 ceedingly multiplied. Every obscure or anomalous pain, to which 
 no other specific character could readily be assigned, it was once 
 the custom to refer to this source, and very often most improperly. 
 By our increased knowledge of the pathology of the nervous sys- 
 tem, we have, however, become more enlightened on the subject, 
 and a nicer discrimination is now practised in the separation of 
 the rheumatic from the neuralgic affections. Nevertheless, such 
 are the diversities of the disease, that it is difficult, and perhaps 
 impossible, to embrace the whole under any general description. 
 
 Chronic articular rheumatism is most commonly exhibited, with 
 the features of the acute, considerably mitigated or subdued, among 
 which are a small, hard, corded, and accelerated pulse, pain 
 peculiarly liable to shift its position, increased by warmth, and 
 especially at night, in bed, when covered by a load of clothes. 
 The tongue is coated by white fur, or clean and florid — the skin 
 dry,with an unequally diffused temperature — the bowels costive — 
 and the articulations, when permanently the seat of it, are cedema- 
 tous, rather than swollen by inflammation. 
 
 In other cases more decidedly chronic, with an absence of the 
 
 37* 
 
438 DISEASES OF THE 
 
 febrile movement, the pulse being, indeed, exceedingly feeble, 
 little pain is felt except on motion, and which is alleviated, in- 
 stead of increased by warmth. The affected limb is cold, and 
 sometimes so torpid and relaxed as to amount nearly to paralysis. 
 There is a further condition, with unrelenting rigidity of one or 
 more of the joints, occasioned by great structural derangement 
 from extravasations, and thickening of the tissues entering into 
 the articulation, attended constantly by more or less of an ache, 
 often exacerbated to excruciation, and tending to hectic fever, or 
 it is fully established. 
 
 Frequently, in this condition, we meet with the most hideous 
 distortions and deformities, and especially when the articulations 
 and muscles are both concerned. 
 
 To these may be added, that variety seated in the periosteum, 
 the symptoms of which have a close resemblance to those of the 
 acute affection, the chief difference consisting in the membrane 
 sometimes undergoing much greater and more prominent changes 
 by thickening or otherwise. It is here that nodes are observable. 
 Not less, perhaps, does muscular rheumatism exhibit its several 
 gradations, from the slightest affection to a total loss of power in 
 one or more of the muscles. Now and then, too, we have in- 
 stances of it characterized by an atrophy of the muscles, in which 
 the interstitial and investing cellular membrane, and, as it would 
 appear, sometimes the muscular substance itself, are so far re- 
 moved, that little else than the tendons and fascia? is left. 
 
 An extraordinary example of this kind was afforded by Calvin 
 Edson, who, some years ago, exhibited his figure as a public 
 spectacle. By long protracted rheumatism, he was reduced from 
 a robust man to comparatively a living skeleton, as he, indeed, 
 denominated himself. 
 
 Two other instances I have seen, one in a patient in the alms- 
 house, and the other in a physician from South Carolina, where 
 the general ravages of the disease, scarcely less, were even more in 
 the hands and wrists, not a vestige of muscle apparently remaining 
 in these parts. Here, though at the time no pain existed, there 
 had been severe and protracted rheumatic suffering. Marasmus 
 of the muscles, however, takes place occasionally without any 
 appreciable rheumatism, or if such attacks as I allude to are of 
 this nature, they must be of the kind vulgarly called dumb rheu- 
 matism, — devoid of expression by symptoms. The disease 
 mostly comes on with no premonition ; sometimes, when the in- 
 
MUSCULAR OR FIBROUS SYSTEM. 439 
 
 dividual seems to be in good health, — and the first indication of 
 it is the obvious wasting of one or more of the large muscles, 
 usually those of the neck or back, or hips, with corresponding 
 imperfection in the motions dependent on these muscles. Gra- 
 dually other muscles become involved to a greater or less extent, 
 and emaciation proceeds in them till it is extreme, and all sorts of 
 distortions and deformities are exhibited. For a long period, the 
 general system seems to sustain little or no detriment from this 
 morbid process, and what is particularly remarkable, the digest- 
 ive functions are, to all appearance, actively performed. But 
 ultimately it is different, and febrile irritation arising, with an 
 aggravation of condition, the result is rapidly hastened. Five 
 cases of this extraordinary affection I have seen, all brought to 
 me from the country, the whole of which ended disastrously. 
 Three of these were brothers, and the fourth, a nephew of them, 
 is now under the care of Drs. Jackson, Mitchell and myself, and 
 I have heard that another member of the same connection has 
 been similarly afflicted. Nevertheless, an hereditary taint cannot 
 be suspected — their parents and remoter ancestors having never 
 betrayed any thing of the kind. The females, too, of the family 
 have entirely escaped. All these cases began to be developed 
 about the season of puberty, and ran on to that of manhood. 
 Horses are very liable to it, the wasting chiefly taking place in 
 the large muscles of the neck, which, by the vulgar, is called the 
 Sweeney. 
 
 Besides these several general conditions, we very often meet 
 with those local muscular affections, pleurodynia, lumbago, scia- 
 tica, &c, formerly noticed as incident to acute rheumatism, and 
 which are febrile and inflammatory, or the reverse, resembling 
 rather nervous irritations. 
 
 Frequently, also, are the internal organs and other structures 
 assailed, presenting similar modifications. The kidneys, heart, 
 and alimentary canal and uterus have especially this liability. 
 Connected with these lesions, the disturbance of the system is very 
 slight, or considerable, the general health pretty well maintained, 
 or greatly deranged in diverse modes. Most commonly, however, 
 I think, some disorder of the digestive process is observable, and 
 with deficient nutrition, hectic fever and emaciation ensue. Each 
 of the varieties of the internal disease is found to exist separately, 
 or complicated with lesions of other parts. 
 
 Chronic rheumatism may be the sequel of the acute, or of an 
 
440 DISEASES OF THE 
 
 original nature, — and the latter is exceedingly prevalent in posi- 
 tions exposed to a damp atmosphere. Every form of it is so 
 much influenced by such a state of weather, that its approach 
 can be often predicted with the accuracy of a barometer by the 
 feelings excited. This susceptibility is vastly increased by any 
 previous injury to a joint or a bone, as a strain, luxation, or frac- 
 ture, and by the abuse of mercury. Even when all is serenity 
 and sunshine, we habitually hear some old rheumatic, grumbling 
 at the exasperation of his aches, and truly proclaiming the forth- 
 coming of rain or a tempest. 
 
 Certain neuralgic affections are the only ones with which this 
 disease can be confounded. 
 
 But having heretofore pointed out the distinctions between them, 
 I shall now only observe, that the former are decidedly paroxys- 
 mal, characterized by the most intense pain, sharp and excru- 
 ciating, without phlogosis or swelling, — and that usually, on 
 examining the spine, some portion of it will be discovered by 
 pressure or percussion, more or less tender. 
 
 Need I remark, that the chronic are far more intractable in 
 the management than recent attacks of rheumatism ? There are 
 states of the disease, indeed, utterly irremediable, and sooner or 
 later prove fatal. Yet, sometimes, after a long endurance of the 
 affection, all irritation ceases, and the individual, crippled and 
 deformed, is restored to health, interrupted only in this respect 
 by the recurrence of aches in unfavourable states of weather. 
 Not easy is it, on the whole, to predict the result of the disease. 
 It sometimes ends fatally in a very short time without any very 
 obvious reason, and on other occasions it will run a lengthened 
 course in a manner equally unintelligible. I have seen it, with 
 no great severity of character, to kill in a few weeks, and to be 
 indefinitely protracted under opposite circumstances. For up- 
 wards of twenty years I attended two ladies with the disease, 
 always suffering, often severely, and who, for more than half this 
 period, were bed-ridden. They had scarcely a joint which was 
 not so rigid as to be immovable, and the limbs, upper and 
 lower, twisted or bent in the most unnatural shapes. The reten- 
 tion of the digestive and nutritive functions is a very favourable 
 sign, and a defect in these, with hectic or nervous irritation, di- 
 rectly the contrary. 
 
 Much of the appearances on dissection in the disease, has been 
 anticipated under a preceding head. Every degree of disorgani- 
 
MUSCULAR OR FIBROUS SYSTEM. 441 
 
 zation of the articular structures is met with in some instances — 
 changes in the bursse mucosae, wasting or thickening of the syno- 
 vial membrane and of the cartilages, rigidity of the ligaments, 
 extravasations, and occasionally firm anchylosis of the joints. It 
 is said, and I believe, correctly, that those saline concretions, so 
 common in gout, never occur in articular rheumatism, not even 
 when it attacks the small joints, however severely or protractedly. 
 
 Nor do the muscles escape. By Portal and Beclard particu- 
 larly, a gelatinous fluid has been observed within the cellular 
 sheath and surrounding the fibres themselves. The latter has 
 also detected concretions of various forms and appearances be- 
 tween the interstices of the muscular fibres, and Lieutaud men- 
 tions osseous deposits in the same positions. But the more com- 
 mon degeneration of muscles is into a withered, condensed, 
 indurated, rigid state, approaching to a tendinous nature, and 
 sometimes to such an extent as to have the whole of the inter- 
 stitial tissue and the cellular membrane covering the muscle 
 absorbed, as in the instances previously cited. 
 
 Excepting the heart and kidney, little is known of what takes 
 place in the internal affections. These organs suffer every sort 
 of injury, from the simplest to the most extensive that inflam- 
 mation can produce. 
 
 Of the pathology of chronic rheumatism I have scarcely a 
 word to say, it being, in every material respect, the same as that 
 of the acute disease. There is, indeed, only one point which I 
 shall, at present, notice. More than in regard to the acute, has 
 it lately been endeavoured by some writers to assimilate it to 
 certain nervous irritations, or, in other words, to take it from the 
 fibrous and muscular, and place it among the lesions of the spinal 
 system. That certain attacks of an extremely painful character 
 following the course of a nerve supposed to be rheumatic, are 
 really neuralgic, cannot be questioned, — and such a view I have 
 inculcated for many years, especially in relation to sciatica. Yet 
 that an essential difference exists between the two affections, 
 neuralgia and rheumatism, I think I have shown on a preceding 
 occasion. 
 
 The treatment of that state of the disease in which there is 
 still a remnant of inflammation, and some activity of the circula- 
 tion, I shall first consider. Moderate bleedings, general or local. 
 are here proper to be occasionally repeated, till the force of this 
 
442 DISEASES OF THE 
 
 diathesis is overcome. As auxiliary to the same design, much 
 may be expected from purging. 
 
 Distinct from the positive evidence of its efficacy in this case, 
 we are now aware of its utility in the chronic articular affections, 
 whatever may be their nature, or the cause by which they are 
 excited. To the late Professor Physick the credit is undoubtedly 
 due for this general extension of it, and which is not the least 
 of the many practical improvements to be traced to his sagacity 
 and experience. There is no chronic inflammation of a joint, 
 into the treatment of which he did not make purging, active and 
 continued, a leading and prominent ingredient. This, indeed, 
 with absolute rest of the limb and the lowest diet, was nearly 
 all which he did, and confessedly, he accomplished many asto- 
 nishing cures. 
 
 Emetics are here also employed by some ; not so much, how- 
 ever, as evacuants, as to mitigate pain and relieve the skin. But, 
 on diaphoretics, properly so called, greater reliance is placed. 
 
 Lest undue excitement may be revived, it will be prudent to 
 commence with the mildest of them, the acetate of ammonia, 
 the dulcified spirit of nitre, the neutral mixture, the antimonials, 
 or the nitrate of potash, alone, or combined with opiates. 
 
 The phlogistic state, however, being removed, or never having 
 existed in the case, another course is to be pursued, Not less to 
 awaken susceptibility to remedial impressions than to relax the 
 surface, the warm bath, and particularly a salt bath, which is 
 far more effectual, is much prescribed. To be of essential ser- 
 vice, it requires to be very often renewed, followed by frictions, 
 so as to excite a glow on the surface. The vapour bath, as now 
 employed, by a convenient apparatus, either the vapour of pure 
 water, or variously medicated, is also a valuable resource. 
 
 Concurring to the same end, the active diaphoretics, as Dover's 
 powder, are given, though profuse sweating, in the feeble or 
 protracted stage of the complaint, is an equivocal process. It 
 may do good, while, more generally, it will be found to be pro- 
 ductive of harm, exhausting strength, without dislodging or 
 breaking up the disease. More is often done by those articles 
 which have a relation to the cutaneous surface without inducing 
 much perspiration. Of this description are camphor, the car- 
 bonate of ammonia, the mezereon, the sassafras, the sarsaparilla, 
 the gum guaiacum, &c. The most powerful of these, in common 
 estimation, are the carbonate of ammonia and the guaiacum, 
 
MUSCULAR OR FIBROUS SYSTEM. 443 
 
 which may be directed separately, or together, forming the vola- 
 tile tincture of guaiacum. By long usage, this medicine has been 
 appropriated to chronic rheumatism. The guaiacum is used in 
 decoction, either alone, or with the sarsaparilla, and other ingre- 
 dients entering into the composition of the Lisbon diet drink. 
 Cases do, moreover, occur, where the sarsaparilla, in simple 
 decoction, is of great advantage. The syrup, as prepared in 
 this city, or that of Cusinier, is, however, on the whole, to be 
 preferred. To this class of medicines belongs sulphur, which, 
 though more generally useful, perhaps, displays its best powers 
 when the disease is seated on the surface of the body. But, in 
 whatever manner any of these articles is prescribed, a decided 
 effect is only gained by perseverance. 
 
 Many years ago, I introduced the savin into the cure of this 
 disease, and my reliance on its powers has increased with my 
 opportunities of witnessing its operations. Of this article I have 
 treated at length in my Therapeutics, to which work I refer 
 for the minute details relative to its use. It is peculiarly adapted 
 to that state of the disease attended by rigidity of the joints, 
 from extravasations — and what is not a little curious, in arrest- 
 ing absorption in marasmus of the muscles. In two of the cases 
 mentioned, brought on by rheumatism, it completely effected the 
 purpose, and in one of the other description, I am assured that it 
 would have succeeded, had it not been impatiently rejected. In 
 no application of it, made by me, was I able to perceive any im- 
 mediate advantage. The system must be fully under its impres- 
 sion, which is evinced by a sense of warmth, itching, or even an 
 eruption, before the disease begins to yield. 
 
 As much as in acute rheumatism, are diuretics here directed, 
 and, perhaps, with greater success, of which, among the best, is 
 the nitrate of potash in very free dilution. Yet, it has not the 
 merit of the colchicum, which, eminently serviceable in every 
 variety of the chronic disease, appears to me to be particularly 
 so in cardiac and nephritic rheumatism. 
 
 The terebinthinates and balsams are also deserving of notice, 
 and especially in lumbago and sciatica. Nearly under the same 
 circumstances mustard seed is serviceable, and more so where 
 torpor of the bowels exists, it being an excellent laxative. 
 
 We have reached another description of remedies, or the tonics, 
 among which are the Peruvian bark, to be administered by itself, 
 or in conjunction with some stimulating article, or preferably 
 
444 DISEASES OF THE 
 
 the sulphate of quinine, and I have to add the arsenical prepara- 
 tions as of great value. These articles very strikingly illustrate 
 the importance of a just adaptation of means to the pathological 
 condition. Each of them is employed in rheumatism, and we 
 have seen with what opposite results, and how unsettled is 
 medical opinion with regard to their efficacy or even propriety. 
 They are wholly misapplied to its febrile or inflammatory state, 
 and are as certainly useful in its advanced or reduced shapes. 
 Better suited to intermittent rheumatism, their utility is far more 
 extensive. Given in any of its weak or atonic conditions, they 
 are sometimes productive of very great advantage. 
 
 It may not be out of place here to notice a popular remedy, 
 which I really think has some claims to attention. My allusion 
 is to the berry of the common poke, the phytolacca decandria 
 of the botanists. Either the juice of the fresh berries, or a tinc- 
 ture of them, is the common preparation, — of which half a wine- 
 glassful may be taken several times a day. By what mode of 
 action it does good, is not very evident. Not without general 
 utility, I have found it especially so in the rheumatic affections of 
 the chest, in confirmation of which, I shall repeat that it is very 
 serviceable in spasmodic asthma. 
 
 As yet, I have said nothing of mercury in chronic rheumatism. 
 Let it not, however, be supposed, on this account, that I attach 
 the less importance to it. As in many other cases, it should be 
 tried when other means have failed. Commonly, I have found 
 it as beneficial, perhaps more so, in chronic, where an inflamma- 
 tory condition prevails, than in acute rheumatism. More than 
 any thing else it seems to subvert the phlogistic diathesis, often 
 so obstinately persistent under other remedies. On many occa- 
 sions, I have remarked, where a hard, contracted, irritated pulse, 
 with blood cupped and sizy, could not otherwise be overcome, the 
 most decided change was at once wrought by a moderate mer- 
 curial impression. It is given by itself, as an alterative, though 
 more generally united with opium and ipecacuanha. This is 
 an excellent prescription. To substitute, in the place of opium, 
 some other of the narcotics, and particularly cicuta, henbane, 
 belladonna, or the stramonium, is a favourite practice with many. 
 But little, I suspect, is gained by the exchange. The stramo- 
 nium, however, has been highly extolled by Marcet and other 
 British authorities, in cases with nervous irritation and acute 
 pain. 
 
MUSCULAR OR FIBROUS SYSTEM. 445 
 
 The difference of sentiment in regard to mercury can only 
 proceed from its abuse. Carried to a great extent, there is no 
 case in which it is not either positively injurious, or its salutary 
 effect diminished. The proper medium here, and under all cir- 
 cumstances where the mercurial impression is desirable, is so to 
 regulate the process as to maintain it moderately, never allowing 
 it to run into excess. 
 
 Nitric, or rather the nitro-muriatic acid, has been a good deal 
 directed in this disease. My own experience will not allow me 
 to decide very positively on the degree of its efficacy, though I 
 have had, occasionally, some reason to be well pleased with it. 
 Many of the European writers speak favourably of it, and from 
 its properties, we should be led to suppose, independently of all 
 evidence, that it might be beneficially employed. When pre- 
 scribed by me, it has been after a mercurial course, or as a sub- 
 stitute for it, where, from debility or other causes, mercury itself 
 seemed to be inadmissible. 
 
 An allusion has already been made to the hydriodate of potash 
 as a remedy represented to be of immense utility in this state of 
 the disease. The confidence of some, indeed, in it, is unqualified, 
 while others speak of it more temperately and more justly. From 
 all I have heard of its use, having really tried it very little myself, 
 though inclined to believe that it has sometimes done good, I 
 cannot concur in the laudation it receives. Distinct from my dis- 
 trust of all new nostrums, with high pretensions, it has been 
 increased, in the present instance, by the consideration that when 
 originally announced, it was declared to be alike appropriate to 
 all the forms of rheumatism, and that now, by common consent, 
 its use is limited pretty much to the chronic states of the perios 
 teal affection. Mistaken in the beginning, as its advocates were. 
 I cannot help suspecting that they may not be right, at present ; 
 and, at all events, I leave to others to go on experimenting till 
 the matter is better determined. Well-tried remedies, like Well- 
 tried friends, I always adhere to, and am very slow and reluctant 
 to abandon either without very sufficient grounds. To do it in 
 the former instance shows a weak and credulous head, and in the 
 latter, a capricious or depraved heart. 
 
 The local treatment is so nearly the same as in the acute dis- 
 ease, that of it I need not say much. It consists of topical bleed- 
 ing, blisters, caustic or moxa issues, frictions, and the flannel 
 roller, accommodated to its several conditions. The latter has 
 3S 
 
446 DISEASES OF THE 
 
 not acquired as much reputation as it deserves, owing to the 
 indiscriminate manner in which it has been employed. As I 
 formerly observed, it has, in the trials which I have made of it, 
 entirely failed in acute rheumatism, the pain of the compression 
 not being endurable. But in that stage of the disease where 
 inflammation is less active and sensibility correspondingly re- 
 duced, I have known it to be highly advantageous. The limb 
 is to be as tightly bandaged as can be conveniently borne, to 
 be removed twice a day, and frictions applied, which should be 
 continued for several weeks in old, obdurate cases. 
 
 The modus operandi of the remedy seems to me very plain. 
 Especially in chronic inflammation, the vessels of a part are pre- 
 ternaturally distended, with a loss, at the same time, of contrac- 
 tility and the power of removing their contents, in consequence 
 of which blood unduly accumulates, and swelling and pain are 
 the results. By compression, the calibre of the relaxed vessels 
 is lessened by the approximation of their sides, the blood pro- 
 pelled out of them, and relief afforded. But, while so much is 
 accomplished, effects no less beneficial are permanently induced, 
 in the support thus lent to the vessels, and, indeed, to all the 
 parts involved in the disease, till they re-acquire their natural 
 tone. 
 
 From frictions, which are to be considered as " merely succes- 
 sive acts of compression," nearly the same effects are attained, 
 though not so certainly, or to an equal extent. 
 
 These processes, in another view, are useful. As much as they 
 promote the circulation in the loaded and oppressed capillaries, 
 do they also invigorate the powers of absorption, — by which 
 effusions and other extraneous matters are removed, and equally 
 tend to preserve the temperature of the part, which is usually 
 low, or ill developed. The practice was directed by me long 
 before I saw Balfour's book. 
 
 Among the means supposed to afford relief to the topical affec- 
 tion, is an operation entitled acupuncturation, from acus, a 
 needle, and punctura, a puncture, which has been strongly ad- 
 vised in this and other analogous affections. It is an ancient and 
 common expedient among the Chinese, and a century and a half 
 ago was much employed on the continent of Europe, having, 
 however, fallen into disuse, and again revived, particularly in 
 France. The operation consists in the introduction of one or 
 more long, delicate needles by a rotary motion between the fore- 
 finger and thumb, through the integuments, to a considerable 
 
MUSCULAR OR FIBROUS SYSTEM. 447 
 
 depth, which are to remain for a longer or shorter time, accord- 
 ing to circumstances. The part most affected is to be selected for 
 the application. 
 
 It seems to be admitted, that this operation is only applicable 
 to local muscular rheumatism and chiefly in the chronic state, of 
 an acutely painful character, resembling neuralgia, such as scia- 
 tica especially. Whatever may be its merits, which I do not 
 rate highly, still more effectual, undoubtedly, are douches, so 
 called by the French. These consist of pouring water through 
 tubes of different calibres, from a height of many feet on the 
 affected part, of various temperatures, from as hot as can be 
 borne down to a very low degree of cold. 
 
 It remains to suggest the importance of early exercising the 
 diseased parts, whether the articulations or muscles. These, on 
 the subsidence of inflammation, are left frequently in a state 
 without motion, or in which it is very imperfectly performed. 
 The joints are inflexible from the extravasations within them, 
 and the muscles from the same cause depositions in their inter- 
 cellular texture, or by long disuse, become rigid or relaxed and 
 wasted, and, as it were, paralytic. Rigidity of the ligaments of 
 the articulations also takes place, and where contraction of the 
 limbs exists, this may become fixed, productive of permanent 
 deformity. Now, with a view to the prevention, or removal of 
 this series of disasters, exercise, in conjunction with the other 
 means proposed, particularly frictions and champooing, should 
 never be neglected. It may be painful at first — though, if there 
 be no inflammation, this is not to be regarded. On each repetition 
 it will be less, and soon no suffering experienced. Yet, should 
 pain be decidedly increased by it, we may infer the continuance 
 of inflammation, and an opposite course is to be adopted, or a state 
 of rest. 
 
 Every measure, however, which I have proposed for the cure 
 of chronic rheumatism, though skilfully applied, will sometimes 
 prove unavailing, — and, as a dernier resort, a trial of the thermal 
 springs of our country should be suggested, — the best of which 
 are those of Virginia, — from which the most extraordinary ad van 
 tage has, in many instances, been derived. I have seen indivi- 
 duals again and again, crippled and deformed, to return from 
 them perfectly cured, and which corresponds very much with the 
 reports we have of the efficacy of similar waters in Europe. My 
 remarks, hitherto, have had reference to the varieties of the exter- 
 nal form of the disease. Deeply interesting as are the affections 
 
448 DISEASES OF THE MUSCULAR OR FIBROUS SYSTEM. 
 
 of some of the internal organs, they are so similar in their ma- 
 nagement to those of gout, already disposed of, that I must be 
 content to refer to what I have said under the latter head, with 
 the single exception of the attacks of the heart, which, from their 
 peculiar importance, claim a distinct consideration, and this they 
 have elsewhere received. 
 
 As rheumatism, in all its diversities, is singularly prone to 
 relapses, to prevent these becomes a matter of consequence. 
 Cold is the most operative of the exciting causes, a protection 
 against which should be secured by wearing adequate and appro- 
 priate clothing, such as flannel over the body and extremities. 
 Yet, owing to idiosyncrasy of constitution, by the entire rejection 
 of flannel, I have known several individuals much afflicted with 
 the disease, and having the liveliest predisposition to it, perfectly 
 cured. For the same end, the habitual use of the cold bath, 
 where it agrees with the patient, is often effectual. The Yellow 
 Springs, in the neighbourhood of this city, the water of which is 
 intensely cold, have justly acquired much repute in this case. 
 
 Of diet I have only to observe, that though it should be more 
 nutritious than in the acute disease, it is still to be moderate in 
 quantity and quality. No case admits of any freedom of indul- 
 gence, either in eating or drinking, it having, on the contrary, 
 invariably the effect of augmenting pain, and exasperating the 
 disease generally. Cordial, and even stimulating condiments, 
 such as Cayenne pepper, mustard and horseradish, are, however, 
 very grateful adjuncts to some grinds of food, and in weakness of 
 the stomach become proper. The two last articles, indeed, are 
 thought to exert some remedial power over the disease itself, and 
 I am inclined to believe really possess it, in certain atonic states. 
 It is under like circumstances, that a small portion of wine or 
 ardent spirits may be allowed, though usually they are very pre- 
 judicial. 
 
 Finally, certain positions, exposed to a chilly, moist air, as 
 along the seacoast, abound in rheumatism, particularly of the 
 heart, and which, once established, is uniformly difficult of cure, 
 and, in many instances, utterly irremediable, except by a removal 
 beyond its influence. He, indeed, who is prone to any of the 
 forms of this disease, will act wisely in selecting for his perma- 
 nent residence, a climate dry, warm, and equable. 
 
 THE END. 
 
JEFFERSON MEDICAL COLLEGE. 
 
 SESSION OF 1846—7. 
 
 The regular Course of Lectures will commence on Monday the 2d day of November, and 
 end on the last day of February. 
 
 Roblet Dunglison, ML D., Professor of Institutes of Medicine. 
 
 Robekt M. Huston, M. D., Professor of Materia Medica and General Therapeutics. 
 
 Joseph Pa^coast, M. D , Professor of General, Descriptive and Surgical Anatomy. 
 
 JoHsr K. Mitchell, M.D., Professor of Practice of Medicine. 
 
 Thomas D. Mutter, M. D., Professor of Institutes and Practice of Surgery. 
 
 Charles D. Meigs, M, D., Professor of Obstetrics and Diseases of Women and Children. 
 
 Franklin Bache, M. D., Professor of Chemistry. 
 
 Every Wednesday and Saturday during the course, Medical and Surgical cases are investigated and pre- 
 scribed for before the class. During the past year not fewer than 1,000 cases were treated, and upwards of 172 
 were operated on. The CJinical Lectures are so arranged as to permit the student, should he desire it, to attend 
 the Medical and Surgical practice and lectures at the Pennsylvania Hospital. 
 
 On and after the 1st of October, the dissecting rooms of the College will be open under the direction of the 
 Professor of Anatomy and the Demonstrator. 
 
 Owing to the large size of the class, which numbered 469 during the last session, it became expedient to 
 make extensive and important alterations in the college edifice. These will be completed by the 1st of Sep- 
 tember. 
 
 R. M. HUSTON, M. D., Dean of the Faculty. 
 
 No. 1 Girard Street. 
 
 ceo. y^^r^^ co ^ 
 
 WKOL.ESAL.E BRUGCJISTS, 
 
 No. 301 Market Street. 
 
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 will extend to such as furnish satisfactory references a liberal credit, and furnish them with articles of the best 
 quality at as low prices as those of like character can be had elsewhere in the United States. 
 
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 A FOURTEENTH AND SUPPLEMENTARY VOLUME OF THE 
 
 ENCYCLOPEDIA AMERICANA. 
 
 BY HENRY VETHAKE, Esq., LL. D., 
 
 One of the Professors in the University of Pennsylvania, S,-c, \c. 
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 ELEMENTS OF PHYSIOLOGY, 
 
 INCLUDING PHYSIOLOGICAL ANATOMY. 
 
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 BY WILLIAM B. CARPENTER, M. D., F. R. S., 
 
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 PRINCIPLES OF HUMAN PHYSIOLOGY, 
 
 "WITH THEIR CHIEF APPLICATIONS TO 
 
 PATHOLOGY, HYGIENE, AND FORENSIC MEDICINE. 
 BY WILLIAM B. CARPENTER, M.D., F.R.S., &c. 
 
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 " The work as it now stands is the only Treatise on Physiology in the English language which exhibits a clear 
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 Monthly Journal. 
 
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 ON VEGETABLE PHYSIOLOGY. 
 
 » In one neat duodecimo volume, extra cloth, with numerous illustrations. 
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 AND ON 
 
 DISEASES AND ACCIDENTS REQUIRING OPERATIONS 
 
 DELIVERED AT UNIVERSITY COLLEGE, LONDON, 
 
 BY ROBERT LISTON, ESQ., F.R.S., &o. 
 
 EDITED, WITH NUMEROUS ALTERATIONS AND ADDITIONS, 
 BY T. D. MUTTER, M.D., 
 
 PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. 
 
 IN ONE LARGE AND BEAUTIFULLY PRINTED OCTAVO VOLUME. 
 WITH TWO HUNDRED AND SIXTEEN ILLUSTRATIONS ON WOOD. 
 This work contains much original matter of Professor Mutter's, amounting to 
 about two hundred and fifty pages, embodying the results of his great experience, 
 and adapting the whole to the wants of the American Profession. The Lectures 
 are those which have attracted so much attention as published in the Lancet 
 They are here reproduced entire, omitting none of the original wood engravings, 
 and introducing many new and valuable ones, rendering this altogether one of 
 the most completely illustrated works of the kind that has for some time been 
 presented to the medical public. Among the additions of Professor Mutter will 
 be found full and elaborate Treatises on Staphyloraphy, the different Plastic Ope- 
 rations, Club-Foot, Affections of the Eye, Deformities from Burns, and many 
 other important subjects, not to be met with in so enlarged a form in, perhaps, 
 any other work on Surgery. The chapters containing them are fully illustrated 
 with numerous original and highly curious engravings. 
 
 "This is a very attractive book, both in resnect to mechanical execution and contents. Printed on fine 
 white paper, with a fair new type, and embellished with more than 200 well executed wood cuts, it presents 
 altogether as beautiful an appearance as a work of art as its matter is interesting and important to tlie prac- 
 tical surgeon. The lecture on operations on the eye is a very lucid and instructive one, but we can only rerer 
 to it in the most cursory manner. The editor has fully supplied everything that was wanting to render the 
 chapter complete, and we would gladly quote his remarks on the operations of Strabismus and Staphyloma, 
 did our limits permit. The chapter on Cataract, by Dr. Mutter, extending over thirty pages, we look upon as 
 one of the most valuable essays on the subject in the language. It is clear and methodical, sufficiently full, yet 
 precise, and abounding in practical precepts of the highest interest. The remarks on deformities of the nose 
 are evidently the result of much experience and observation. The operations for hare-lip and cieft palate are 
 treated at considerable length, and made exceedingly clear by means of the accompanying illustrations: we 
 can recommend these sections alone as worth far more to the surgeon than many times the price of the whole 
 work. The same remark will apply to the next lecture, on the Diseases of the Antrum, Carious Teeth. Erected 
 Tumours of the Face, and Solid and Encysted Tumors. We know of no systematic work on surgery in which 
 the anaplastic operations for removal or remedying deformities of the face are so fully and satisfactorily de 
 scribed as in this. But we have already exceeded our limits, and can only say in conclusion that Listou's Lec- 
 tures, with Mutter's additions, should be in every surgeon's library, and in every student's hands, who wishes 
 to post up his surgical knowledge to the present moment." — The New York Journal of 'Medicine. 
 
 " These lectures will be found eminently practical, a point of no small moment in a work 
 on Surgery. Indeed, we have no hesitation in affirming, that it is a compendium of the 
 modern practice of Surgery as complete and accurate as any treatise of similar dimensions 
 in the English language. — The Western Lancet. 
 
 Lately Published, a New and Much Improved Edition of 
 DRUITT'S SURGERY. 
 
 THE PRINCIPLES AND PRACTICE OF MODERN SURGERY, 
 
 By ROBERT DRUITT, Surgeon. 
 FROM THE THIRD LONDON EDITION. 
 
 ILLUSTRATED BY ONE HUNDRED AND FIFTY-THREE WOOD ENGRAVINGS. 
 
 WITH NOTES AND COMMENTS. 
 
 By JOSHUA B. FLINT, M. M., S. S. 
 In One Volume, Octavo. 
 
 "An unsurpassable compendium not only of surgical but of medical practice."— London 
 Medical Gazette. 
 
LEA & BLANCHARD'8 PUBLICATIONS. 
 
 BRODIE'S SURGICAL WORKS 
 
 NOW READY, 
 
 CLINICAL LECTURES ON SURGERY, 
 
 DELIVERED AT ST. GEOSGE'S HOSPITAL 
 
 By SIR BENJAMIN BRODIE, Bart., V. P. R. S„ 
 
 SERJEANT SURGEON TO THE QUEEN, ETC. ETC. 
 
 IN ONE NEAT OCTAVO VOLUME. 
 
 These Lectures, in passing through the columns of "The Medical News,*' during the 
 last year, have received the unanimous approbation of the profession in this country, and 
 will no doubt be eagerly sought for in their complete state. 
 
 " Sir Benjamin Brodie has long been distinguished as a surgeon, even among those in the front 
 rank, and may now be regarded as occupying the first place in Great Britain, if not in the world. 
 It is not as a mere operator that he is distinguished — that, it must be conceded by all right thinking 
 minds, is but a very humble part of the qualifications of a surgeon — but as a profound pathologist 
 and therapeutist. We may be prejudiced or mistaken, but in these higher and really intellectual 
 qualifications, we know of no living surgeon that approaches him. His well considered opinions 
 and practical instructions are conveyed, too, in language so appropriate, so simple, clear and chaste, 
 that one scarcely knows whether most to admire the excellence of the matter or the beauty of the 
 style in which it is clothed. Theory and practice go hand in hand throughout. Rarely is a pre- 
 cept given without being illustrated by some apposite case, selected from his vast experience, and 
 always in the fewest and most expressive words. Nothing more than is necessary to enforce the 
 point is said, and nothing that is necessary is left untold." — The Medical Examiner. 
 
 "It would not be easy to find in the same compass more useful matter than is embraced in each 
 of these discourses, or indeed in this volume. We the less regret the limited extracts we have it 
 in our power to make from it, because we feel sure that it will in a short time find its way into all 
 the medical libraries in the country.' — The Western Journal of Medicine and Surgery. 
 
 "Sir B. Brodie has rendered his clinical lectures — what all clinical lectures should be — clear, 
 impressive and practical expositions of curative measures, in which all the most important features 
 of the subject are plainly set forth, without being unnecessarily encumbered with details. We 
 attach a very high value to these Lectures: their style is clear, demonstrative and unaffected, de- 
 cided and energetic; but altogether free from dogmatism or over-confidence. They are strictly 
 practical ; and much of the information which they contain will assuredly do the reader and his 
 patients good service in time of need." — Medical Gazette. 
 
 BRODIE ON URINARY ORGANS, 
 
 LECTURES 
 
 OX THE DISEASES OF THE URINARY ORGANS. 
 
 FROM THE THIRD LONDON EDITION. 
 
 WITH ALTERATIONS AND ADDITIONS. 
 
 In One Small Octavo Volume, Cloth. 
 This work has been entirely revised throughout, some of the author's views have been 
 modified, and a considerable proportion of new matter has been added, among which is 
 a lecture on the Operation of Lithotomy. 
 
 BRODIE ON THE JOINTS. 
 
 PATHOLOGICAL AND SURGICAL OBSERVATIONS 
 
 ON THE DISEASES OF THE JOINTS. 
 
 FROM THE FOURTH LONDON EDITION. 
 
 GEtftfi the Author's alterations atrti SlWfttons. 
 
 In One Small Octavo Volume, Cloth. 
 r "To both the practical physician and the student, then, this little volume will be one of much 
 service, inasmuch as we have here a condensed view of these complicated subjects thoroughly 
 investigated by the aid of the light afforded by modern Pathological Surgery.-' — N. Y. Journal of 
 Medicine. 
 
LEA & ELANCHARD'S PUBLICATIONS. 9 
 
 THE SIXTH EDITION OF DUNGLISOFS MEDICAL DICTIONARY. 
 
 To 1846. 
 
 medicaxTlexicon, 
 
 A DICTIONARY 
 
 MEDICAL "SCIENCE. 
 
 CONTAINING 
 
 A CONCISE ACCOUNT OF THE VARIOUS SUBJECTS AND TERMS ; WITH 
 THE FRENCH AND OTHER SYNONYMES ; NOTICES OF CLIMATES 
 AND OF CELEBRATED MINERAL WATERS; FORMULAE 
 FOR VARIOUS OFFICINAL AND EMPIRICAL PREPA- 
 RATIONS, &c. 
 
 BY ROBLEY DUNGLISON, M. D., 
 
 Professor of the Institutes of Medicine, &c. in Jefferson Medical College, Philadelphia. 
 
 SIXTH EDITION, REVISED AND GREATLY ENLARGED. 
 
 In one Royal Octavo Volume of over 800 very large pages, double columns. 
 
 Strongly bound in the best leather, raised bands. 
 
 It is not necessary for the author to say more, as a preface to this sixth edition of his dictionary, than that he 
 has bestowed the same care on its revision and improvement, which he did on the others. In proof of this, he 
 may remark, that the present edition comprises nearly two thousand five, hundred subjects arid terms not con- 
 tained in the last. Many of these have been introduced into medical terminology in consequence of the pro- 
 gress of the science ; and others had escaped him in previous revisions. 
 
 It is the author's anxious wish to render the work a satisfactory and desirable — if not indispensable — Lexicon, 
 in which the student may search without disappointment for every term that has been legitimated in the nomen- 
 clature of the science. This desideratum he is enabled to attempt in successive editions, by reason of the work 
 not being stereotyped; and the present edition certainly offers stronger claims to the attention of the practi- 
 tioner and student than any of its predecessors.— Preface to Sixth Edition, May 1846. 
 
 A NEW EDITION OF 
 
 THE MEDICAL STUDENT, 
 OR AIDS TO THE STUDY OF MEDICINE. 
 
 A REVISED AND MODIFIED EDITION. 
 
 BY ROBLEY DUNGLISON, M. D., 
 In One neat 12mo. volume. 
 
 HUMAN HEALTH; 
 
 OR, THE INFLUENCE OF ATMOSPHERE AND LOCALITY, CHANGE OF AIR 
 AND CLIMATE, SEASONS, FOOD, CLOTHING, BATHING AND MINE- 
 RAL SPRINGS, EXERCISE, SLEEP, CORPOREAL AND INTEL- 
 LECTUAL PURSUITS, &c. &c, ON HEALTHY MAN: 
 CONSTITUTING 
 ELEMENTS OF HYGIENE. 
 
 BY ROBLEY DUNGLIS ON, M. D. 
 
 A New Edition with many Modifications and Additions. In One Volume, Svo. 
 
 DUNGLISON ON NEW 4 REMEDIES. 
 
 MEW REMEDIES, 
 
 PHARMACEUTICALLY AND THERAPEUTICALLY CONSIDERED. 
 
 FOURTH EDITION. 
 
 WITH EXTENSIVE MODIFICATIONS AND ADDITIONS, 
 BY ROBLEY DUNGLISON, M.D., &c. 
 The numerous valuable therapeutical agents which have of late years been introduced into the M 
 Medic a, render it a difficult matter for the practitioner to keep up with the advancement of the >o:enoe. espe- 
 cially as the descriptions of them are difficult of access, being scattered so widely through transac 
 learned societies, journals, monographs, &c. &C. To obviate this difficulty, and to place within reach 
 profession this important information in a compendious form, is the object of the present volume, and the num- 
 ber of editions through which it has passed show that its utility has not been underrated. 
 IP 5 * Apothecaries and Physicians may rely upon having a hue edition of this useful work. 
 
10 LEA & BLANCHARD'S PUBLICATIONS. 
 
 PROFESSORHDUNGLISOr^WORKS. 
 
 NOW READY.— A NEW EDITION OP 
 
 DUNGLISON'S PHYSIOLOGY, 
 
 Brought up to 1846. 
 
 HUMAN PHYSIOLOGY, 
 
 WITH 
 
 THREE HUNDRED AND SEVENTH ILLUSTRATIONS. 
 
 BY ROBLEY DUNGLISON, M. D., 
 
 PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, 
 
 &C. &C. 
 
 SIXTH EDITION. 
 
 GREATLY IMPROVED. 
 In two large octavo volumes, containing nearly 1350 pages. 
 " It is but necesary for the Author to say that all the cares that were bestowed 
 on the preparation of the fifth edition have been extended to the sixth, and even 
 to a greater amount. Nothing of importance that has been recorded since its 
 publication, has, he believes, escaped his attention. Upwards of seventy illustra- 
 tions have been added ; and many of the former cuts have been replaced by others. 
 The work, he trusts will be found entirely on a level with the existing advanced 
 state of physiological science." 
 
 In mechanical and artistical execution, this edition is far in advance of any former one. The 
 illustrations have been subjected to a thorough revision, many have been rejected and their places 
 supplied with superior ones, and numerous new wood-cuts have been added wherever perspicuity or 
 novelty seemed to require them. 
 
 THE PRACTICE OF MEDICINE, 
 
 OR A TREATISE ON 
 
 SPECIAL PATHOLOGY AND THERAPEUTICS. 
 
 BY ROBLEY DUNGLISON, M. D. 
 CONTAINING 
 
 THE DISEASES OF THE ALIMENTARY CANAL, THE DISEASES OF THE 
 CIRCULATORY APPARATUS, DISEASES OF THE GLANDULAR OR- 
 GANS, DISEASES OF THE ORGANS OF THE SENSES, DISEASES 
 OF THE RESPIRATORY ORGANS, DISEASES OF THE GLAN- 
 DIFORM GANGLIONS, DISEASES OF THE NERVOUS SYS- 
 TEM, DISEASES OF THE ORGANS OF REPRODUC- 
 TION, DISEASES INVOLVING VARIOUS ORGANS, 
 &c. &c. 
 
 In Two Volumes, Octavo. 
 
 This work has been introduced as a text-book in many of the Medical Colleges, 
 and the general favor with which it has been received, is a guarantee of its value 
 to the practitioner and student. 
 
 " In the volumes before us, Dr. Dunglison has proved that his acquaintance with the present facts 
 and doctrines, wheresoever originating, is most extensive and intimate, and the judgment, skill, 
 and impartiality with which the materials of the work have been collected, weighed, arranged, and 
 exposed, are strikingly manifested in every chapter. Great care is everywhere taken to indicate 
 the source of information, and under the head of treatment, formula? of the most appropriate reme- 
 dies are everywhere introduced. In conclusion, we congratulate the students and junior practi- 
 tioners of America on possessing in the present volumes a work of standard merit, to which they 
 may confidently refer in their doubts and difficulties." — Brit, and For. Med. Rev. for July, 1842. 
 
 " Since the foregoing observations were written, we have received a second edition of Dungli- 
 son's work, a sufficient indication of the high character it has already attained in America, and 
 justly attained." — Ibid, for October, 1844. 
 
LEA & BLANCHARD'S PUBLICATIONS. 11 
 
 NOW READY, 
 
 DUNGLISON'S THERAPEUTICS. 
 
 A NEW EDITION, MUCH IMPROVED, TO 1848. 
 
 GENERAL THERAPEUTICS AND MATERIA MED1CA. 
 
 WITH ONE HUNDRED AND TWENTY ILLUSTRATIONS. 
 ADAPTED FOR A MEDICAL TEXT-BOOK. 
 
 BY ROBLEY DUNGLISON, M.D., 
 
 Professor of Institutes of Medicine, etc. in Jefferson Medical College; Late Professor of Materia Medica, etc. 
 in the Universities of Virginia and Maryland, and in Jefferson Medical College. 
 
 Third Edition, Revised and Improved, in Two Octavo Volumes, well bound. 
 
 In this edition much improvement will be found over the former ones. The author has subjected 
 it to a thorough revision, and has endeavored to so modify the work as to make it a more complete 
 and exact exponent of the present state of knowledge on the important subjects of which it treats. 
 The favor with which the former editions were received, demanded that the present should be ren- 
 dered still more worthy of the patronage of the profession, and this alteration will be found not 
 only in the matter of the volumes, but also in the numerous illustrations introduced, and the gene- 
 ral improvement in the appearance of the work. 
 
 LIST OF ILLUSTRATIONS.— Vol. I. 
 
 1. Cephaelis Ipecacuanha. 17. Legume and leaflet of C. 37. Cetraria Islandica. 57. Lyeopus Virginicus. 
 
 2. Brown Ipecacuan. root. obovata. 38. Fucus vesiculosus. 58. Strychnos Nux Vomica. 
 
 3. Striated ipecacuan. root IS. Tinnevelly Senna. 39 Inhaler. 59. Ruta graveolens. 
 
 — Undulated Ipecacu- 19. Cassia Marilandica. 40. Cantharides. 60. Secale cornutum. 
 
 anh a root. 20. Podophyllum. 41. Leontodon Taraxacum. 61. Cinnamomum Zeylani- 
 
 4. Tonidium Ipecac, root. 21. Hebradendroncambogi-42. Erigeron Philadelphi- cum. 
 
 5. Gillenia stipulacea. o'ides. cum. 62. Cardamom. 
 
 6. Lobelia inflata. 22. Momordica Elaterium. 43. Arbutus Uva ursi. 63. Cariophyllus aromaticus 
 
 7. Sanguinaria Canadensis 23. Apocynum cannabinum44. Eupaioriumperfoliatum.64. Fceniculum vulgare. 
 
 8. Apocynum Androsasmi- 24. Convolvulus panduratus45. Asclepias tuberosa. 65. Monarda coccinea. 
 
 folium. 25. Chenopodium Anthel- 46. Arum triphyllum. 66. Hedeoma pulegioides. 
 
 9. Erythronium America- minticum. 47. Carthamus tinctorius. 67. Myristica moschata. 
 
 num. 26. Spigelia Marilandica. 48. Warm-bath. 63. Nutmeg in the shell sur- 
 
 10. Euphorbia corollata. 27. Nephrodium Filix max. 49. Hip-bath. rounded by ihe mace. 
 
 11. Ficus Carica. 28. Punica granatum. 50 Foot-bath. 69. Gaultheria procumbens. 
 
 12. Ricinis communis. 29, 30. Inhaling Bottles. 51. Hyoscyamus Niger. 70. Juniperus communis. 
 
 13. Rheum palmatum. 31. Balsamadend'n Myrrha. 52. Datura Stramonium. 71. Citrus Aurantium. 
 
 14. Rheum compactum. 32. Acacia Arabica. 53. Conium maculatum. 72. Laurus camphora. 
 
 15. Aloe Socotorina. 33. Olea Europaea. 54. Humulus Lupulus 73. Drymis Winieri. 
 
 16. Legume and leaflet of 34. Saccharum ofricinarum.55. Dried lupulinic grain74 Acorus Calamus. 
 
 Acute leaved Alexan- 35. Linum usitatissimum. with itshilummagnifi'd 75. Piper nigrum, 
 
 drian Senna. 36. Astragalus verus. 56. Cannabis sativa. 76. Electrical Apparatus for 
 
 Medical purposes. 
 VOL. II. 
 
 1. Cocculus palmatus. 13. Hepatica Americana. 26. Abies excelsa. 35. Partic's of Potato starch 
 
 (Male plant.) 14. Indigo. 27. Ranunculus acris. seen by the microscope. 
 
 2. Gentiana Catesbaei. 15. Cornus Florida. 28. Aralia nudicaulis. 36. Janipha Manihot. 
 
 3. Frasera Walteri. 16. Liriodendron tulipifera 29. Solanum dulcamara. 37. Particles of Tapioca as 
 
 4. Sabbatia angularis. 17. Dyospyros Virginiana. 30. Tacca pinnatifida. seen by the microscope. 
 
 5. Coptis trifolia. 18. Heuchera acerifolia. 31. Particles of Tahiti Ar-38. Sagus Rumphii. 
 
 6. Aletris farinosa. 19. Spiraea tomentosa. row-root. 39 Particles of Sago-meal. 
 
 7. Aristolochiaserpentaria20. Statice Caroliniana. 32. Particles of white East 40. Particles of Potato sago. 
 
 8. Asarum Canadense. 21. Colchicum autumnale. India Arrow-root. 41. Cycas revoluta or the 
 
 9. Anthemis Cotula. 22. Veratrum Album. Var. 33. Particles of West India Japan Sago-tree. 
 
 10. Magnolia glauca. Albiflorum. Arrow-root. 42. Averia Saliva. 
 
 11. Magnolia macrophylla. 23. Cirmcifuga racemosa. 34. Particles of Tous-les- 43. Parti'sof Wheat Starch 
 
 12. Geum Virginianum. 24, 25. Shower-bath. mois. 
 
 "Our junior brethren in America will find in these volumes of Professor Dunglison. a 'Thesaurus Medic a- 
 Minum,' more valuable than a large purse of gold." — Medico-Chirurgical Reviaofor Jan. 1845. 
 
 ELLIS'S MEDICAL FORMULARY, 
 NEW AND IMPROVED EDITION, TO JULY, 1846. 
 
 THE MED ICAL FO~R MULARY: 
 
 BEING A COLLECTION OF PRESCRIPTIONS, DERIVED FROM THbRvRITINGS AND PRACTICE OF MANY OF 
 
 THE MOST EMINENT PHYSICIANS OF AMERICA AND EUROPE. 
 
 TO WHICH IS ADDED AN APPENDIX, 
 
 CONTAINING THE USUAL DIETETIC PREPARATIONS AND ANTIDOTES FOR POISONS. 
 
 THE WHOLE ACCOMPANIED WITH A FEW BRIEF PHARMACEUTIC AND MEDICAL OHSKUV ATlOXS. 
 
 BY BENJAMIN ELLIS, M.D., 
 
 Late Professor of Materia Medica and Pharmacy In the Philadelphia College of Pharmacy. 
 
 EIGHTH EDITION, WITH EXTENSIVE ALTERATIONS AND ADDITIONS. 
 
 BY SAMUEL GEORGE MORTON, M. D. 
 
 In One neat Octavo Volume. 
 
 This popular work has been too extensively and favorably known to the profession in the United States to 
 require any remarks in introducing a new edition, except to state that the improvements in it will be foam) to 
 be numerous and important. Great care has been taken in its passage through the press to insure the utmost 
 accuracy, and it is confidently presented as worthy the increased confidence oi physicians and apothecaries. 
 
12 LEA & BLANCHARD'S PUBLICATIONS. 
 
 HASSE'STPATHOLOGI^ 
 
 AN ANATOMICAL DESCRIPTION 
 
 OF THE DISEASES OF THE 
 
 ORGANS OF CIRCULATION AND RESPIRATION. 
 
 BY CHARLES EWALD HASSE, 
 
 Professor of Pathology and Clinical Medicine in the University of Zurich, &c. 
 TRANSLATED AND EDITED BY 
 
 W. E. SWAINE. M.D., &c. 
 
 In one octavo volume. 
 
 A New Work, Just Heady.— July 1846. 
 HOPE ON THE HEART,— New Edition. 
 
 A TREATISE ON THE DISEASES 
 
 OF THE HEART AND GREAT VESSELS, 
 
 AND ON THE AFFECTIONS WHICH MAY BE MISTAKEN 
 
 FOR THEM. 
 
 COMPRISING THE AUTHOR'S VIEW OF THE PHYSIOLOGY OF THE HEART'S 
 
 ACTION AND SOUNDS AS DEMONSTRATED BY HIS EXPERIMENTS 
 
 ON THE MOTIONS AND SOUNDS IN 1830, AND ON THE 
 
 SOUNDS IN 1S34-5. 
 
 BY J. HOPE, M.D., F.R.S., &c. &c, 
 
 Second American from the Third London Edition. 
 WITH NOTES AND A DETAIL OF RECENT EXPERIMENTS. 
 
 BY C. W. PENNOCK, M.D., &c. 
 
 In one octavo volume of nearly 600 pages, with lithographic plates. 
 
 HUGHES ON THE LUNGS AND HEART. 
 
 CLINICAL INTRODUCTION TO THE PRACTICE OF AUSCULTATION, 
 
 AND OTHER MODES OF PHYSICAL DIAGNOSIS. 
 INTENDED TO SIMPLIFY THE STUDY OF THE DISEASES OF THE HEART 
 
 AND LUNGS. 
 BY H. M. HUGHES, M.D., &c. 
 
 In One Duodecimo Volume, with a plate. 
 
 A NEW WORK.— PHILLIPS ON SCROFULA. 
 
 JTUST UEvlDW— July 1846. 
 
 SCR O^F U L A, 
 
 ITS NATURE, ITS PREVALENCE, ITS CAUSES, AND THE PRINCIPLES OF 
 
 ITS TREATMENT. 
 BY BENJAMIN PHILLIPS, M.D., F.R. S., &c. 
 
 In one neat octavo volume, with a plate. 
 
 '•'• There can be no doubt that there was ample room for a fresh review of scrofula, and that a work on the 
 subject, from a writer of learning, industry, and talent, must be acceptable ; and such, after a careftd perusal, 
 the work before us appears to be. Very uncommon pains seem to have been taken in collecting information 
 from men as well as books. Our impression of this work is, that it is a very important accession to our profes- 
 sional literature, and does the greatest credit to the industry, research and talent of the author. Its utility is, 
 we think, likely to extend far beyond the limits of professional society." — The London Medical Gazette. 
 
 This work is just published. The author has been for years engaged in the collection of materials and sta- 
 tistics from all parts of the world. » 
 
 SMALL BOOKS ON GREAT SUBJECTS. 
 
 ^VOtr* READY, 
 
 "The Connection between Physiology and Intellectual Science." 
 
 Forming Xo. 2 of a series of small works now issuing at Twenty-five Cents each. 
 
 To be fojjowed shortly by "Philosophical Theories and Philosophical Experience," — On Man's 
 Power over Himself to Prevent or Control Insanity," — "An Introduction to Practical Organic Che- 
 mistry," — " An Introduction to Vegetable Physiology, with References to the Works of De Can- 
 dolle^ Lindley, &c," and several other new and valuable works. Each one to form a very neat 
 and portable volume. 
 
 (KF* These works have acquired great popularity in England, and the publishers take pleasure 
 in introducing the series neatly printed, and at so low a price. 
 
LEA & ELANCHARD'S PUBLICATIONS. 13 
 
 COMPENDIU^^ 
 
 A COMPENDIUM OF LECTURES 
 
 ON THE 
 
 THEORY AND PRACTICE OF MEDICINE. 
 
 DELIVERED BY PROFESSOR CHAPMAN IN THE UNIVERSITY OF PENN- 
 SYLVANIA. 
 
 PREPARED. WITH PERMISSION. FROM DR. CHAPMAN'S MANUSCRIPTS, 
 AND PUBLISHED WITH HIS APPROBATION, 
 
 BY N. D. BENEDICT, M. D. 
 
 IN ONE VERY NEAT OCTAVO VOLUME. 
 
 CONTENTS. 
 
 Remarks on the Classification of Diseases — Fever in General — Intermittent Fever — Remittent Fever 
 — Continued Fever, (Mild, Intermediate, and Extreme Forms) — 'Yellow Fever — Endemic Pneu- 
 monic, or Spotted Fever— Diseases of the Heart and Blood-vessels, (Inflammatory, Organic, and. 
 Nervous) — Acute Carditis, Pericarditis, and Endocarditis — Chronic Carditis, Pericarditis, and En- 
 docarditis — Hypertrophy of the Heart — Dilatation of the Heart — Atrophy of the Heart — Rupture 
 of the Heart — Affections of the Valves of the Heart — Palpitations — Acute Arteritis — Degenera- 
 rations of Arteries — Aneurism of Arteries — Phlebitis — Acute Inflammation of the Throat — Chronic 
 Inflammation of the Throat — Dysphagia — Parotitis — Dysentery, (Inflammatory) — Dysentery, (Con- 
 gestive) — Diarrhoea — Cholera Morbus — Cholera Infantum — Flatulent Colic — Bilious Colic — Colica 
 Pictonum — Acute Peritonitis — Chronic Peritonitis — Acute Catarrh — Catarrhus iEstivus — Chronic 
 Catarrh — Acute Bronchitis — Chronic Bronchitis — Catarrhus Senilis — Acute Infantile Bronchitis — 
 Chronic Infantile Bronchitis — Croup — Acute Infantile Asthma — Whooping-Cough — Acute Laryn- 
 gitis — Chronic Laryngitis— Pleuropneumonia — Congestive Pneumonia — Chronic Pleurisy and 
 Pneumonia — Apoplexy — Palsy — Epilepsy — Hysteria — Chorea — Neuralgia — Diabetes. 
 The subjects treated of in this volume are entirely distinct from those considered in Dr. 
 
 Chapman's two works on "Thoracic and Abdominal Viscera," and on "Eruptive Fevers," 
 
 &c. These works are all printed and bound to match, and form three very neat octavo 
 
 volumes. 
 
 LECTURES ON THE MORE IMPORTANT DISEASES 
 
 OF THE 
 
 THORACIC AND ABDOMINAL VISCERA 
 
 DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. 
 BY N. CHAPMAN, M. D. 
 
 PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE, ETC. 
 
 In One Volume, Octavo. 
 
 CHAPMAN ON FEVERS, &c. 
 
 LECTURES ON THE MORE IMPORTANT 
 
 ERUPTIVE FEVERS, HEMORRHAGES AND DROPSIES, 
 
 AND ON GOUT AND RHEUMATISM, 
 
 DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. 
 By N. CHAPMAN, M.D., 
 
 PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE, ETC. ETC. 
 
 In One Neat Octavo Volume. 
 "The name of Chapman stands deservedly high in the annals of American medical science. A teacher and 
 a lecturer for nearly forty years, in the oldest and, we believe, the first medical school on this side of-the A:- 
 lantic, the intimate friend and companion of Rush, Kuhn, Physlck, Wistar, Woodhouse, Dewees, and 
 of others, scarcely less renowned, Professor Chapman reflects upon the profession of this generation something 
 of the genius and wisdom of that which has passed ; he stands out the able and eloquent champion ol ll 
 trines and principles of other times, when Cullen's " first lines" formed the rule o\ faith for all the Doctors in 
 Medicine throughout Christendom. In him is embodied the experience o\ three score and Leo., Strengthened 
 by reading, and enlightened by a familiar intercourse with many oi the ablest medical men in the New and 
 Old World. In conclusion, we must declare our belief that the name o( Chapman will survive when that o( 
 many of his cotemporaries shall have been forgotten ; when oilier generations shall tre.id the groat t! < 
 human affairs, and when other discoveries yet undisclosed, shall shed a brighter light upon the path of medi- 
 cal science. The various lectures which he has been publishing, containing, as they do, the doctri 
 he has so long and so eloquently taught to large and admiring classes, wo doubt not will be welcomed with 
 delight by his numerous pupils throughout the Union."— New Orleans Medical A . 
 
14 LEA & BLANCHARD'S PUBLICATIONS. 
 
 H R N EITS^TnTt M Y , 
 
 NEW EDITION— To be Ready by October, 
 
 S P E C I AL AN ATOMY 
 
 AND 
 
 HISTOLOGY. 
 
 BY 
 
 WILLIAM E. HORNER, M.D., 
 
 PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, &c. &c. 
 
 SEVENTH EDITION, 
 
 WITH MANY IMPROVEMENTS AND ADDITIONS. 
 In two Octavo Volumes, with Illustrations on Wood. 
 This standard work has been so long before the profession, and has been 
 so extensively used, that, in announcing the new edition, it is only neces- 
 sary to state that it will undergo a most careful revision ; the author wilL 
 introduce many illustrations relating to Microscopical Anatomy, and will 
 add a large amount of text on these various points of investigation that 
 are rapidly advancing and attracting so much attention. This new edi- 
 tion will be arranged to refer conveniently to the illustrations in Smith 
 and. Horner's Anatomical Atlas, and will be ready for the Fall Lectures. 
 
 HORNER'S JDISSECTOR. 
 
 THE UNITED STATES DISSECTOR, 
 
 BEING A NEW EDITION, WITH EXTENSIVE MODIFICATIONS, AND 
 ALMOST REWRITTEN, 
 
 \\ 
 
 HORNER'S PRACTICAL ANATOMY." 
 
 IN ONE VERY NEAT VOLUME, 
 ROYAL 12mo. 
 With many Illustrations on Wood. 
 The numerous alterations and additions which this work has under- 
 gone, the improvements which have been made in it, and the numerous 
 wood-cuts which have been introduced, render it almost a new work. 
 
 It is the standard work for the Students in the University of Pennsyl- 
 vania. 
 
 BUDD ON THE LIVER. 
 
 ON DISEASES OF THE LIVER. 
 
 BY GEORGE BUDD, M.D., F.R.S., 
 
 Professor of Medicine in King's College, London, &c. &c. 
 With colored plates, and numerous wood-cuts. In one neat octavo volume. 
 " We cannot too strongly recommend the diligent study of this volume. The work cannot fail to rank the 
 name of its author among the most enlightened pathologists and soundest practitioners of the day."— Medico- 
 Ckvrurgical Review. 
 
a ittAftDnrxcEnrT and cheap work. 
 
 SMITH & -HORNER'S ANATOMICAL ATLAS, 
 
 Just Published, Price Five Dollars in Parts. 
 
 AN 
 
 ANATOMICAL ATLAS 
 
 ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. 
 
 BY HENRY H. SMITH, M. D., 
 
 Fellow of the College of Physicians, $c 
 UNDER THE SUPERVISION OF 
 
 WILLIAM E. HORNER, M. D., 
 
 Professor of Anatomy in the University of Pennsylvania. 
 
 In One large Volume, Imperial Octavo. 
 
 This work is but just completed, having been delayed over the time intended by the great difficulty in giving 
 to the illustrations the desired finish and perfection. It consists of five parts, whose contents are as follows : 
 
 Part I. The Bones and Ligaments, with one hundred and thirty engravings. 
 
 Part II. The Muscular and Dermoid Systems, with ninety-one engravings. 
 
 .Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. 
 
 Part IV. The Organs of Respiration and Circulation, with ninety-eight engravings. 
 
 Part V. The Nervous System and the Senses, with one hundred and twenty-six engravings. 
 Forming altogether a complete System of Anatomical Plates, of nearly 
 
 SIX HUNDRED AND FIFTY FIGURES, 
 executed in the best style of art, and making one large imperial octavo volume. Those who do not want it in 
 parts can have the work bound in extra cloth or sheep at an extra cost. 
 
 This work possesses novelty both in the design and the execution. It is the first attempt to apply engraving 
 on wood, on a large scale, to the illustration of human anatomy, and the beauty of the parts issued induces the 
 publishers to flatter themselves with the hope of the perfect success of their undertaking. The plan of the 
 work is at once novel and convenient. Each page is perfect in itself, the references being immediately under 
 the figures, so that the eye takes in the whole at a glance, and obviates the necessity of continual reference 
 backwards and forwards. The cuts are selected from the best and most accurate sources ; and, where neces- 
 sary, original drawings have been made from the admirable Anatomical Collection of the University of Penn- 
 sylvania. It embraces all the late beautiful discoveries arising from the use of the microscope in the investi- 
 gation of the minute structure of the tissues. 
 
 In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they 
 now present it to the profession, with the full confidence that it will be deemed all that is wanted in a scientific 
 and artistical point of view, while, at the same time, its very low price places it within the reach of all. 
 
 It is particularly adapted to supply ilie place of skeletons or subjects, as the profession wiU see by examining the Hit 
 of plates 
 
 "These figures are well selected, and present a complete and accurate representation of that wonderful fabrie, 
 the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its 
 superb artistical execution, have been already pointed out. We must congratulate the student upon the 
 completion of this atlas, as it is the most convenient work of the kind that has yet appeared ; and, we must 
 add, the very beautiful manner in which it is ' got up' is so creditable to the country as to be flattering to our 
 national pride." — American Medical Journal. 
 
 "This is an exquisite volume, and a beautiful specimen of art. We have numerous Anatomical Atlases, 
 but we will venture to say that none equal it in cheapness, and none surpass it in faithfulness and spirit. We 
 strongly recommend to our friends, both urban and suburban, the purchase of this excellent work, for winch 
 both editor and publisher deserve tlie thanks of the profession." — Medical Examiner. 
 
 "We would strongly recommend it, not only to the student, but also to the working practitioner, who, 
 although grown rusty in the toils of his harness still has the desire, and often the necessity, of refreshing his 
 knowledge in this fundamental part of the science of medicine." — New York Journal of Medicine and Surg. 
 
 " The plan of this Atlas is admirable, and its execution superior to any thing of the kind before published m 
 this country. It is a real labour-saving affair, and we regard its publication as the greatest boon that could be 
 conferred on the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy 
 means of recalling the details learned in the dissecting room, and which are soon forgotten.'' — American Mtdu 
 cal Journal. 
 
 "It is a beautiful as well as particularly useful design, which should be extensively patronized by physicians, 
 Burgeons and medical students." — Boston Med. and Surg. Journal. 
 
 " It has been the aim of the author of the Atlas to comprise in it the valuable points of all previous works, to 
 embrace the latest microscopical observations on the anatomy of the tissues, and by placing it at a moderate 
 price to enable all to acquire it who may need its assistance in the dissecting or operating room, or other BeW 
 of practice." — Western Journal of Med. and Surgery. 
 
 "These numbers complete the series of this beautiful work, which fully merits the praise bestowed upon the 
 earlier numbers. We regard all the engravings as possessing an accuracy only equalled by their beauty, 
 and cordially recommend the work to all engaged in the study of anatomy. ■'— A< w York Journal cf Medici'. c 
 and Surgery. 
 
 "A more elegant work than the one before us could not easily be placed by a physician upon the table of 
 his student.*' — Western Journal of Medicine and Surgery. 
 
 "We were much pleased with Part T, but the Second Part gratifies us still more, both as regards the . 
 lve nature of the subject, (The Dermoid and Muscular Systems.) and the beautiful arusiieal execution 
 Jlustrations. We have here delineated the most accurate microscopic views of some of the tissues, is 
 instance, the cellular and adipose tissues, the epidermis, rete mucosum and cutis vera, the sebaceous and 
 perspiratory organs of the skin, the perspiratory glands and hairs of the skin, and the hair and nails. Then 
 follows the general anatomy of the muscles, and, lastly, their separate delineations. We would recommend 
 this Anatomical Atlas to our readers in the very strongest terms." — N&D York Journal 0/ 
 eery. 
 
16 LEA & BLANCHARD'S PUBLICATIONS. 
 
 THERAPEUTICAL LIBRARY 
 
 PEREIRA'S MATERIA MEDICA, 
 
 WITH NEARLY THREE HUNDRED ENGRAVINGS ON WOOD. 
 
 A NEW EDITION, LATELY PUBLISHED. 
 
 THE ELEMENTS OF 
 
 MATERIA MED1CA AND THERAPEUTICS, 
 
 COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPO- 
 SITION, EFFECTS AND USES OF MEDICINES. 
 
 BY JONATHAN PEREIRA, M.D., F.R.S. andL.S., 
 
 Member of the Society of Pharmacy of Paris; Examiner in Materia Medica and Pharmacy of the University 
 of London; Lecturer on Materia Medica at the London Hospital, &c. &c. 
 
 Second American, from the last London Edition, enlarged and improved. 
 WITH NOTES AND ADDITIONS BY JOSEPH CARSON, M.D. 
 
 In Two Volumes, Octavo, containing Fifteen Hundred very large Pages, illustrated by- 
 Two Hundred and Seventy-five Wood-cuts. 
 
 Part I. contains the General Action and Classification of Medicines and the Mineral Materia 
 Medica. Part II., the Vegetable and Animal Kingdoms, including diagrams explanatory of the 
 Processes of the Pharmacopoeias, a tabular view of the History of the Materia Medica, from the 
 earliest times to the present day, with the Introduction of the Processes of the New Edinburgh 
 Pharmacopoeia, and a very copious index. It also contains additional articles on Mental Remedies, 
 Light, Heat, Cold, Electricity, Magnetism, Exercise, Dietetics and Climate, and many additional 
 Wood-cuts, illustrative of Pharmaceutical Operations, Crystallography, Shape and Organization of 
 the Feculas of Commerce, and the Natural History of the Materia Medica. 
 
 In passing through the press the second edition of this standard work, the opportunity has been 
 taken by the editor to correct any mistakes or inadvertencies that may have escaped him or the 
 author, in the first edition. It may now be considered as entirely worthy of the confidence of the 
 physician and pharmaceutist, as an accurate edition of the most complete work extant on the subject. 
 
 "x\n Encyclopcedia of knowledge in that department of medical science— by the common consent of the pro- 
 fession the most elaborate and scientific Treatise on Materia Medica in our language."— Western Journal of 
 Medicine and Surgery. 
 
 THE STUDENT'S TEXT-BOOK OF MATERIA MEEIGA. 
 
 MOW AT PRESS, 
 
 A MANUAL OF 
 MATERIA MEDICA AND THERAPEUTICS. 
 
 By J. FORBES EOYLE, M. D., 
 
 PROFESSOR IN KING'S COLLEGE, LONDON. 
 
 EDITED BY 
 
 J. CARSON, M.D.,- 
 
 Professor of Materia Medica and Pharmacy in the Philadelphia College of Pharmacy, etc. etc. 
 
 In One Octavo Volume, with Numerous Splendid Illustrations. 
 
 This work will contain all the most recent information and investigations in the various 
 branches connected with the Materia Medica, and under the supervision of its able editor, 
 will, receive whatever alterations and additions may be necessary to adapt it to the United 
 States Pharmacopoeia, and to the practice of this country. The high character of the author 
 will attract attention to the work as a text-book for the next session of the various colleges, 
 if ready. The numerous and beautiful illustrations will far surpass anything that has as 
 yet been attempted in this way. This volume will be brought out in a style to match Fer- 
 guson's Surgery, Wilson's Anatomy, &c, and will be sold at a low price. 
 
LEA & BLANCHARD'S PUBLICATIONS. 17 
 
 THE GREATliEDICAL 
 THE CYCLOPEDIA OF PRACTICAL MEDICINE; 
 
 COMPRISING TREATISES ON THE 
 
 NATURE AND TREATMENT OF DISEASES, 
 
 MATERIA MEDIGA k THERAPEUTICS, 
 
 DISEASES OE WOMEN AND CHILDREN, 
 MEDICAL JURISPRUDENCE, &c. &c. 
 
 EDITED BY 
 
 JOHN FORBES, M. D., F. R. S., 
 ALEXANDER TWEEDIE, M.D., F.R.S., 
 
 AND 
 
 JOHN CONOLLY, M.D. 
 
 REVISED, WITH ADDITIONS, 
 
 By ROBLEY DUNGLISON, M. D. 
 
 THIS WORK IS NOW COMPLETE, AND FORMS 
 
 FOUR LARGE SUPER-ROYAL, OCTAVO VOLUMES, 
 
 CONTAINING THIRTY-TWO HUNDRED AND FIFTY-FOUR 
 UNUSUALLY LARGE PAGES IN DOUBLE COLUMNS, 
 
 PRINTED ON GOOD PAPER, WITH A NEW AND CLEAR TYPE. 
 THE WHOLE WELL AND STRONGLY BOUND, 
 
 WITH RAISED BANDS AND DOUBLE TITLES. 
 Or, to be had in twenty-four parts, at Fifty Cents each. 
 
 For a list of Articles and Authors, together with opinions of the press, see Supplement to the No- 
 vember number of the Medical News and Library. 
 
 This work having been completed and placed before the profession, has 
 been steadily advancing in favor with all classes of physicians. The nu- 
 merous advantages which it combines, beyond those of any other work ; 
 the weight which each article carries with it, as being the production of 
 some physician of acknowledged reputation who has devoted himself 
 especially to the subject confided to him, the great diversity of topics 
 treated of; the compendiousness with which everything of importance is 
 digested into a comparatively small space ; the manner in which it has 
 been brought up to the day, everything necessary to the American prac- 
 titioner having been added by Dr. Dunglison ; the neatness of its mecha- 
 nical execution, and the extremely low price at which it is afforded, 
 combine to render it one of the most attractive works now before the pro- 
 fession. As a book for constant and reliable reference, it presents advan- 
 tages which are shared by no other work of the kind. To country prac- 
 titioners, especially, it is absolutely invaluable, comprising in a mode- 
 rate space, and trifling cost, the matter for which they would have to 
 accumulate libraries, when removed from public collections. The steady 
 and increasing demand with which it has been favored since its completion, 
 shows that its merits have been appreciated, and that it is now univers 
 considered as the 
 
 LIBRARY FOR CONSULTATION AND REFERENCE. 
 
18 LEA & BLANCHARD'S PUBLICATIONS. 
 
 WORKS BY PROFESSORS CHURCHILL, MEIGS, &c. 
 CHURCHILL'S MIDWIFERY. 
 
 A New Edition, Just Published. 
 
 ON THE THEORY AND PRACTICE OF MIDWIFERY. 
 
 BY FLEETWOOD CHURCHILL, M.D., M.R.I. A., 
 
 Licentiate of the College of Physicians in Ireland; Physician to the Western Lying-in Hospital ; Lecturer on 
 Midwifery, &c, in the Richmond Hospital Medical School, &c. &c. 
 
 WITH NOTES AND ADDITIONS 
 
 BY ROBERT M. HUSTON, M. D., 
 
 Professor of Materia Medica and General Therapeutics, and formerly of Obstetrics and the Diseases of Wo- 
 men and Children in the Jefferson Medical College of Philadelphia ; President of the Philadelphia 
 Medical Society. &c. &c. 
 
 SECOND AMERICAN EDITION. 
 
 WITH ONE HUNDRED AND TWENTY-EIGHT ILLUSTRATIONS, 
 
 ENGRAVED BY GILBERT FROM DRAWINGS BY BAGG AND OTHERS. 
 
 In One beautiful Octavo Volume. 
 The call for a second edition of Dr. Churchill's Midwifery, within so short a time after the ap- 
 pearance of the first, is satisfactory evidence that the profession in this country appreciate the high 
 value of the work. Both as a text-book for the student and as a manual for the practitioner, it has 
 a deservedly great reputation, especially for the fulness and clearness with which the physiological 
 details are wrought out and brought to illustrate the practical part. To render the present edition 
 worthy of a continuance of the favor and confidence so signally manifested towards its predecessor, 
 the editor has carefully added all the new facts and observations which have transpired since the 
 publication of the last edition, or such at least as appeared to him deserving of being recorded. 
 These relate to some of the most important points in physiology and obstetrical practice. Various 
 new illustrations have been introduced, and the whole brought up, as far as possible, to the day of 
 publication. 
 
 A NEW EDITION OF CHURCHILL ON FEMALES. 
 
 THE DISEASES OF FEMALES, 
 
 INCLUDING THOSE OF 
 
 PREGNANCY AND CHILDBED. 
 BY FLEETWOOD CHURCHILL, M.D., 
 
 Author of " Theory and Practice of Midwifery," &c. &c. 
 THIRD AMERICAN, FROM THE SECOND LONDON EDITION, WITH ILLUSTRATIONS' 
 EDITED, WITH NOTES, 
 BY ROBERT M. HUSTON, M. D., &c. &c. 
 
 In One Volume, 8vo. 
 " In complying with the demand of the profession in this country for a third edition, the Editor 
 has much pleasure in the opportunity thus afforded of presenting the work in its more perfect form. 
 All the additional references and illustrations contained in the English copy are retained in this." 
 
 A TREATISE ON THE DISEASES OF FEMALES, 
 AND ON THE SPECIAL HYGIENE OF THEIR SEX. 
 
 WITH NUMEROUS WOOD-CUTS. 
 
 BY COLO MB AT DE L'ISERE, M. D., 
 
 Chevalier of the Legion of Honor ; late Surgeon to the Hospital of the Rue de Valois, devoted to the Diseases 
 
 of Females, &c. &c. 
 
 TRANSLATED, WITH MANY NOTES AND ADDITIONS, 
 
 By C. D. MEIGS, M.D., 
 
 Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, &c. &c. 
 
 In One Large Volume, 8vo. 
 "We are satisfied it is destined to take the front rank in this department of medical science; it is 
 beyond all comparison, the most learned Treatise on the Diseases of Females that has ever been 
 written, there being more than one thousand distinct authorities quoted and collected by the inde- 
 fatigable author. It is in fact a complete exposition of the opinions and practical methods of all 
 the celebrated practitioners of ancient and modern times. The Editor and Translator has per- 
 formed his part in a manner hardly to be surpassed. The translation is faithful to the original, and 
 yet elegant. More than one hundred pages of original matter have been incorporated in the text, 
 constituting a seventh part of the whole volume." — New York Journal of Medicine, 
 
LEA & BLANCHARD'S PUBLICATIONS. 19 
 
 works fFprofessorTwT^^ 
 
 NEW EDITIONS. 
 
 DEWEES'S MIDWIFERY. 
 
 A COMPREHENSIVE SYSTEM OF MIDWIFERY. 
 
 CHIEFLY DESIGNED TO FACILITATE THE INQUIRIES OF THOSE WHO MAY BE PUR- 
 SUING THIS BRANCH OF STUDY. 
 
 ILLUSTRATED BY OCCASIONAL CASES AND MANY ENGRAVINGS. 
 
 Tenth Edition, with the Author's last Improvements and Corrections. 
 
 BY WILLIAM P. DEWEES, M. D., 
 
 LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. 
 
 In one volume, octavo. 
 That this work, notwithstanding the length of time it has been before the profession, and the 
 numerous treatises that have appeared since it was written, should have still maintained its ground, 
 and passed to edition after edition, is sufficient proof that in it the great practical talents of the 
 author were fully placed before the profession. Of the book itself it would be superfluous to 
 speak, having been so long and so favorably known throughout the country as to have become 
 identified with American Obstetrical Science. 
 
 DEWEES ON FEMALES. 
 
 A TREATISE ON THE DISEASES OE FEMALES, 
 
 BY WILLIAM P. DEWEES, M. D., &c. 
 
 LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. 
 
 EIGHTH EDITION, 
 With the Author's last Improvements and Corrections. 
 
 In one octavo volume, with plates. 
 
 DEWEES ON CHILDREN. 
 
 A TREATISE ON THE 
 
 PHYSICAL AND MEDICAL TREATMENT OF CHILDREN, 
 
 BY WILLIAM P. DEWEES, M.D., 
 
 LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. ETC. 
 
 EIGHTH EDITION. 
 
 In one volume, octavo. 
 
 This edition embodies the notes and additions prepared by Dr. Dewees before his death, and will be found 
 much improved. 
 
 The objects of this work are, 1st, to teach those who have the charge of children, either as parent or guardian, 
 the most approved methods of securing and improving their physical powers. This is attempted by pointing 
 put the duties which the parent or the guardian owes for this purpose, to this interesting but helpless class of 
 beings, and the manner by which their duties shall be fulfilled. And 2d, to render available a long experi- 
 ence to those objects of our affection when they become diseased. In attempting this, the author has avoided 
 as much as possible, "technicality," and has given, if he does not flatter himself too much, to each disease of 
 which he treats, its appropriate and designating characters, with a fidelity that will prevent any two being con- 
 founded together, with the best mode of treating them, that either his own experience or that of others has 
 suggested. 
 
 Physicians cannot too strongly recommend the use of this book in all families. 
 
 ASHWELL ON THE DISEASES OF FEMALES. 
 
 A PRACTICAL TREATISE ON THE 
 
 DISEASES PECULIAR TO WOMEN. 
 
 ILLUSTRATED BY CASES 
 
 DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. 
 
 By SAMUEL ASHWELL, M. D., 
 
 Member of the Royal College of Physicians; Obstetric Physician and Lecturer to Guv's Hospital, fee. 
 
 Edited by PAUL BECK GODDARD, M. D. ' 
 
 The whole complete in one large octavo volume. 
 M The most able, and certainly the most standard and practical work on female diseases that 
 have yet seen.' 
 
20 LEA & BLANCHARD'S PUBLICATIONS. 
 
 LATELY PUBLISHED, 
 A NEW EDITION OF 
 
 WILSON'S HUMAN ANATOMY, 
 
 MUCH IMPROVED. 
 
 A SYSTEM OF HUMAN ANATOMY, 
 
 GENERAL AND SPECIAL. 
 
 BY ERASMUS WILSON, M.D., 
 
 LECTURER ON ANATOMY, LONDON. 
 
 SECOND AMERICAN EDITION, EDITED BY 
 
 PAUL B. GODDARD, A.M.,M.D., 
 
 Professor of Anatomy and Histology in the Franklin Medical College, Philadelphia. 
 
 WITH OVER TWO HUNDRED ILLUSTRATIONS. 
 
 Beautifully Printed from the Second London Edition, in One very neat Octavo Volume. 
 
 "Mr. Wilson, before the publication of this work, was very favorably known to the profession by his trea- 
 tise on Practical and Surgical Anatomy; and, as this is the Second American Edition, from the second London 
 Edition, since 1840, any special commendation of the high value of the present work, on our part, would be 
 supererogatory. Besides, the work has been translated at Berlin, and overtures were repeatedly made to the 
 London publisher for its reproduction in France. The work is, undoubtedly, a complete system of human 
 anatomy, brought up to the present day. The illustrations are certainly very beautiful, the originals having 
 been expressly designed and executed for this work by the celebrated Bagg of London; and, in the American 
 edition they have been copied in a masterly and spirited manner. As a text-book in the various colleges we 
 would commend it in the highest terms."— New York Journal of Medicine. 
 
 WILSON'S DISSECTOR, 
 
 THE DISSECTOR; 
 
 OR, PRACTICAL AND SURGICAL ANATOMY. 
 
 BY ERASMUS WILSON, 
 
 Author of " A System of Human Anatomy, &c. 
 
 WITH ONE HUNDRED AND SIX ILLUSTRATIONS. 
 
 MODIFIED AND RE-ARRANGED BY 
 
 PAUL B. GODDARD, M. D., 
 
 Professor of Anatomy and Histology in the Franklin Medical College, Philadelphia. 
 In One Large Royal Duodecimo Volume., Sheep. 
 " It strikes us as being all that a "Dissector" should be. The wood-cuts are numerous and will 
 afford the student the most essential aid in the dissecting room." — West. Journ. of Med. and Surg. 
 
 WILSON ON THE SKIN 
 
 A PRACTICAL AND THEORETICAL TREATISE 
 
 ON THE 
 
 DIAGNOSIS, PATHOLOGY AND TREATMENT 
 
 OF DISEASES OF THE SKIN; 
 
 ARRANGED ACCORDING TO A NATURAL SYSTEM OF CLASSIFICATION, 
 
 AND PRECEDED BY 
 
 AN OUTLINE OF THE ANATOMY AND PHYSIOLOGY OF THE SKIN. 
 BY ERASMUS WILSON, 
 
 Lecturer on Anatomy and Physiology in the Middlesex Hospital Medical School, &c. &c. 
 In One Neat Octavo Volume, Cloth. 
 " It is a sound book of practice. As a practical guide to the classification, diagnosis arid treatment of the dis 
 eases of the skin, the book is complete. We know nothing, considered in this aspect, better in our language : 
 it is a safe authority in all the matters which, in this range of diseases, engage the practitioner's attention, and 
 possesses the high quality, unknown, we believe, to every older manual, of being on a level with Science's high 
 water mark.— Medical Times. 
 
LEA & BLANCHARD'S PUBLICATIONS. 21 
 
 A NEW AND COMPLETE WORK ON FEVERS. 
 
 FEVERS; 
 
 THEIR DIAGNOSIS, PATHOLOGY & TREATMENT. 
 
 PREPARED AND EDITED WITH LARGE ADDITIONS, 
 
 FROM THE ESSAYS ON FEVER IN 
 
 TWEEDIE'S LIBRARY OF PRACTICAL MEDICINE, 
 
 BY 
 MEREDITH CLYMER, M.D., 
 
 Professor of the Principles and Practice of Medicine in Franklin Medical College, Philadelphia ; 
 Consulting Physician to the Philadelphia Hospital ; Fellow of the Col- 
 lege of Physicians, fyc. SfC. 
 
 In one octavo volume of 600 pages. 
 
 The want of a distinct treatise on Fevers, embodying the received doctrines of their pathology and 
 treatment has long been felt and generally acknowledged. To supply this deficiency in medical 
 literature is the object of the present volume. It has been prepared from the Essays on Fever 
 contributed by Drs. Christison, Shapter, Burrows, Gregory and Locock, to Dr. Tweedie's " Library 
 of Practical Medicine," and will be found to embrace the whole class of 
 
 Idiopathic Fevers,— -Continued, Periodical, Eruptive, and Puerperal. 
 
 The additions of the Editor, amounting to about one-half of the volume, have been chiefly made 
 with reference to the Fevers of this country. It has been his aim to render the work as complete as 
 possible, and to adapt it particularly to the necessities of the American Practitioner. 
 
 WILLIAMS' PATHOLOGY. 
 
 PRINCIPLES OF MEDICINE, 
 
 COMPRISING 
 
 GENERAL PATHOLOGY AND THERAPEUTICS, 
 
 AND A GENERAL VIEW OF 
 
 ETIOLOGY, NOSOLOGY, SEMEIOLOGY, DIAGNOSIS AND PROGNOSIS. 
 BY CHARLES J. B. WILLIAMS, M. D., F.R.S., 
 
 Fellow of the Royal College of Physicians, &c. 
 
 WITH NOTES AND ADDITIONS, 
 
 BY MEREDITH CLYMER, M.D.,&c. 
 
 In one volume, 8vo. 
 
 WILLIAMS AND CLYMER ON THE CHEST, &c 
 
 A TREATISE ON THE 
 
 DISEASES OF THE RESPIRATORY [ORGANS, 
 
 INCLUDING 
 
 THE TRACHEA, LARYNX, LUNGS, AND PLEURA. 
 
 BY CHARLES J. B. WILLIAMS, M.D., 
 
 Consulting Physician to the Hospital for Consumption and Diseases of the Chest; Author of 
 "Principles of Medicine," &c. &c. 
 WITH NUMEROUS ADDITIONS AND NOTES, 
 BY MEREDITH CLYMER, M.D., &c. 
 In one neat octavo volume, with cuts. 
 This work recommends itself to the notice of the profession as containing a more particular and 
 detailed account of the affections of which it treats than perhaps any other volume before the public. 
 'The wood-cuts illustrating the physical exminatiou ot" the chest, are admirably executed, ami the whole 
 mechanical execution of the work does much credit to the publishers. This work is undoubtedly deal 
 take precedence ot" all others yet published on the ' Respiratory Organs.' and as a uv.-book tor teachers and 
 students, no better in the present state of the. science is to be expected."— Ac u< York Journal of Midiein*. 
 
22 LEA & BLA CHARD'S PUBLICATIONS. 
 
 KIRBY & SPENC^^ USE, 
 
 AN INTRODUCTION TO ENTOMOLOGY; 
 
 OR, ELEMENTS OF THE NATURAL HISTORY OF INSECTS : COMPRISING 
 
 AN ACCOUNT OF NOXIOUS AND USEFUL INSECTS, OF THEIR 
 
 METAMORPHOSES, FOOD, STRATAGEMS, HABITATIONS, 
 
 SOCIETIES, MOTIONS, NOISES, HYBERNATION, 
 
 INSTINCT, &c, &c. 
 
 With Plates. Plain or Colored. 
 
 By WILLIAM KIRBY, M.A., F.R.S. And WILLIAM SPENCE, Esq., F.R.S. 
 
 FROM THE SIXTH LONDON EDITION. 
 
 Which was Corrected and Considerably Enlarged, 
 
 In One Large Octavo Volume, extra cloth. 
 
 This work, as it at present stands, is acknowledged to be the best extant as a popular introduction to the 
 science, containing an immense amount of singular and interesting information, conveyed in a simple and 
 agreeable manner. In preparing the last edition, from which this is primed, the authors have omitted the two 
 last volumes, as being too scientific for popular use, and arranged it as it now is, forming a complete exposi 
 tion of the principles of the study, unincumbered with Anatomical or scientific details. 
 
 "We are well aware that the physician engaged in an engrossing practice, whether in town or country, 
 has not much leisure for the perusal of books unconnected with his profession ; but we know just as well, that 
 while the few are thus immersed in business, the many have the command of more time than they are disposed 
 to give to professional reading. How many are the hours wasted by nearly every young physician, waiting 
 for practice— anxious, dreary hours, because unoccupied ! Why not spend these hours in the study of such 
 works as that of Kirby & Spence, wherein the physiologist, farmer, horticulturist, philosopher, and moralist, 
 may find matter to instruct him.— The Western Journal of Medicine and Surgery. 
 
 "The republication of this work, which has for many years enjoyed a very high and constantly increasing 
 popularity in Great Britain, confers a decided benefit upon natural science in this country. It is a free, careful 
 and authentic exposition of the very extensive department of study, of which it treats, and has done much 
 abroad to attract attention to a branch which, until its publication, has found comparatively little favor with the 
 scientific students of Great Britain. The treatise of Messrs. Kirby & Spence is well adapted, not only by its 
 intrinsic merit, but by its attractive style, to introduce the subject to popular favor. It is thrown into the form 
 of letters, and although abounding to some extent in scientific terms, it is divested of technicality so far as pos- 
 sible, and by a very agreeable intermixture of anecdotes, &c, is made a pleasant and entertaining, as well as 
 very instructive and important work. It is now reprinted from the sixth London edition, which has been 
 revised and corrected, and forms a very handsome octavo volume of about 600 pages. Those who have never 
 given any attention to the subject of which it treats, will find embodied in it <an immense amount of very inte- 
 resting and useful information, set forth in an agreeable and attractive style."— iV. Y Courier and Enquirer. 
 
 THE CHEMISTRY 
 
 OF THE 
 
 FOUR SEASONS, 
 
 BY THOMAS GRIFFITH, 
 
 Lecturer on Chemistry at St. Bartholomew's Hospital, &c. &c. 
 IN ONE VERY NEAT DUODECIMO VOLUME. 
 
 With Numerous Wood- cuts. A New Work. 
 The object of this little book is to show in a popular and agreeable manner the chemical agency 
 exerted in the various phenomena of nature. It forms a neat volume for the Centre Table. 
 
 A TEXT BOOK OF 
 
 PRACTICAL GEOLOGY AND MINERALOGY. 
 
 WITH INSTRUCTIONS FOR THE QUALITATIVE ANALYSIS OF MINERALS, 
 
 BY JOSHUA TRIMMER, F. G. S. 
 
 WITH TWO HUNDRED AND TWELVE WOOD-CUTS. 
 
 A handsome octavo volume, bound in embossed cloth. 
 
 This is a systematic introduction to Mineralogy, and Geology, admirably calculated to instruct the student in 
 those sciences. The organic remains of the various formations are well illustrated by numerous figures, which 
 are drawn with great accuracy. 
 
LEA & BLANCHARD'S PUBLICATIONS. 23 
 
 GRAHAM'S CHEMISTRY, 
 THE ELEMENTS OF CHEMISTRY. 
 
 INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS. 
 
 With Numerous Illustrations. 
 BY THOMAS GRAHAM, F. R. S. L. and E. D. 
 
 Professor of Chemistry in University College, London, &c. &c. 
 WITH NOTES AND ADDITIONS, 
 
 BY ROBERT BRIDGES, M. D., &c. &c, 
 
 In One Volume Octavo. 
 The great advancement recently made in all branches of chemical investigation, renders neces- 
 sary an enlarged work which shall clearly elucidate the numerous discoveries, especially in the 
 department connected with organic Chemistry and Physiology, in which such gigantic strides 
 have been made during the last few years. The present treatise is considered by eminent judges 
 to fulfil these indications, and to be peculiarly adapted to the necessities of the advanced medical 
 student and practitioner. In adapting it to the wants of the American profession, the editor has 
 endeavored to render his portion of the work worthy the exalted reputation of the first chemist ot 
 England. It is already introduced in many of the Colleges, and has universal approbation. 
 
 FOWNES'S CHEMISTRY FOR STUDENTS. 
 
 ELEMENTARY CHEMISTRY 
 
 THEORETICAL AND PRACTICAL. 
 
 By GEORGE FOWNES, Ph. D., 
 
 Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c. 
 
 With Numerous Illustrations. Edited, with Additions, 
 By ROBERT BRIDGES, M. D., 
 
 Professor of General and Pharmaceutical Chemistry in the Philadelphia College ol Pharmacy, &c. &c. 
 In one large duodecimo volume, sheep or extra cloth. 
 
 The character of this work is such as to recommend it to all colleges in want of an elementary 
 text-book, and to all practitioners who wish to place a compendious manual in the hands of their 
 students. It is fully brought up to the day, containing all the late views and discoveries that have 
 so entirely changed the face of the science, and it is completely illustrated with very numerous 
 wood engravings explanatory of all the different processes and forms of apparatus. Though strictly 
 scientific, it is written with great clearness and simplicity of style, rendering it easy to be mastered 
 by those commencing the study. The low price at which it is sold, places it within the reach of all. 
 
 Though this work has been so recently published, it has already been adopted as a text-book by 
 many of the Medical Institutions throughout the country. As a work for the first class student, and 
 as an introduction to the larger systems of Chemistry, such as Graham's, there has been but one 
 opinion expressed concerning it, and it may now be considered as 
 
 THE TEXT-BOOK FOR THE CHEMICAL STUDENT. 
 
 SIMON'S CHEMJSTRY OF MAN. 
 
 ANIMAL CHEMISTRY. 
 
 WITH REFERENCE TO THE PHYSIOLOGY & PATHOLOGY OF MAX. 
 
 BY DR. J. FRANZ SIMON. 
 
 TRANSLATED AND EDITED BY 
 GEORGE E. DAY, M. A. & L. M. Cantab., &c. 
 
 With plates. In one octavo volume, of over seven hundred pages, sheep, or in two parts. boe.- 
 
 This important work is now complete and may be had in one large octavo volume. Those who 
 obtained the first part can procure the second separate. 
 
 "No treatise on physiological chemistry approaches, In fulness and accuracy of detail, the work which 
 stands at the head of this article. It is the production of a man of true German assiduity, who has added to his 
 dwii researches the results of the labors of nearly every other inquirer in this interesting branch o( science, — 
 The death of such a laborer, which is mentioned in the preface to the work as haying occurred preinar. 
 .842, is indeed a calamity to science. He had hardly reached die middle term of life, and yel had made himself 
 tnowii all over Europe, and in our country, where his name has been familiar for several years as among the 
 
 most Successful of the cultivators of the Chemistry of Man It is a vast repository o( facts, to which the 
 
 teacher and student may refer with equal satisfaction."— The IVtstem Journalo/Malicim and Surgery. 
 
24 LEA & BLANCHARD'S PUBLICATIONS. 
 
 WATSONTmiCTICri^PHYSIC, 
 
 New Edition by Condie. 
 
 LECTURES ON THE 
 
 PRINCIPLES AND PRACTICE OF PHYSIC. 
 
 DELIVERED AT KING'S COLLEGE, LONDON. 
 
 BY THOMAS WATSON, M. D., &c. &c. 
 Second American, from the Second London Edition. 
 
 REVISED, WITH ADDITIONS, 
 
 BY D. FRANCIS CONDIE, M. D., 
 Author of a work on the "Diseases of Children," &c. 
 
 In one Octavo Volume, 
 
 Of nearly ELEVEN HUNDRED Large Pages, strongly bound with raised bands. 
 
 c< We know of no work better calculated for being placed in the hands of the student, and for a 
 text-book, and as such we are sure it will be very extensively adopted. On every important point 
 the author seems to have posted up his knowledge to the day." — American Medical Journal. 
 
 The rapid sale of the first edition of this work is an evidence of its merits, and of its general 
 favor with the American practitioner. To commend it still more strongly to the profession, the 
 publishers have gone to a great expense in preparing this edition with larger type, finer paper, and 
 stronger binding, with raised bands. It is edited with reference particularly to American practice, 
 by Dr. Condie ; and with these numerous improvements, the price is still kept so low as to be within 
 the reach of all, and to render it among the cheapest works offered to the profession. It has been 
 received with the utmost favor by the medical press, both of this country and of England, a few of 
 the notices of which, together with a letter from Professor Chapman, will be found in the Supple- 
 ment to The Medical News and Library, for November, 1845. 
 
 A NEW AND IMPROVED EDITION OF 
 
 HAMSBOTHAM'S STANDARD WORK ON PARTURITION. 
 
 THE PRINCIPLES AND PRACTICE OF 
 
 OBSTETRIC MEDICINE AND SURGERY, 
 
 IN REFERENCE TO 
 
 THE PROCESS OF PARTURITION. 
 
 ILLUSTRATED BY 
 
 One hundred and forty-eight JLarge Figures an 55 Lithographic Plates, 
 
 BY FRANCIS H. RAMSBOTHAM, M. D., &c 
 
 A NEW EDITION, FROM THE ENLARGED AND REVISED LONDON EDITION. 
 In one large imperial octavo volume, well bound. 
 The present edition of this standard work will be found to contain numerous and important improvements 
 over the last. Besides much additional matter, there are several more plates and wood-cuts, and those which 
 were before used have been re-drawn. This book has long been known to the profession, by whom it has 
 been most flatteringly received. A. more extended advertisement, with a recommendatory letter from Professor 
 Kodge of the University of Pennsylvania, may be seen in the November Supplement to The Medical News. 
 
 CONDIE ON__CHILDREN. 
 
 A PRACTICAL TREATISE ON 
 
 THE ? DISEASES OF CHILDREN, 
 
 BY D. FRANCIS CONDIE, M. D., 
 
 Fellow of the College of Physicians; Member of the American Philosophical Society, &c. &c 
 IN ONE VOLUME, OCTAVO. 
 Uj=" The Publishers would particularly call the attention of the Profession to an examination of this work. 
 "Dr. Condie, from the very great labor which he has evidently bestowed upon this book, is entitled to ou r 
 respect as an indefatigable and conscientious student; but if we consider the results of his labor, we cannot 
 but admit his claim to a place in the very first rank of eminent writers on the practice of medicine. Regard- 
 ing his treatise as a whole, it is more complete and accurate in its descriptions, while it is more copious and 
 more judicious in its therapeutical precepts than any of its predecessors, and we feel persuaded that the Ame- 
 rican medical profession will very soon regard it, not only as a very good, but as the very best 'Practica 
 Treatise on the Diseases of Children.' "—Am. Med. Journal, 
 
LEA & BLANCHARD'S PUBLICATIONS. 25 
 
 THE SURGICAL WORKS OF SIR ASTLEY COOPER. 
 
 LEA & BLANC HARD have how completed the last volume of the illustrated works of Sir Aslley Cooper. 
 They form an elegant series; the works on Hernia, the Testis, the Thymus Gland and the Breast, being printed, 
 illustrated and bound to match, in imperial octavo with numerous LITHOGRAPHIC PLATES, while the 
 Treatise on Dislocations is in a neat medium octavo form, with NUMEROUS WOODCUTS similar to the 
 last London edition. 
 
 SIR ASTLEY COOPER ON HERNIA, 
 
 With One Hundred and Thirty Figures in Lithography* 
 
 THE ANATOMY AND SURGICAL TREATMENT OF 
 
 ABDOMINAL HERNIA. 
 
 By Sir ASTLEY COOPER, Bart. 
 Edited by C. Aston Key, Surgeon to Guy's Hospital, &c. 
 
 This important work of Sir Astley is printed from the authorized second edition, published in London, in large 
 snper-royal folio, and edited by his nephew, Professor Key, It contains all the Plates and all the Letterpress — 
 there are no omissions, interpolations, or modifications — it is the complete work in 
 One Large Imperial Octavo Volume. 
 With over 130 Figures on 26 Plates, and over 400 Large Pages of Letterpress. 
 
 The correctness of the Plates is guaranteed by a revision and close examination under the eye of a distin- 
 guished Surgeon of this city. 
 
 ANOTHER VOLUME OF THE SERIES CONTAINS HIS TREATISE 
 
 ON THE STROCTOei AND DISEASES OF THE TESTIS. 
 
 Illustrated by liO Figures. From the Second London Edition. 
 BY BRANSBY B. COOPER, ESQ. 
 
 AND ALSO ON THE ANATOMY OF THE THYMUS GLAND. 
 
 Illustrated by 57 Figures. 
 
 The two works together in one beautiful imperial octavo volume, illustrated with twenty-nine plates in the 
 best style of lithography, and printed and bound to match. 
 
 The Series is concluded by 
 
 COOPER ON THE 
 
 ANATOMY AND DISEASES OF THE BREAST, &o., 
 
 This large and beautiful volume contains THE ANATOMY OF THE BREAST: 
 
 THE COMPARATIYE ANATOMY OF THE MAMMARY GLANDS: 
 
 ILLUSTRATIONS OF THE DISEASES OF THE BREAST; 
 
 And Twenty-five Miscellaneous Surgical Papers ; now first published in a collected form. 
 
 By Sir ASTLEY COOPER, Bart., F. R. S., &c. 
 
 The whole in one large imperial octavo volume, illustrated with two hundred and fifty-two figures on 
 thirty six Lithographic Plates ; well and strongly bound. 
 
 COOPER ON FRACTURES AND DISLOCATIONS, 
 
 WITH NUMEROUS WOOD-CUTS. 
 
 A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. 
 
 By Sir ASTLEY COOPER, Bart., F. R. S., Sergeant Surgeon to the King, See. 
 
 A NEW EDITION MUCH ENLARGED J 
 
 Edited by BRANSBY COOPER, F. R. S., Surgeon to Guy's Hospital. 
 
 WITH ADDITIONAL OBSERVATIONS FROM 
 
 Professor JOHN C. WARREN, of Boston. 
 With numerous engravings on wood, after designs by Bagg, a memoir and a splendid portrait 
 
 Astley. In one octavo volume. 
 
 The peculiar value of this, as of all of sir Astley Cooper's work.-;, consists in its eminently practical charac- 
 ter. His nephew, Bransby B. Cooper, from his own experience, lias added a number o\ cases. Besides this, 
 Sir As'.ley left behind him very considerable additions in MS. tor the t z press purpose ol bi ing introduced into 
 this edition. The volume is embellished with OWE HUNDRED AND THIRTY-THRfiE WOODCUTS, 
 and contains the history of no less than three hundred and sixty-one cases, thus embodying the roc f 
 lifeof practice of the Author and his various editors. There are also additional Observations from notes fur- 
 nished by John C. Warren, M. D., the Professor o\ Anatomy ami Surgery in Harvard University. 
 
 " After the fiat of the profession, it would be absurd in us to eulogize Sit Astley Cooper's Work on Fractures 
 and Dislocations. It is a national one, and will probably subsist as long as English Sarj 
 rurgical Review, 
 
26 LEA & BLANCHARD'S PUBLICATIONS. 
 
 A NEW MEDICAL DICTIONARY, 
 In one Volume, large 12mo., now ready, at a low price. 
 
 A DICTIONARY OF 
 
 THE TERMS USED IN MEDICINE 
 
 AND 
 
 THE COLLATERAL SCIENCES; 
 By RICHARD D. HOBLYN, A.M., Oxon. 
 
 FIRST AMERICAN, FROM THE SECOND LONDON EDITION. 
 
 KETISED, WITH NUMEROUS ADDITIONS, 
 
 By ISAAC HAYS, M.D., 
 
 Editor of the American Journal of the Medical Sciences. 
 
 Believing that a work of this kind would be useful to the profession in this country, the publishers 
 have issued an edition in a neat form for the office table, at a low price. Its object is to serve as 
 an introduction to the larger and more elaborate Dictionaries, and to assist the student commencing 
 the study of Medicine, by presenting in a concise form an explanation of the terms most used in 
 Medicine and the Collateral Sciences, by giving the etymology and definition in a manner as simple 
 and clear as possible, without going into details ; and bringing up the work to the present time by 
 including the numerous terms lately introduced. This design the author has so ably executed as 
 to elicit the highest encomiums of the medical press. 
 
 It has been edited with especial reference to the wants of the American practitioner, the native 
 medicinal plants being introduced, with the formula? for the various officinal preparations : and the 
 whole being made to conform to the Pharmacopoeia of the United States. It is now ready in one 
 neat royal duodecimo volume of four hundred pages in double columns. 
 
 TAYLOR'S MEDICAL JURISPRUDENCE. 
 
 MEDICAL JURISPRUDENCE. 
 
 By ALFRED S. TAYLOR, 
 
 Lecturer on Medical Jurisprudence and Chemistry at Guy's Hospital, &c. 
 
 With Numerous Notes and Additions, and references to American Practice and Law. 
 
 BrR. E. GRIFFITH, M.D. 
 
 In one volume, 8vo. 
 
 " We recommend Mr. Taylor's work as the ablest, most comprehensive, and, above all, the most practically 
 useful book which exists on the subject of legal medicine. Any man of sound judgment, who has mastered 
 the contents of Taylor's ' Medical Jurisprudence,' may go into a court of law with the most perfect confidence 
 of being able to acquit himself creditably." — Medico-Chirurgical Review. 
 
 " As we expected, it has become truly the manual of both the medical and legal professions, 
 and is regarded by all as the standard authority on the subject; the author, also, as we find from 
 the public prints, is the person consulted, almost as a matter of course, in the more difficult medico- 
 legal cases. — The British and Foreign Medical Review. 
 
 LAWRENCE ON THE EYE. New Edition— Now Ready. 
 
 A TREATISE ON THE DISEASES OF THE EYE, 
 
 BY W. LAWRENCE, F.R.S., 
 
 Surgeon Extraordinary to the Queen, Surgeon to St. Bartholomew's Hospital, &c, &c. 
 
 SECOND AMERICAN, FROM THE LAST LONDON EDITION, 
 
 With many Modifications and Additions, and the Introduction of over one hundred Illustrations, 
 
 BY ISAAC HAYS, M.D., 
 
 Surgeon to "Will's Hospital, Physician to the Philadelphia Orphan Asylum, &c. &c. 
 
 IN ONE LARGE OCTAVO VOLUME. 
 The character of this work is too well known to require a word of commendation. It is justly considered the 
 best we possess on the subject. In this edition will be found many important alterations and improvements, 
 bringing the work up to the level of the present state of knowledge on the subjects of Ophthalmic Surgery and 
 Practice. The chapters on the Anatomy and Physiology of the Organ have received especial augmentations, 
 and many new cuts have been introduced, rendering the whole clear and comprehensible. 
 
LEA & BLANCHARD'S PUBLICATIONS. 27 
 
 MILLER'S SURGICAL WORKS. 
 
 THE PRINCIPLES OF SURGERY. 
 
 BY JAMES MILLER, F.R. S.E., F.R.C.S.E., 
 
 Professor of Surgery in the University of Edinburgh, &c. 
 In one neat octavo volume, to match the Author's volume on " Practice." 
 
 " No one can peruse this work without the conviction that he has been addressed by an accom- 
 plished surgeon, endowed with no mean literary skill or doubtful good sense, and who knows how 
 to grace or illumine his subjects with the later lights of our rapidly advancing physiology. The 
 book deserves a strong recommendation, and must secure itself a general perusal." — Medical Times. 
 
 " We feel no hesitation in expressing our opinion that it presents the philosophy of the science 
 more fully and clearly than any other work in the language with which we are acquainted." — Phi- 
 ladelphia Medical Examiner. 
 
 " To the student who wishes to acquire a useful practical knowledge of the pathology of sur- 
 gical diseases, it is impossible to recommend a better guide than the present treatise by Mr. Mil- 
 ler." — Edinburgh Medical and Surgical Journal. 
 
 "An admirable epitome of the surgical science of the day. Being written by a sound practical 
 surgeon accustomed to the public teaching of his science, it has the clearness of diction and ar- 
 rangement which renders it an excellent manual for the students as well as that amount of scien- 
 tific and practical information which makes it a safe and valuable guide to the practitioner." — The 
 Lancet. 
 
 JUST PUBLISHED. 
 
 THE PRACTICE OF SURGERY. 
 
 BY JAMES MILLER. 
 
 Professor of Surgery in the University of Edinburgh. 
 In one neat octavo volume. 
 
 This work is printed and bound to match the " Principles of Surgery," by Professor Miller, lately 
 issued by L. & B. Either volume may be had separately. 
 
 " This work, with the preceding one, forms a complete text-book of surgery, and has been under- 
 taken by the author at the request of his pupils. Although, as we are modestly informed in the 
 preface, it is not put forth in rivalry of the excellent works on practical surgery which already exist, 
 we think we may take upon ourselves to say, that it will form a very successful and formidable 
 rival to most of them. While it does not offer the same attractive illustrations, with which some of 
 our recent text-books have been embellished, and while it will not, as indeed is not its design, set 
 aside the more complete and elaborate works of reference which the profession is in possession of, 
 we have no hesitation in stating that the two volumes form, together, a more complete text-book 
 of surgery than any one that has been heretofore offered to the student." — The Northern Journal 
 of Medicine. 
 
 " Mr. Miller is already known in his profession as an able writer and a well informed surgeon, 
 and the book before us is calculated to maintain his reputation. We recommend it to those who 
 want a sound guide, or wish to refresh their recollections. The characteristics which especially 
 distinguish the work are, its plain good sense, or the selection of the important from the unimport- 
 ant announcements in surgery ; the sound indications of the judgment to be exercised in the treat- 
 ment of surgical diseases." — The Lancet. 
 
 A NEW AND IMPROVED EDITION OF 
 
 FERGUSSON'S OPERATIVE SURGERY. 
 
 A SYSTEM OF PRACTICAL SURGERY. 
 
 BY WILLIAM FERGUSSON, F.R. S.E. 
 
 SECOND AMERICAN EDITION, REVISED AND IMPROVED. 
 
 With Two Hundred and Fifty-two Illustrations from Drawings by Bagg, Engraved by Gilbert, 
 
 With Notes and Additional Illustrations, 
 
 BY GEORGE W. N ORRIS, M. D., &c. 
 
 In one beautiful octavo volume of six hundred and forty large pages. 
 
 "If we were to say that this volume by Mr. Fergasson, is one excellently adapted to the student, and the vet 
 
 inexperienced practitioner of surgery, we should restrict unduly its range. It is of the kind which every med> 
 
 Ical man ought to have by him for ready reference, as a guide to the prompt treatment o( many accidents and 
 
 injuries, which whilst he hesitates, may be followed by ineurable defects, ami deformities of structure, if not by 
 
 Ideath itself. In drawing to a close our notice of Mr. Fergussoifs Praotioal Surgery, we cannot refrain from 
 
 lagain adverting to the numerous and beautiful illustrations by woodcuts, which contribute so admirably to 
 
 lefucidate the descriptions in the text. Dr. Norris has, as usual, acquitted himself judiciously in his office, of 
 
 lannotator. His additions are strictly practical and to the point."— Bulletin o/Mutical Science. 
 
23 LEA & BLANCHARD'S PUBLICATIONS. 
 
 LIBRARY OF SURGERY. 
 
 CHELIUS'S SYSTEM OF SURGERY, 
 
 A SYSTEM OF SURGERY. 
 
 By J. M. CHELIUS, 
 
 Doctor in Medicine and Surgery, Public Professor of General and Ophthalmic Surgery, etc. etc. in the 
 
 University of Heidelberg. 
 
 TRANSLATED FROM THE GERMAN, 
 AND ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS, 
 
 By JOHN F. SOUTH, 
 
 SURGEON TO ST. THOMAS'S HOSPITAL. 
 
 EDITED, WITH REFERENCE TO AMERICAN AUTHORITIES, 
 By GEORGE W. NORRIS, M.D. 
 
 Publishing in Numbers, at Fifty Cents each. 
 
 Nine Numbers are now ready: and the whole is expected to be complete by September next, forming 
 
 Three Large Octavo Volumes. 
 
 That this work should have passed to six editions in Germany, and have been translated into no less than 
 seven languages, is sufficient proof of its value. It contains what is, perhaps, embraced to an equal extent 
 by no other work on the subject now before the public— a complete System of Surgery, both in its principles 
 and practice. The additions of the translator, Mr. South, are very numerous, bringing the work up to the very 
 day of publication, and embodying whatever may have been omitted by the author respecting English Sur- 
 gery; while Dr. Norris will take equal care in representing the state of the Science in America. 
 
 "Judging from a single number only of this work, we have no hesitation in saying that, if the remaining por- 
 tions correspond at all with the first, it will be by far the most complete and scientific System of Surgery in tire 
 English language. We have, indeed, seen no work which so nearly comes up to our idea of what such a pro- 
 duction should be, both as a practical guide and as a work of reference, as this; and the fact that it has passed 
 through six editions in Germany, and been translated into seven languages, is sufficiently convincing proof of 
 its value. It is methodical and concise, clear and accurate; omitting all minor details and fruitless speculations, 
 it gives us all the information we want in the shortest and simplest form "—The New York Journal of Medicine. 
 
 "The scope of Professor Chelius's Manual is indicated by its title: it professes to treat, systematically, of the 
 science and art of Surgery, but within such compass as to render the work an appropriate introduction and 
 companion to his lectures. The care, however, which has been bestowed upon its construction, and the labor 
 which its research evinces, would be ill repaid were it confined to this sphere; and we may conscientiously 
 say, that we know of no Manual of Surgery, on the whole, more deserving of public confidence, or more valu- 
 able as a guide and refresher to the young practitioner. It is not our intention at present critically to analyze 
 Mr. South's labors; but we should be guilty of an injustice to him and to our readers if we did not cordially 
 recommend his work as having fair promise of forming, what it is the translator's ambition it should be, a sound 
 and comprehensive system of Practical Surgery. The notes and text are so intermingled as to render it con- 
 tinuously readable, without presenting those abrupt transitions which are so disagreeable in many works simi- 
 larly arranged. The faults of omission. &c, at which we have hinted in our comments on the first chapter of 
 our author's work, (viz. that on 'Inflammation') have been amply compensated by the copious and excellent 
 digest of his translator and annotator. who is justly proud of availing himself of the labors of our own coun- 
 trymen in this department of pathology, while he gives their due meed of notice and respect to the contributions 
 of our continental brethren. The references which are given to original works have evidently been carefully 
 collated, and will be found of great value to the student and practitioner who may wish for more copious in- 
 formation on any particular branch of Surgery, and the practical remarks and illustrations with which the 
 work abounds, are a good guarantee of the translator's ability to do justice to his task, at the same time that 
 they prove that Mr. South has not failed to avail himself industriously of the large opportunities which his Hos- 
 pital appointment has afforded him." — The British and Foreign Medical Review. 
 
 " We will, therefore, content ourselves for the present with directing the attention of the profession to it, as 
 being the most complete system of Surgery in any language, and one that is of equal utility as a practical guide 
 and as a work of reference. The fact of its having reached six editions in Germany, and its having been trans- 
 lated into seven languages^are more convincing proofs of its value than anything that we can say. Mr. South 
 has performed his task with much judgment, and has certainly made a most useful addition to the medical lite- 
 rature of this country by rendering Chelius's work into English "—The Lancet. 
 
 "This work has long been the chief text-book on Surgery in the principal schools of Germany, and the pub- 
 lication of five editions of it in the original and of translations into no less than eight foreign languages, show 
 the high estimation in which it is held. As a systematic work on Surgery it has merits of a high order. It is 
 methodical and concise— and on the whole clear and accurate. The most necessary information is conveyed 
 in the shortest and simplest form. Minor details and fruitless speculations are avoided. It is in fact, essen- 
 tially" a practical book. This work was first published nearly twenty years ago and its solid and permanent 
 reputation has no doubt led Mr. South to undertake the present translation of the latest edition of it. which, we 
 are informed, is still passing through the press in Germany". We should have felt at a loss to select any- one 
 better qualified for the task than the translator of Otto's Compendium of Human and Comparative Pathological 
 Anatomy — a surgeon to a large hospital, whose industry and opportunities have enabled him to keep pace with 
 the improvements of his time." — The Medico-Chirurgical Review. 
 
 "•Although Great Britain can boast of some of the most skilful surgeons, both among her past and her present 
 professors'of that branch of medical science, no work professing to be a complete system of Surgery has been 
 published in the British dominions since that of Benjamin Bell, now more than half a century old. 
 
 "Ttiis omission in English medical literature isfully and saiisfactorily supplied by the translation of Professor 
 Chelius's System of Surgery by a gentleman excellently 7 fitted for the task, both by his extensive reading, and 
 the opportunities of practical experience which he has enjoyed for years as surgeon to one of our largest me- 
 tropolitan hospitals. The fact of Professor Cheiius's work having been translated into seven languages is suf- 
 ficient proof of the estimation in which it is held by our continental brethren, and the English edition, now in 
 course of publication, loses none of the value of ihe original from the treatment received at the hands of its 
 translator. The notes and additions of Professor South are numerous, and contain the opinions resulting from 
 his vast experience, and from that of his colleague. 
 
 " We are free to confess, prejudiced though perhaps we are, in favor of the English practice of surgery, that 
 this work is one of great value, and one which every practitioner and advanced student should possess."-^I%e 
 Medical Times. 
 
WORKS 
 
 IN 
 
 VARIOUS DEPARTMENTS 
 
 OF 
 
 MEDICINE AND SURGERY, 
 
 PUBLISHED 
 
 BY LEA & BLANCHARD. 
 
 AMERICAN JOURNAL OF THE MEDICAL SCIENCES. Edited by Isaac Hays, M. D. 
 Published quarterly at $5 00 per annum. 
 
 ANDRAL ON THE BLOOD. Pathological Hematology ; an Essay on the Blood in Dis- 
 ease. Translated by J. F. Meigs and Alfred Stille. In one octavo volume, cloth. 
 
 ARNOTT'S PHYSICS. The Elements of Physics in plain or non-technical language. A 
 New Edition. Edited by Isaac Plays, M. D. In 1 vol. 8vo., sheep, with 176 wood-cuts. 
 
 ABERCROMBIE ON THE STOMACH. Pathological and Practical Researches on Dis- 
 eases of the Stomach, Intestinal Canal, &c. Fourth Edition. In 1 vol. 8vo., sheep. 
 
 ABERCROMBIE ON THE BRAIN. Pathological and Practical Researches on the Dis- 
 eases of the Brain and Spinal Cord. A New Edition. In one octavo volume, sheep. 
 
 ALISON'S PATHOLOGY. Outlines of Pathology and Practice of Medicine. In three 
 parts, containing Preliminary Observations, Inflammatory and Febrile Diseases, and 
 Chronic or Non-Febrile Diseases. In one neat octavo volume, sheep. • 
 
 BIRD ON URINARY DEPOSITS. Urinary Deposits, their Diagnosis, Pathology and The- 
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 BERZELIUS ON THE KIDNEYS AND URINE, in 1 vol. 8vo., cloth. 
 
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 BRIDGEWATER TREATISES. The whole complete in 7 vols. 8vo., containing Roger's 
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 BARTLETT ON FEVERS OF U. S. The History, Diagnosis and Treatment of Typhus 
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 BARTLETT'S PHILOSOPHY OF MEDICINE. Essay on the Philosophy of Medical 
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 BRIGHAM ON MIND, &c. The Influence of Mental Excitement and Mental Cultivation 
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 Fourth London Edition. In one octavo volume, cloth. 
 
 CHITTY'S MEDICAL JURISPRUDENCE. A Practical Treatise on Medical Jurispru- 
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 CLATER AND SKINNER'S FARRIER. Every Man his own Farrier. Containing, the 
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 GUTHRIE ON THE BLADDER, occ. The Anatomy of the Bladder and Urethra 
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 29 
 
30 
 
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 KIRBY ON ANIMALS. The History, Habits and Instinct of Animals. A Bridgewater 
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 HARRISON ON THE NERVES. An Essay towards a correct Theory of the Nervous 
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 LAWRENCE ON RUPTURES. A Treatise on Ruptures, from the fifth London Edition. 
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 perience. Illustrated by 241 Lithographic Figures and 54 Wood-cuts. Translated by 
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 MULLER'S PHYSIOLOGY. Elements of Physiology. Translated by Wm. Baly, M.D., 
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 YOUATT ON THE HORSE. The Horse : containing a full account of the Diseases of 
 the Horse, with their mode of Treatment; his Anatomy, and the usual Operations per- 
 formed on him; his Breeding, Breaking, and Management; and Hints on his Sound- 
 ness, and Purchase and Sale. Together with a General History of the Horse ; a Dis- 
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 with numerous Cuts. 
 
 JfLEDICAIi WORKS, at Press and Preparing-* 
 
 A MANUAL OF MATERIA MEDICA AND 
 Therapeutics. By J. Forbes Royle, M. D., &c. 
 Edited by J. Carson, M. D., &c. In 1 vol. 8vo., 
 numerous wood-cuts, {nearly ready). 
 
 TODD & BOWMAN'S PHYSIOLOGICAL ANA- 
 tomy and Physiology of Man. Many wood-cuts, 
 {publishing in the Medical News and Library). 
 
 A TREATISE ON OPHTHALMIC MEDICINE 
 and Surgery. By T. Wharton Jones. In 1 vol. 
 beautifully illustrated. 
 
 PRINCIPLES OF GENERAL AND COMPA- 
 rative Physiology. By Wm. B. Carpenter, 
 M. D.,&c. From a new London edition, with 
 numerous improvements and additions. In 1 
 vol. large 8vo., many steel plates. 
 
 A TREATISE ON ANIMAL PHYSIOLOGY, 
 with very numerous illustrations. By Wm. B. 
 Carpenter. — To be followed by his other works 
 on Natural Science. 
 
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 Carson, M. D., &c. In one volume, {preparing). 
 
 A SYSTEM OF SURGERY. By J. M.Chelius. 
 Translated by South, and Edited by Norris. — 
 Publishing in numbers at 50 cents each. To 
 be complete in three octavo volumes. 
 
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 large 12mo. vol., with many cuts, {nearly ready.) 
 
 AN ANATOMICAL DESCRIPTION OF THE 
 Diseases of the Organs of Circulation and Re- 
 spiration. By C. E. Hasse. Translated and 
 Edited by W. E. Swaine, M. D., &c. In 1 vol. 
 8vo., {nearly ready). 
 
 A TREATISE ON AURAL SURGERY. In 1 
 vol. 8vo., many illustrations. 
 
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 adapted to the United States. By R. E. Grif- 
 fith, M. D. In 1 vol. large 8vo., with many 
 illustrations. 
 
 LECTURES ILLUSTRATIVE OF VARIOUS 
 Subjects in Pathology and Surgery. By Sir B. 
 Brodie — completing his works. 
 
 CALORIC, its Mechanical, Chemical, and Vital 
 Agenci$6 in the Phenomena of Nature. By S. 
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 GOLDING BIRD'S ELEMENTS OF NATU- 
 RAL PHILOSOPHY. With numerous wood- 
 cuts. 
 
 VOGEL'S PATHOLOGICAL ANATOMY.— 
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 In 1 vol. large 8vo., many plates. 
 
 BURROWS ON CEREBRAL CIRCULATION, 
 with plates. 
 
 Together with other JYew Works, 
 
 
 3477 
 
 Jf