LIBRARY OF CONGRESS DD000aS537t, 4 PAINTED BY SULLY EKGR.WED BY CHA S HEATH . PUBLISHED BY JOSEPH DELAPLAWE mo 'maci WM LECTURES ON THE THEORY AND PRACTICE OF PHYSIC, DELIVERED IN THE COLLEGE OF PHYSICIANS AND SURGEONS OF THE UNIVERSITY OF THE STATE OF NEW YORK. BY THE LATE DAVID HOSACK, M. D. ? LL. D., F. R. S. PROFESSOR OF THE THEORY AND PRACTICE, ETC. AND OP CLINICAL MEDICINE IN THAT INSTITUTION. WITH AN INTRODUCTORY LETTER, BY NATHANIEL CHAPMAN, M.D. PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, ETC. EDITED BY HIS FRIEND AND FORMER PUPIL, HENRY W. DUCACHET, D.D. RECTOR OF ST. STEPHEN'S CHURCH, PHILADELPHIA. PHILADELPHIA : HERMAN HOOKER, CHESNUT STREET. 1838. Entered according to Act of Congress, in the year 1838, by HERMAN HOOKER, in the Clerk's Office of the District Court for the Eastern District, of Pennsylvania. o \J TO NATHANIEL CHAPMAN, M. IX P?*ofessor of the Theory and Practice of Medicine, in the University of Pennsylvania. Dear Doctor, I know not any one to whom I can inscribe these Lectures with so much propriety as to yourself. My revered preceptor was your friend, and you were his. You have been engaged the greater part of your life in teaching the same branch of science which he so eloquently taught. And the profession have agreed in placing you both in the same rank with the eminent men who have been celebrated as the most able and successful of our medical teachers. I pray you to accept this offering, as the sincere expression of my high appreciation of your talents, your eloquence, and your learning ; and as the evidence of the personal regard and attach- ment of your friend and Pastor, HENRY W. DUCACHET. Philadelphia, October 9, 1838. INTRODUCTORY LETTER. Mr Dear Sir : I have carefully read the copy of the Lectures of the late Professor Hosack, which you had the kindness to send to me. The high expectations I had formed of their merits, have been fully realised. They embody a very large mass of curious and useful information, clearly and agreeably conveyed. Excepting some pathological doctrines, I find little in them to which 1 would object. The practical part I consider sound, or at least, it corresponds very much with my own views. Long and exten- sively engaged in the profession, and with his acute and discrimi- nating mind, he could scarcely fail to arrive at just conclusions in whatever regards the management of disease. He deserves, and will no doubt rank, among the most authoritative of our writers on the subject. You have done well in publishing the work. No effort shall I spare to promote its distribution; and I mean especially to recommend it to the attention of my class. I have the honour to be, dear sir, Very faithfully, your friend, &c. N. CHAPMAN. The Rev. Dr. Ducachet. Philadelphia, Oct. 10, 1838. PREFACE BY THE EDITOR. It was my privilege in early life to become the private pupil of the late Dr. Hosack. The attachment he conceived for me during the years I enjoyed the happiness of his professional in- structions, continued uninterrupted ever after; and I possessed the honour of his friendship till he died. On the death of my beloved preceptor and friend, all his papers, agreeably to his direc- tions before his decease, were delivered into my hands. I found them, indeed, an immense collection. Among them were manu- script notes upon almost every subject, and particularly upon his favourite science; and courses of lectures upon almost every branch of medicine, for he had taught them all, and had held suc- cessively nearly every professorship in the college. Dr. Hosack had been a student all his life; he had corresponded for years with almost every celebrated literary and scientific cha- racter in America and Europe; he had practised physic forty years, and seen in that long practice as many patients perhaps as any other physician in this country ever did; he had held a high rank among the most distinguished of the profession ; and had been pronounced by the public voice to be worthy of being ranked as a teacher of medicine, with such men as Rush, and Wistar, and Physic, and Chapman. He was, therefore, no ordi- Xll PREFACE. nary man. Abroad, as well as at home, he was regarded and honoured as one of the very first physicians of the age, both as a man of varied and profound professional attainments, and of great practical skill. I was sure that in such a collection of papers, made by such a man, there must be much that was valuable ; and something that would benefit the medical profession. But it was impossible for me, withdrawn as I am from medical pursuits, and immersed as I am in the labours of an extensive and responsible parochial city charge, to undertake the task of examining them all, and judging of their worth. I knew, however, his reputation as a lecturer on the theory and practice of physic. I recollected well with what eloquence, with what clearness, with what admi- rable sagacity, he used to teach that branch while I was at the University ; and I knew that his celebrity in that department suf- fered no diminution during the subsequent period he continued his labours there. I came to the determination, therefore, to select his lectures on that subject for the press. I thought that, even if the lectures embodied in this volume were of inferior value, the public at large, and the profession especially, would be gratified to know how medicine was taught by so celebrated and experienced a^ teacher. From them they will derive some idea of his method, his style, and his system. It is true, as they ap- pear, excellent as they are, they do not full justice to his merits. The reader has not his frequent and oftentimes eloquent extem- pore illustrations: the numerous cases he used to adduce to fortify his principles and exemplify his practice; the constantly recur- ring anecdotes which gave so much interest and charm to his lectures, and served so well to keep up and enliven the attention of the audience ; and, worst of all, most of his beautiful classical allusions, and of his learned references and quotations, are lost. All these were so familiar to him, that they were seldom written. PREFACE. Xlll The manuscripts would perhaps contain a memorandum here and there that would remind one who had often heard him, of the many striking and learned illustrations he was in the habit of ad- ducing — but could not enable the editor entirely to recover them, or to give them with any thing like tolerable accuracy. And then, the manner could not be represented. The vivid flashes of his keen eye; his fine, manly, commanding voice; his animation of delivery, rising, as it often did, to enthusiasm; and his graceful, powerful gesticulation — all these are gone. No reader can imagine them. He must have heard, and have seen the man, to understand what he was in his lecture room. Certainly, if he had adopted St. Augustine's rule for preaching, as a rule for his prelections, he could not have come nearer the venerable father's standard of perfection. There was in his style or his manner nothing that appeared like the " obtuse, defor?niter, frigide;" — but every thing was done and said, " acute, ornate, vehe?nen- ter." — Augttstin. de Doct. Christ, lib. 4. cap. 5. But I make no farther apologies for the work, or for myself. I commit it to the judgment of the profession, with the confi- dence that, whatever may be their decision as to its merits, all must acknowledge, or if any refuse to acknowledge, they must know, that few, if any, courses of lectures on the theory and practice of physic, have been more clear, more learned, more practical, or more exactly adapted to the purposes of such a course, than these. The intelligent reader cannot fail to discover that Dr. Hosack was considerably in advance of his own times. He lived to have the satisfaction of seeing many of the views and principles for which he had contended almost single-handed, adopted exten- XIV PREFACE. sively in Europe and his native country; and, had he lived a few years more, his triumph, I have no doubt, would have been greater still. The present volume contains, it will be perceived, only his lectures on fevers and the phlegmasia^. These made the principal part of the course. Whether the remainder will hereafter be published, must depend upon circumstances which cannot at present be foreseen or controlled. TABLE OP CONTENTS Page. Lecture I. — On the Classification of Diseases, 17 " II. — Observations and Criticisms upon Dr. Cullen's Classifi- cation of Diseases, - - - » -27 " III. — Of Fevers in general, .... 45 " IV. — Of Fevers in general, - - - - 56 " V. — Of Fevers in general, 67 " VI. — Of Fevers in general, - - - - 79 " VII. — Of Fevers in general, 93 " VIII. — Of Fevers in general, and the Evidences of a vitiated condition of the Fluids, - 106 " IX.— The Typhoid State of Fever, - - - 117 " X. — The Causes of Fever — Predisposing and Exciting Causes, ------ 128 " XL — Exciting Causes of Fever — Exercise, Heat, Cold, 139 XII.— Causes of Fever— Cold, - - - - 150 XIIL— Causes of Fever, .... 156 " XIV. — Causes of Fever — Miasma and Contagion, - - 167 " XV. — Contagion and its Laws, - - - - 180 " XVI. — Contagion and its Laws, - 198 " XVII. — Contagion and its Laws. - - - 215 " XVIII.— The Proximate Cause of Fever, - - - 227 " XIX. — The General Treatment of Fever. — Treatment of the First Stage, ... 240 " XX.— The General Treatment of Fever.—Treatment of the Second Stage, - - - - - 250 " XXL— The General Treatment of Fever.—Treatment of the Third Stage, 263 " XXIL— Treatment of the Typhoid State of Fever, - 271 " XXIIL— Treatment of the Typhoid State of Fever, - 281 " XXIV. — Divisions and Characteristics of Fevers, - - 298 " XXV.— Treatment of Intermittents, - - 310 XVI CONTENTS. Lecture XXVI. — Remittent Fevers, .... " XXVII. — Continued Fevers — Synocha — Characteristic Symptoms — Treatment — Synochus vel Typhus, « XXVIIL— Dysentery, " XXIX.— Dysentery, ----- " XXX. — Fevers — Plague, or Pestis Orientalis, XXXI.— Yellow Fever, " XXXII. — Phlegmasia? — Inflammation, " XXXIII. — Phlegmasia? — Inflammation, " XXXIV.— Treatment of Inflammation, " XXXV. — Phlogosis — Phlegmon — Erysipelas, - " XXXVI. — Anthrax, or Carbuncle, the third species of Phlo- gosis, -.--_. " XXXVII. — Phrenitis, or Inflammation of the Brain, XXXVIII.— Ophthalmia, XXXIX.— Otitis— Odontitis, - - - - " XL.— Parotitis, ------ « XLL— Catarrh, ..... " XLII. — Trachitis — Cynanche Trachealis, or Inflammation of the Trachea, - XLIIL— Pertussis, - - - - - " XLIV. — Pneumonia, - " XLV. — Diaphragmitis and Carditis, " XLVI.— Phthisis Pulmonalis, - - - " XLVIL— Phthisis Pulmonalis, XLVIIL— Phthisis Pulmonalis, - " XLIX. — Cynanche Tonsillaris vel Tonsillitis, - " L. — Cynanche Maligna, - " LI. — Peritonitis, - - - - " LIL— Gastritis, - - " LIII.— Hepatitis, - - - " LIV. — Splenitis — Nephritis — Hysteritis, and Cystitis, " LV. — Urethritis, or Gonorrhoea— Orchitis, " LVI. — Cruritis, or Phlegmasia dolens, " LVII. — Rheumatismus vel Myitis, " LVIIL— Arthritis, or Gout, - " LIX. — Causes and treatment of Gout, - Page. 327 334 345 356 372 383 394 405 413 422 438 446 460 474 486 494 511 530 538 553 557 568 577 593 559 604 609 615 634 645 653 664 674 685 LECTURE I. ON THE CLASSIFICATION OF DISEASES. The immediate object of the course of lectures upon which we are now to enter, is the exhibition of the nature, causes, and cure of diseases. But when we look at the multitude of dis- eases to which the human frame is liable, where shall we be- gin — what shall be our order of proceeding? Let us in the first place endeavour to arrange into some order the numerous ob- jects which are to come before us. This is the business of nosology.* Nosology may be defined to be an arrangement of diseases, in such order as will be best calculated to give us a knowledge of them, and of the most prominent characteristics by which they are to be distinguished from each other. Where many objects are presented to our notice, you will readily admit some order becomes necessary to a correct view of them; and especially to enable the mind to retain the impression of them. In natural history the objects are so nu- merous that the memory could not possibly contain them with- out the aid of a system, or some methodical arrangement; especially the numerous objects of the vegetable kingdom. There are now upwards of thirty thousand species of plants well described by botanists, and distinguished from each other. But without some classification of those objects, what memory could retain them? — They must be associated, to be remem- bered. * Nosology is a term composed of two Greek words — vctre? which signifies disease, and xo^o?, discourse. 3 18 LECTURE I. In the animal or the mineral kingdoms, the objects are not so numerous : nevertheless arrangement in those departments of natural science is no less useful and necessary in acquiring a knowledge of the various objects they embrace. In a word, no art or science, where the objects of which it treats are nu- merous, can be acquired without it: for none can be clearly treated of or communicated without arrangement. In describing diseases, a somewhat similar or analogous mode of arrangement has been adopted, and has been formed upon the resemblances and distinctions which are found to exist between them. This mode of arranging diseases was first suggested (at least practically suggested) by Sydenham and Baglivi. They were the first who proposed the distribution of diseases upon similar principles with those afterwards adopted by botanists — into classes, orders, genera, and speeies; and they were the first who connected with them characteristic definitions, in which are detailed the distinctive or pathogno- monic symptoms of each individual form of disease. I may here remark that various other modes of arrangement have been adopted, and have had their abettors ; but they have all given place to that which is now most generally pursued as founded upon the distinctive symptoms of diseases. Aretseus and Ccelius Aurelianus divided diseases according to their duration, into acute and chronic. Johnston, Sennertus, and Morgagni, and I may add Dr. Mead in his "Medical Precepts and Cautions," distribute dis- eases according to their seat — into those of the head, chest, belly, limbs, &c; making the anatomical division of the body the basis of their arrangement. Indeed the late physiological system of Dr. Good is founded upon this principle; and the same is adopted by Dr. Chapman, in the school of Pennsyl- vania. Boerhaave, Riverius, and Hoffman, again, adopted a different principle of arrangement. They divided diseases according to the supposed causes from which they were produced. This system of arrangement has been denominated the ^Etiological arrangement, from the term a ^;«, signifying a cause. But all these several methods have yielded to that now ge- nerally in use, founded upon the pathognomonic symptoms, and which, as most true to itself, is now considered as the most wor- CLASSIFICATION OF DISEASES. 19 thy of attention. For, notwithstanding the influence which cli- mate, constitution, temperaments, and peculiar frame of body, may have in varying or modifying the character of diseases, the great features or leading symptoms by which any individual disease is attended, are so constant and strongly marked, that they furnish us with the best possible basis of an arrange- ment by which diseases are to be distinguished and ascertained, and which is essentially necessary before we attempt to inves- tigate their nature or their causes — or prescribe for their relief. « - The hint suggested by Sydenham, was first realised by the learned Sauvages, the professor of botany and medicine, at Montpelier, — the Boerhaave of Languedoc, as he was sur- named, such was his learning and so extended his reputation. Sauvages first published the outlines of his plan in 1731, in a little modest duodecimo volume, under the title of " Nouvelles Classes de Maladies," but not until he had submitted his inten- tion to the judgment of Boerhaave. In this edition, he only descended to the genera. In 1763, four years before his death, he published a new and more extensive edition in five volumes octavo, embracing the species of diseases. This second edi- tion may be considered as the first in reality ; and upon it he had patiently laboured upwards of thirty years. So important was the subject of nosological arrangement in the opinion of the great and learned: Sauvages. But his last and still more complete edition, which he had prepared with the utmost care, he did not live to publish. It appeared in 1768, the year after his death, in two volumes quarto. He died 19th February, 1767, aged sixty-one. A methodical arrangement of diseases was next followed by Linnaeus in 1763. A pupil of Linnaeus had published an outline of his method in 1759. Afterwards succeeded Vogel, the pro- fessor at Gottingen. In 1764, Vogel published a close approximation to the work of Sauvages, but containing much personal observation of the phenomena of diseases. His work is entitled " Definitiones Generum Morborum." This appeared at Gottingen in 1764, in a single octavo volume. These were followed by the " Systema Morborum Symptomaticum" of Sagar, the pro- fessor at Vienna, published in 1776, which is another modifi- 20 LECTURE I. cation of the system of Sauvages. Dr. M'Bride also, has left an imperfect arrangement of diseases, which, on account of the skill he has displayed in the arrangement of his genera and species, deserves the attention of the nosologist. Lastly appeared, the Nosologia Methodica of Dr. Cullen, whose classification has been considered as the most perfect of any systematic arrangement that has yet been published. I pass over altogether, the visionary views of Brown and Darwin, on this subject. In 1731, Sauvages, as I before remarked, first attempted his system of arrangement, but he did not give it publicity, until he had matured it during thirty years' observation. It is, ac- cordingly, the best that appeared prior to that of Dr. Cullen. Sauvages divided diseases into ten classes, which compre- hended upwards of forty orders, more than three hundred genera, and an innumerable host of species. No wonder Monsieur De Rette exclaimed, " Quel nombre prodigieux d'ennemis." This number of species was diminish- ed by Linnseus and Vogel, who succeeded him. The classifica- tion of Sauvages, notwithstanding the labour he bestowed upon it, is not free from several errors and imperfections. Some of these it possesses in common with all other attempts to arrange into classes the works of nature ; for anomalies occur in dis- eases as in the objects of natural history, which disturb the unity of artificial arrangements, uniting dissimilar genera, and rendering necessary the separation of others which a general analogy would connect. Other imperfections, however, in the classification of Sauvages appear to be the result of a want of accurate attention or discrimination. It is true, that Felix Platerus, about the end of the sixteenth century, and the begin- ning of the seventeenth, (his work was published in 1602, under the title of Praxis Medica,) had made an attempt to arrange diseases upon the symptomatic plan, but it was so imperfectly executed as not to be considered as a system of nosology. Yet it is very possible that Sydenham availed himself of it — he was at least actuated by the same quickening spirit, for his various treatises and epistles, are a practical comment upon Plater's principle : and it is probable too, that Sauvages took some hints from it, imperfect as it was. They are, however, few and but of little importance. CLASSIFICATION OF DISEASES. 21 Mr. Good considers Platerus, as " the morning star that first glimmered in the hemisphere of symptomatology, as Servetus was in that of the circulation of the blood. The light of both," he adds, " was feeble and tremulous, but it twinkled in the midst of darkness and led on to the brightness of day." But to Sydenham, in my opinion, Sauvages was most in- debted for the full illustration of that symptomatic method which constituted the great improvement that this subject has received at his hands, and which has been matured by his suc- cessors — particularly by Dr. Cullen. Linnseus of Upsal, the great botanist, and who had been much occupied in devising arrangements of the vegetable king- dom — his favourite department of science, and Vogel of Got- tingen, as I said, gave the world two other systems ; but they followed that of Sauvages so closely, that medicine has re- ceived but little benefit from their labours. Indeed, in the opinion of Dr. Cullen, both Linnseus and Vogel have embar- rassed nosology — the former by the introduction of terms that are unnecessary — the latter by those which are actually frivo- lous and improper. In the year 1817, another system appeared which, although rejected by the College of Physicians, attracted much notice from the learned in Great Britain. It is the physiological sys- tem of that distinguished scholar and surgeon, Dr. Good of London. He calls it a physiological system, thereby denoting that it is founded upon a physiological view of the diseases it describes. So far as our purpose is concerned, it is liable to two promi- nent objections. 1. Diseases of the same nature as it regards their general character, are treated of in each and every class, merely be- cause they happen to be seated in different parts of the body. 2. His terminology is new. — This is not wanted. The truth is, he is a better scholar than physician. All nosological arrangement has been objected to by some physicians. But the abuse of it is certainly no argument against its use. The great objection that has been generally alleged against nosology is, that each systematic has been guided by his own theoretical or rather hypothetical notions. Medical science 3* 22 LECTURE I. has certainly been injured in this respect, in all ages, by the undue application of the predominant and fashionable sciences to explain the laws of the animal economy. It has been in- jured even by the exact sciences, mathematics and mechanics, which were applied to explain the functions of the body, after Sir Isaac Newton had rendered those branches of study po- pular in the world, by the numerous improvements he intro- duced into them. While the mechanicians (as in the examples of Pitcairn and Keill,) calculated the force of the stomach in the digestion of the food, or the power of the heart and arteries in circulating the blood — while they measured the momentum of the fluids, together with the shape and dimensions of the tubes they move in, as if belonging to an hydraulic machine — and while the chemists in like manner, examined the change of properties those fluids acquire by such motion through the body, and un- dertook to explain secretion and excretion by their art, they forgot that the vital principle also, controls and governs all the phenomena of the living body, and that animation is the predo- minant power in our system. Metaphysics have also been applied in the same exclusive manner in accounting for the phenomena which our bodies exhibit, both in the healthy and the morbid state. Hence, the anima medica of Stahl, and the errors it has introduced. Chemistry in like manner has injured medicine, by the undue extension of the discoveries of Dr. Black, Priestley, and La- voisier, in explaining the phenomena of diseases. Even elec- tricity was had recourse to by its ardent cultivators, to account for the phenomena of disease. According as the electric fluid predominated or- was diminished in our system, whether plus or minus, so were the characters of its diseases. And these were to be removed by restoring the equilibrium. Shaw's sys- tem of medicine is exclusively founded on these principles. It is surprising to observe the inordinate attachment which parents manifest to these children of the imagination ! — And it happens too that frequently, in proportion to the deformity with which they come into the world, will be the efforts made to perpe- tuate their existence. As with the electrician, so it is with the mechanical philoso- pher, the mathematician, the metaphysician, and the chemist, in CLASSIFICATION OF DISEASES. 23 the application of their doctrines to medicine. It is not in- tended to depreciate the utility of those departments of know- ledge to the physician — their use and their application must be admitted by all — but, like the vires naturae medicatrices, they should be the handmaids and not the mistresses of our science. They should follow, but never exclusively direct, our researches. While some eminent physicians in consequence of this abuse of the application of the different sciences to medicine, are disposed to decry nosological arrangement, let us not go to the other extreme, by rejecting it altogether. The object of nosology is not merely to assemble diseases — it also furnishes the characteristic, or more prominent, symptoms by which diseases are designated : and thence we are led readily to distinguish them one from the other. But we are not only by such arrangement, led to the know- ledge of the pathognomonic symptoms of each family or genus — our inquiries immediately extend to the species or members of each family, and even the varieties it exhibits under parti- cular circumstances. This is not all — knowing the peculiar character of diseases, we are equally induced to ascertain and to discriminate between the various remote causes from which those diseases severally proceed ; and thence we ascend to a knowledge of the more immediate or proximate cause — our great guide in the cure, inasmuch as such assemblages of dis- eases lead to general principles in practice. We may say, therefore, of diseases as of style or painting, according to Ovid's description of the twin sisters, " Facies non omnibus una, nee diversa tamen." They are not all the same — yet they are not so widely dif- ferent, but that they have some common principles by which they are connected. Yet, according to circumstances they differ in their grade, or, perhaps, in their specific character; and thence demand each its peculiar treatment. We see this illus- trated in croup. This disease, and very lately too, was consi- dered by some as a malignant species of cynanche forbid- ding the lancet. See Dr. Bard's dissertation. See also, Fo- thergill, Douglas of Boston, and Johnston of Worcester, who have all treated of the malignant ulcerous sore-throat, which 24 LECTURE I. frequently exhibited in its termination the symptoms of croup. Dr. Cullen understood it, and has given Dr. Bard's work on croup, its proper place in his nosological arrangement. He considered it as in reality not a primary croup, but in its com- mencement the malignant ulcerous sore-throat, which ended in croup. In the treatment, therefore, they were governed by its primary character, and the cause from whence it originated. Again, by others, it has been considered as a spasmodic disease ; but since that period it has been satisfactorily shown, that its spasmodic symptoms arise from the sensibility of the part in which the inflammation takes place. Accordingly, the disease, with all the various characters which it assumes, is now well understood. We know its symptoms, causes, species, whether idiopathic or symptomatic ; and thence the general prin- ciples of treatment become apparent. So of hysteritis. There are two species ; one purely inflammatory, the other sympto- matic of a typhoid state of body — each calling for its peculiar treatment. So of pneumonic inflammation. The pathognomonic symp- toms are " fever, pain in some part of the chest, dyspnoea and cough." These combined, constitute pleurisy, and call for active depletion, venesection, &c. Again ; take away the cough and fever, and you have a rheumatic affection of the muscles of the ribs. Venesection now, in some instances, is contraindicated and even injurious. — Or take away the pain — the cough may be symptomatic of other diseases, as typhus fever, indigestion, worms, &c, and the treatment must be directed accordingly. If, then, it is important to distinguish diseases for the pur- poses of practice, it is no less necessary to class and arrange diseases for the purpose of knowing those distinctions as sub- servient to practice ; and these, as Dr. Cullen has justly ob- served, can only be explained by a rightly constructed nosolo- gical method. And, in the language of Linnaeus, " System is the Ariadnean thread, without which all is confusion." Our countryman, Dr. Rush, objected to all nosological ar- rangement as injurious, yet he himself had his own unitarian system. He considered all the varieties of diseases, in what- ever shape they may appear — in whatever part of the system they may be seated ; whether in the solids or fluids, in the nerves, CLASSIFICATION OF DISEASES. 25 the blood-vessels, or absorbents, as one and the same morbid action, viz. excitement, &c. To use his own language, " Dis- ease is unit ;" i. e. a modification of the same diseased action of the system. — Not only is his nosology thus limited, but his materia medica contains but one remedy ; that is, that the reme- dies proper for those diseases are to be considered as having all the same general action upon the system. Notwithstanding Dr. Rush's late attachment to this unitarian doctrine in medicine, he formerly was as warmly attached to the Cullenian arrangement. I remember the day when he re- commended to his pupils, for I was at that time one of them, to commit even the definitions of Dr. Cullen to memory as he should do the rules of grammar in learning the Latin tongue, or the first axioms and propositions of Euclid in learning ge- ometry. " Let me advise you," he then said to his pupils, " never to prescribe until you have investigated the disease and given it its proper place, its class, its order, its genus and species." I hope I have profited by his instruction, and that I shall be permitted to adhere to his first lessons as more correct than his last doctrines on this subject : but let us recollect that even his unitarian doctrine of diseases calls for, and he has accordingly made, subdivisions denoting the various grades, forms and seats of diseases, or in other words, denoting the peculiar characters of individual diseases, and their associations arising out of those peculiar characters. He himself admits, " that in applying the principles of physiology, pathology and therapeutics to the practice of physic, some order is necessary in speaking of in- dividual diseases." Indeed, we may say of the physician what Dr. Rush says of a philosopher, that he can no more be formed by a fortuitous concourse of ideas than a world can be pro- duced by a similar concourse of atoms. As it is not my intention to go into a very minute history of each disease, but to confine myself to the characteristic or pa- thognomonic and diagnostic symptoms as essentially subservi- ent to practice, I shall insist the more on those symptoms as they are detailed in such system of nosology, referring you for the more ample details to the best books on each subject. For all controversial matter too, upon the rationale of the causes of disease, I shall refer you to books also — when you have gotten the facts, I shall refer you to Brown, Cullen and 26 LECTURE I. Darwin for their several speculations. My object is to give you the facts I have been enabled to collect, either from books, my own observation, or other sources ; and these I shall ar- range in the best order I can devise, both as it regards your remembrance of them and the general principles to which they may give rise. The inductive system, as far as I am capable of distinguishing between truth and error, shall be strictly pur- sued upon every subject of which we shall treat ; that is, I shall lay before you the facts that I believe to be well established ; and you shall draw the conclusions to which they lead ; or ra- ther facts will draw their own conclusions : for as I have said before, facts, well assembled, constitute general truths or prin- ciples. This leads me to make some remarks on the arrange- ment of Dr. Cullen, which is now most generally received by the medical world. — As to the nutshell system of Brown, divid- ing diseases into sthenic and asthenic, like that of Thessalus of old, into strictum and laxum, I altogether reject it as un- worthy of our notice for the purposes of practice. — Like the unitarian doctrine of Dr. Rush, it is saying little more than " that disease is disease." In the arrangement which I have adopted, you will find that I am neither unitarian nor methodist; but an eclectic, or uni- versalist, if you please ; and, like the eclectics of old, I shall take truth, at least what I believe to be truth, from all their systems, wheresoever I can find it. My motto shall be the language of Pliny: " Auctorem neminem unum sequar sed ut quemque verissimum in qua parte arbitrabor."— Plin. Hist. Nat lib. iii. 27 LECTURE II. OBSERVATIONS AND CRITICISMS UPON DR. CULLEN'S CLASSIFY CATION OF DISEASES, &c. As I remarked yesterday, the same principles of arrange- ment that have been adopted by the naturalist, in the disposal of the numerous objects of natural history, have been made use of by physicians in the distribution of diseases. They are assembled into parcels or classes, according to some manifest or well known circumstances, in which the members of each class have a resemblance, or possess properties or characters in common. Each class is next arranged into subordinate di- visions, in which each sub-division is designated by some marks peculiar to itself. Those divisions of the classes are called orders. Each order again is made up of families called genera, possessing characteristic marks by which every such genus is distinguished from its congeners. Each family or genus, again consists of members denominated species — each species being designated by some characteristic marks that separate it from its fellow members of the same family. Let us now by this standard, examine Dr. Cullen's arrange- ment, which has been most approved. To understand what I shall say, you must have before you a synopsis of his system, which I present you accordingly. DR. CULLEN'S SYSTEMATIC ARRANGEMENT OF DISEASES, CLASS I.— PYREXLE. Ord. I. — Febres. § 1. Intermittentes. § 2. Continues. 1. Tertiana. 4. Synocha. 2. Quartana. 5. Typhus. 3. Quotidiana. 6. Synochus. 28 LECTURE II. 7. Phlogosis. 8. Ophthalmia. 9. Phrenitis. 10. Cynanche. 11. Pneumonia. 12. Carditis. 13. Peritositis. 14. Gastritis. 15. Enteritis. 25. Variola. 26. Varicella. 27. Rubeola. 28. Scarlatina. 29. Pestis. 35. Epistaxis. 36. Haemoptysis. 39. Catarrhus. 41. Apoplexia. 43. Syncope. 44. Dyspepsia. 47. Tetanus. 48. Trismus. 49. Convulsio. 50. Chorea. 51. Raphania. 52. Epilepsia. 53. Palpitatio. 54. Asthma. 55. Dyspnoea. 64. Amentia. 65. Melancholia. 68. Tabes. § 1. Adiposes. 70. Polysarcia. § 2. Flatuosa. 71. Pneumatosis. 72. Tympanites. 73. Physometra. § 3. Aquosa. 74. Anasarca. 75. Hydrocephalus. Ord. II. — Phlegmasia. 16. Hepatitis. 17. Splenitis. 18. Nephritis. 19. Cystitis. 20. Hysteritis. 21. Rheumatismus. 22. Odontalgia. 23. Podagra. 24. Arthropuosis. Ord. III. — Exanthemata. 30. Erysipelas. 31. Miliaria. 32. Urticaria. 33. Pemphigus. 34. Aphtha. Ord. IV. — Hemorrhagic. 37. H emorrhois. 38. Menorrhagia. Ord. V. — Profluvia. 40. Dysenteria. CLASS II.— NEUROSES. Ord. I.— Comata. 42. Paralysis. Ord, II. — Adynamic 45. Hypochondriasis, 46. Chlorosis. Ord. III. — Spasmi. 56. Pertussis. 57. Pyrosis. 58. Colica. 59. Cholera. 60. Diarrhoea. 61. Diabetes. 62. Hysteria. 63. Hydrophobia. Ord. IV. — VesanijE. 66. Mania. 67. Oneirodynia. CLASS III.— CACHEXIA. Ord. I. — Marcores. 69. Atrophia. Ord. II. — Intumescentic 76. Hydrorachitis. 77. Hydrothorax. 78. Ascites. 79. Hydrometra. 80. Hydrocele. § 4. Soli da. 81. Physconia. 82. Rachitis. dr. cullen's classification. 29 83. Scrofula. 84. Syphilis. 85. Scorbutus. 86. Elephantiasis. 91. Caligo. 92. Amaurosis. 93. Dysopia. 94. Pseudoblepsis. 95. Dyseccea. Ord. III. — Impetigines. 87. Lepra. 88. Framboesia. 89. Trichoma. 90. Icterus. CLASS IV.— LOCALES. Ord. L- -DySjESTHESIjE. 96. Paracusis. 97. Anosmia. 98. Agheustia. 99. Anaesthesia. Ord. II. — Dysorexi^e. § 1. Appetitus Erronei. 105. Nostalgia. 100. Bulimia. 101. Polydipsia. § 2. Appetitus deficientes. 102. Pica. 106. Anorexia. 103. Satyriasis. 107. Adipsia. 104. Nymphomania. 108. Anaphrodisia. 109. Aphonia. 110. Mutitas. 111. Paraphonia. 112. Psellismus. 116. Profusio. 117. Ephidrosis. 118. Epiphora. 122. Obstipatio. 123. Ischuria. 124. Dysuria. 127. Aneurisma. 128. Varix. 129. Ecchymoma. 130. Scirrhus. 131. Cancer. 132. Bubo. 133. Sarcoma. 141. Hernia. 142. Prolapsus. 144. Vulnus. 145. Ulcus. 146. Herpes. 147. Tinea. Ord. III. -Dyscinesi^e. 113. Strabismus. 114. Dysphagia. 115. Contractura. Ord. IV. — Apocenoses. 119. Ptyalismus. 120. Enuresis. 121. Gonorrhoea. Ord. V. — Epischeses. 125. Dyspermatismus. 126. Amenorrhoea. Ord. VI. — Tumores. 134. Verruca. 135. Clavus. 136. Lupia. 137. Ganglion. 138. Hydatis. 139. Hydarthrus. 140. Exostosis. Ord. VII. — Ectopia. 143. Luxatio. Ord. VIII. — Dialyses. 148. Psora. 149. Fractura. 150. Caries. He divides all diseases, you will perceive, into four classes, viz. 1. Pyrexiae ; 2. Neuroses ; 3. Cachexia? ; and 4. Locales. 4 30 LECTURE II. His first class, Pyrexiae, is a bad class ; and independently of the incorrectness of his definition of it, should be expunged. Under this head, you will observe, Dr. Cullen professes to in- clude all diseases attended with fever or increased heat, as the term pyrexiae imports, being derived from the Greek word ™§, signifying fire. In the first place I remark, then, this class is objectionable, as it includes the order haemorrhagiae, which are not necessa- rily, nor are they always or even generally, febrile diseases. On the contrary, they are frequently without fever, especially hemorrhage from the uterus, the liver, lungs, bowels, haemor- rhoids, and the haemorrhage in scurvy. Indeed, I scarcely know any case of haemorrhage that is febrile, unless it may prove so in its effects : even then, fever is an accidental and not a ne- cessary attendant. 2. It excludes other diseases that are acknowledged to be of a febrile character, which Dr. Cullen has distributed in his other classes. Pertussis, 56, which is usually febrile, he has placed among the Neuroses. Syphilis, dropsy, placed in Cachexiae, are oftentimes febrile. So, too, are obstipatio, 122 ; vulnus, 144 ; fractura, 149 ; her- nia incarcerata, 141 ; hydarthrus, 139 — all which he makes Locales. Observe, I do not object to the place assigned to these dis- eases ; but as Dr. Cullen set out with the intention of assembling all febrile or pyrexious diseases in the same class, he should either have adhered to his original intention, or he should not have made a class of this extensive character, as he has done his pyrexiae. Again — 3dly. This class is defective, it wants a number of inflammatory diseases — it wants diaphragmitis, a distinct species ; periostitis also is wanting. It wants phlegmasia dolens, otitis, odontitis, mastitis. In- deed, it might almost be said that this class of Pyrexiae is so general, that almost every disease might be included in it. For scarcely a disease exists that is not sometimes attended with fever. The class pyrexiae is, therefore, too general to stand as a class. The second class, Neuroses, is a good class and should have dr. cullen's classification. 31 a place in every system of arrangement ; but constructed as it is by Dr. Cullen, it is exceptionable. The first objection to it is, that it contains some diseases in which the blood-vessels and secretions are manifestly affected, and in which the nervous system is not primarily affected, viz. pertussis, 56. This disease comes on like a common catarrh — is a febrile disease, and properly one of the Pyrexiae. 2dly. This class contains some diseases which chiefly consist of increased natural evacuations ; as, cholera, 59 ; diarrhoea, 60; diabetes, 61. These are every thing else but Neuroses, and belong to a totally different class of diseases, not at all provided for by Dr. Cullen. These diseases should not be placed in the class Neuroses, because of a particular symptom — otherwise every disease might be included in this class ; for every disease exhibits some affection of the nervous system. Nor should they be placed in Dr. Cullen's order of profluvia ; because these diseases are generally without fever ; whereas his profluvia have fever, and are in his class of pyrexious dis- eases. 3dly. Dr. Cullen's Neuroses contains some diseases as genera and species, which are only symptoms of other diseases. Chlorosis, 46, is symptomatic of amenorrhcea or suppres- sion of the menses, or a species of dyspepsia, but not an idio- pathic disease. Pyrosis, 57, is only a modification of indigestion, one of the symptoms of dyspepsia, but not a disease in itself. And dyspnoea, 55, is in like manner symptomatic of catarrh, pneumonia, hydrothorax, an excessive quantity of fat, angina pectoris, and other affections of the chest, but is not an idiopathic dis- ease ; and therefore should be expunged. Indeed, it should have no place in any system, as it is only a symptom, and not itself a disease. 4thly. This class is defective, as it does not contain many diseases which are exclusively nervous, and are arranged in the other classes, — such as amaurosis, 92, of the first order of locales, and the other paralyses of the senses, as 96, 97, 98, &c. paracusis, anosmia, agheustia, aphonia, 109. 5thly. It does not contain all the diseases of the mind — as 32 LECTURE II. nostalgia, 105, which is a species or a peculiar form of melan- cholia. See second order of class Locales, where it is most strangely located. 6thly. The class Neuroses does not contain the affections of the stomach, connected with dyspepsia, 44, as the dysorexise, thrown into the second order of class Locales, in which he sepa- rates bulimia, 100; pica, 102; anorexia, 106; from dyspepsia, of which they are modifications or symptoms, and with which, therefore, they should be associated. The third class, Cachexias — meaning diseases of a bad habit of body. This class, as its name imports, ought to include all diseases which arise from a vitiated or bad habit of body. Does it do so 1 No — it does not ; it is defective. 1. It does not contain among his intumescentise or swell- ings, all the dropsical diseases, as hydrops pericardii, hydrops ovarii, hydrops articuli. 2. It wants mollities ossium ; fragilitas ossium ; lithiasis or calculus ; the yaws, or framboesia ; and the form of syphi- lis denominated laanda Africana, as described by Dr. Winter- bottom. 3. This class is not only defective — it is faulty. It contains some eruptive diseases, as in the third order, impetigines, as, elephantiasis, 86 ; lepra, 87 ; frambcesia, 88 ; while other erup- tive diseases are dispersed in other classes, some in the first class among the exanthemata, as small-pox. Others again are in the fourth class Locales, viz. tinea, 147 ; herpes, 146 ; psora, 148 ; and which are not always local or confined to a part. These eruptive diseases should all be associated in one class, in order that a comparative view may be taken of them, and that some general principles may be derived from such asso- ciation, and thereby lead to some general results as to their treatment. 4. The order impetigines contains diseases which are without eruptions, yet they are placed here under the head of scabby or eruptive diseases, as the term impetigines imports, viz. scrofula, 83, which is not eruptive ; syphilis, 84, which is not invariably so ; icterus, 90, which is a suppression or retention of bile, in which there is no eruption, but only a yel- lowness of skin. This surely is not sufficient to justify its DR. CULLEX'S CLASSIFICATION. 33 place here ; if it is, then yellow fever, and bilious remittent, and hepatitis, should be here too. Class 4 — Locales. In this class too, we shall find a very objectionable arrangement. 1. It contains in the first and third orders, several of the paralyses, (viz. in the first order, amaurosis, 92 ; paracusis, 96 ; anosmia, 97 ; agheustia, 98 ; anaesthesia, 99 : and in the third order, aphonia, 109; mutitas, 110; dysphagia, 114;) which, though they are partial, yet are of the same nature and character with the general palsies, and should be arranged with them among the Neuroses, especially too, as they call for the same general principles of treatment. 2. It contains nostalgia, 105, which is a disease of the mind and manifestly belonging to the class Neuroses. — Upon what principle, then, can it be placed among the local diseases ? 3. It contains many diseases which are of a general, not of a local nature, viz. obstipatio, 122; ischuria, 123; amenor- rhcea, 126 ; which belong to a totally different class of dis- eases — the class of suppressiones, which have no distinct or appropriate place in Dr. Cullen's system. If these diseases or other suppressions of natural discharges have a place in the class Locales, upon the same principle all the phlegmasia have equal claims to this class. 4. The class Locales contains many diseases which should be constituted a different class, in which excessive discharges are brought together — another class, not provided for by Dr. Cullen — profluvia, viz. profusio, 116; this should be associated with hemorrhages; ephidrosis, 117; epiphora, 118; ptyalis- mus, 119; enuresis, 120. These being general, not local dis- eases, have no business here, but should belong to the class of Profluvia, or increased discharges. 5. It contains gonorrhoea virulenta, 121, and hydarthrus, 139, which belong to the inflammatory diseases, the phlegma- siae — excepting gonorrhoea, properly so called — I mean in- creased seminal discharges, according to its etymology: that should be one of the profluvia. 6. It contains also eruptive diseases, viz. herpes, 146 ; tinea, 147 ; psora, 148, which should not be separated from the other eruptive or cutaneous diseases. He even, as before remarked, separates them from lepra, and other eruptive diseases in the 4* 34 LECTURE II. third class, as well as from urticaria, of the first class, but which should all be associated in one class of cutaneous dis-. eases. 7. It contains contractura, 115, as a distinct disease, which is either an original deformity, or is symptomatic of some pre- vious injury. In like manner he has bubo, 132 ! This too, is a mere symptom — it is symptomatic of syphilis, of pestis, scrofula, phlogosis. 8. It contains many diseases which belong to dyspepsia, being symptomatic of it, or so nearly allied, that they should at least be associated with it in the same class, and not among the Locales. See second order of Locales, viz. bulimia, 100 ; pica, 102; anorexia, 106; adipsia, 107; polydipsia, 101. 9. This class is defective, it wants several genera, viz. bronchocele, fungus haematodes, polypus of the nose and throat. I shall now proceed to make a few remarks upon the sub- ordinate arrangements of Dr. Cullen's classification. (1.) I observe that he has no remittents in his first order — confining himself entirely to the intermittent and combined forms of fever— whereas remittents, especially in warm cli- mates, are certainly altogether distinct from intermittents in their character, and require a totally different treatment. They therefore should have an appropriate place in a system of prac- tical nosology. In this country this distinction is essentially important. 2. Dr. Cullen too, as you will perceive in his section called continued fevers, distinguishes typhus from synochus, making them two distinct genera ! — yet in his notes he acknowledges he cannot distinguish between them. " Inter typhum tamen et synochum limites accuratos ponere non possum ; et an revera pro diversis generibus habenda vel positis diversis, utri eorum synonima auctorum referenda sunt, dubito.' , 3. Dr. Cullen's febres do not embrace the plague, 29, one of the most formidable febrile diseases that man can be afflicted with. This, Dr. Cullen has very improperly placed among his eruptive diseases, in the third order, 29 ! merely because of the petechias sometimes attendant upon it. He should for the same reason place typhus in the same order with plague. 4. Nor does this order, febres, contain another violent and dr. cullen's classification. 35 dangerous form of fever, dysentery, which holds a very im- proper place among his profluvia ! for it is every thing else but profluvia. (2.) The second order, phlegm asiae, is no less defective. As I have already observed, it wants, first, several inflammatory diseases, and which indeed are wanting altogether in his system of arrangement. It wants otitis, odontitis, mastitis, auritis, phlegmasia dolens, periostitis. 1. In this order Dr. Cullen should also have included many diseases which he has elsewhere distributed. This order should have contained, first, catarrhus, 39, which is placed in his fifth order, profluvia. 2. Phthisis pulmonalis, embraced under the head of hae- moptysis, 36 ! ! 3. Urethritis — see Locales, order 4, 121 ! 4. Hydarthrus, 139, Locales, order 6, tumores. Phlogosis, the first of his phlegmasia?, might for the same reason as a tumour have been here among the Locales. (3.) Dr. Cullen's third order, exanthemata, is no less in- correct and incomplete. 1. It is incorrect inasmuch as it contains pestis, 29, which is not an eruptive disease any more than any other form of fever. And he himself expresses the doubt whether pestis should not be placed among the fevers. As I have no doubt on this sub- ject, I have placed it among the fevers, in the arrangement I have offered for your consideration. 2. This order is incomplete, as other eruptive ;diseases are omitted, and placed among other classes — viz. some in his third class, order 3. Impetigines ; and others in his fourth class, eighth order, as dialysis and herpes, &c. (4.) His hsemorrhagise, order 4, are imperfect — besides the error of placing it among the Pyrexiae, this order wants 1. Haematemesis — 2, haematuria, and 3, hepatirrhcea, a dis- charge of blood from the liver as in disease of that organ — as occurring, occasionally, in typhus fever, but most fre- quently attendant on yellow fever. In the latter disease indeed few die without that symptom ; hence the yellow fever is com- monly called by the Spaniards, vomito prieto ; but in other fe- brile diseases it is only an occasional occurrence, and then fre- 36 LECTURE II. quently is owing to preceding disease of the liver, and that too, most generally from intemperance. (5.) His order, profluvia, is exceptionable — it has what does not belong to it, and wants all that strictly do belong to it. It is incorrect as containing two diseases that have no claim to this place ; on the contrary, catarrhus is properly one of the phlegmasia;, and is constituted by a diminished discharge from the membrane, the seat of disease. So with dysentery, its companion, in this order ; it should be in the order of febres, for it too is constituted by diminished instead of increased dis- charges from the intestines. Thus you see that these are any thing else but profluvia ! This order of profluvia, too, is incomplete, inasmuch as it excludes many other diseases of the character here professed, as ephidrosis, 117; ephiphora, 118; ptyalismus, 119; cholera, 59; diarrhoea, 60; diabetes, 61 ; enuresis, 120; which are distri- buted in other parts of his system ; and leucorrhcea, absurdly placed, too, among his haemorrhages. This order is also incomplete, by excluding altogether some other diseases, as otirrhoea, gelactirrhoea, and gonorrhoea — I mean strictly so, as its name imports, seminal weakness, from yovo?, semen — not urethritis. The subdivisions of his second class are no less exception- able. (1.) Comata, strictly speaking, is a bad order — kojua signifies a propensity to sleep. This is not the case with all the palsies, for paraplegia, when proceeding from injury of the spine, is not always attended with coma. The partial palsies should also be here associated — whereas they are improperly placed among the Locales, first order ! ! (2.) Adynamia^ is incorrect and incomplete — incorrect, as it contains a disease of the mind, hypochondriasis, a grade of mania, which therefore should be associated with the other dis- eases belonging to the vesanise, fourth order. It contains, too, chlorosis, 46, which is symptomatic of ame- norrhoea, and is no more than a species of dyspepsia. • This order, too, is defective, as it separates dyspepsia from its congeners. Its opposite diseases are contained in the Locales, second order, viz. pyrosis, 57 ; bulimia, 100, &c. DR. CULLERS CLASSIFICATION". 37 It is defective, too, as it excludes altogether, asphyxia, which is not contained at all in his system, and anaphrodisia, 108, the loss of the venereal appetite and capacity. This is placed among the Locales without any regard to the genera] state of the system or the general remedies to be presented for its relief, for it is sometimes owing to the pressure on the brain by plethora. (3.) His spasmi are incorrect and defective. 1. Incorrect, as they contain pertussis, 56, one of the phleg- rnasias ; pyrosis, 57, not a spasmodic affection at all, but which is properly one of the adynamia^, or rather a symptom of dyspepsia ; colica, 58, which embraces many varieties or species of enteritis; cholera, 59; diarrhoea, 60; diabetes, 61; which are without spasm frequently, and belong to the profluvia. 2. It contains also dyspnoea, 55 ; a mere symptom, but of a great variety of diseases. 3. It wants a number of diseases, altogether omitted in his system ; as tic doloureux, or neuralgia ; tremor ; angina pecto- ris.; nephralgia ; hysteralgia ; hepatalgia. This order of Dr. Cullen's, notwithstanding these omissions, appears to be " a common receptacle for the refuse of the whole nosology." This order stands ready to receive every disease that happens to be rejected from the other orders. Wilson may well ask where is the similarity between hydrophobia and dia- betes ? between colic and whooping-cough ? between dyspnoea and epilepsy? His fourth order, vesanias, wants hypochondriasis, 45, im- properly placed among the adynamia?. Objections to the subdivisions of his third class — Cachexias. His first order, marcores, is somewhat questionable. This signi- fies leanness, emaciation — emaciation alone is not sufficient to form an order upon, being always symptomatic of other dis- eases, as of ulcer, phthisis, abscess, scrofula, poisons. Atro- phia, 69, is not a distinct disease, but generally arises from bad food, old age, or is symptomatic of dyspepsia, as in dirt-eaters. The second order, intumescentias, wants three dropsies, viz. of the pericardium, of the ovarium, and of the joints. This order also contains an improper genus, rachitis, one of those diseases analogous to syphilis, or those arising from a morbid condition 38 LECTURE II. of the system — it is therefore properly one of the vitia, and should not be placed here on account of the tumour attending it. The third order, the impetigines, is also exceptionable. It contains icterus, 90, which arises from a suppression of bile, and belongs to a distinct class of suppressiones, not provided for by Dr. Cullen. It also contains scrofula, which belongs to vitia, denoting the deranged state of the whole system, both solids and fluids ; but neither of these should be placed among the impetigines or scabby diseases. His impetigines, too, are superfluous, as it separates the cuta- neous diseases from those in the third order of that class, and those of the eighth order of the fourth class. Let us now look at his class Locales. The first order, if we except caligo, 91, is superfluous — it is improper that anosmia should be in the first order, 97, and aphonia, in the third, 109. The second order of the fourth class is altogether superflu- ous — the affections of the stomach, dysorexise, belong mani- festly to the same place with dyspepsia, with the adynamise. Satyriasis, 103; nymphomania, 104; anaphrodisia, 108, also belong to adynamic, i. e. debility of the natural functions. Nostalgia, 105, is nearly allied to melancholia, one of the vesanise, and is so arranged by Vogel, 65. This disease, nostalgia, is a species of melancholy in which the predominant symptom is the unceasing and ardent desire to re- turn home — of course it only occurs in those who are absent from their friends or their native country. It is so called from voo-Tav t to return, and *\yos, dolor, pain, or grief — the maladie du pays, as the French call it. That Sauvages and Dr. Cullen should have given it this place is most extraordinary, as one would suppose that there was some particular organ in the body in which the amor patriae resides, as hunger and thirst in the sto- mach. This disease is not confined to the Swiss, but in a pe- culiar manner affects the Swiss and the unhappy African, as well as the people of other countries, torn from their native land and the society of their friends and connexions. 3. The third order are all neuroses, all palsies, excepting contractura, which is symptomatic of wounds or other inju- ries, or should be placed among the deformitates. DR. CULLEN'S CLASSIFICATION. 4. The fourth order are all profluvia, not Locales, viz. ephi- drosis. 5. The fifth order, are all general diseases, not local. They belong strictly to suppressiones or obstructions. 6. The sixth order, tumores, is incorrect, containing bubo, 132, which is generally symptomatic — hydarthrus, 139, of the phlegmasia^. It is also imperfect ; it wants bronchocele, fungus hasmatodes, polypus. 7. The ectopias are unexceptionable. 8. Dialyses. Ulcer and caries are synonymous, as caries is an ulcer of the bone. This order is also faulty, contain- ing cutanei — and especially as these are not all local. Besides, it involves a gross absurdity to bring together diseases so per- fectly incongruous as some of those embraced in this class ; for what possible connexion or affinity, I ask, can be found be- tween psora, the itch, and a broken bone ? They stand next to each other as you perceive in Dr. Cullen's arrangement. I shall now proceed to make a few remarks relative to the arrangement here adopted, and which I propose to observe in the prosecution of this course of lectures. Adverting to the s}moptical view which is prefixed to the plan proposed, you will perceive, in the first place, I have re- jected the class Pyrexias altogether, as too general. It is difficult, upon many occasions, to make precise distinctions between diseases that are febrile and those without pyrexia. Many diseases are febrile upon some occasions, but not so on others. Many local diseases become febrile by the severity of pain or the continuance of the irritation, or by derangement of particular organs. Any cause that gives a great shock to the constitution is capable of producing general pyrexia, and vice versa. As local complaints often produce pyrexia, so on the other hand, pyrexia predisposes to, and produces local com- plaints — hence local complaints in typhus fever or abscesses. Pneumonia and rheumatism are oftentimes the produce of general inflammatory fever ; and the disease changes its name. Dysentery and diarrhoea frequently produce fever, and fever, in some cases, produces those diseases. I have therefore unhesitatingly rejected Pyrexias, as a class, as being too general, for indeed, for the reasons I have assigned, 40 LECTURE II. it might have embraced almost every disease of the human body. I have therefore commenced my classification with fevers, strictly so called ; that is, those diseases which are more espe- cially so denominated by writers, and are acknowledged to be such by the profession, and by mankind in general. I now propose to you the following classification, as one which, though still very imperfect, I really think more conform- able to nature than any yet proposed ; and more than any other, subservient to the great purposes of practice — and this shall be the order in which the diseases of which I shall treat, will be considered. SYNOPTICAL VIEW OF THE SYSTEM PROPOSED BY DAVID HOSACK. CLASS L— FEBRES. Ord. I. Intermittentes. 1. Quotidiana. 3. Quartana. 2. Tertiana. Ord. II. Remittentes. 4. Remittens biliosa. 5. Remittens infantilis. Ord. III. Continues. 6. Synocha. 9. Pestis orientalis. 7. Typhus vel Synochus. 10. Pestis tropicus. 8. Dysenteria. CLASS II.— PHLEGMASIA. 11. Phlogosis. 25. Carditis. 12. Phrenitis. 26. Phthisis. 13. Ophthalmia. 27. Glossitis. ,14. Otitis. 28. Tonsillitis. 15. Odontitis. 29. Pharyngitis. 16. Parotitis. 30. (Esophagitis. 17. Mastitis. 31. Peritonitis. 18. Catarrhus. 32. Gastritis. 19. Laryngitis. 33. Enteritis. 20. Trachitis. 34. Hepatitis. 21. Bronchitis. 35. Splenitis. 22. Pertussis. 36. Pancreatitis. 23. Pneumonia. 37. Nephritis. 24. Diaphragmitis. 38. Hysteritis. dr. hosack's classification. 41 39. Cystitis. 43. Cruritis. 40. Urethritis. 44. Rheumatismus. 41. Orchitis. 45. Arthritis. 42. Proctitis. 46. Paronychia. CLASS III.— CUTANEI * Ord. I. Papula. 47. Strofulus. 49. Prurigo. 48. Lichen. Ord. II. Squamje. 50. Lepra. 52. Pityriasis. 51. Psoriasis. 53. Ichthyosis. Ord. III. Exanthemata. 54. Rubeola. 57. Roseola. 55. Scarlatina. 58. Purpura. 56. Urticaria. 59. Erythema. Ord. IV. Bullc 60. Erysipelas. 62. Pompholyx. 61. Pemphigus. Ord. V. Pustule. 63. Impetigo. 66. Variola. 64. Porrigo. 67. Scabies. 65. Ecthyma. Ord. VI. VEsicuLiE. €8. Varicella. 72. Miliaria. 69. Vaccinia. 73. Eczema. 70. Herpes. 74. Apthse. 71. Rupia. Ord. VII. Tubercula. 75. Phyma. 80. Sycosis. 76. Verruca. 81. Lupus. 77. Molluscum. 82. Elephantiasis. 78. Vitiligo. 83. Framboesia. 79. Acne. Ord. VIII. Macule. 84. Ephelis. 85. Nsevus, Spilus, &c CLASS IV.— PROFLUVIA. Ord. I. Hemorrhagic. 86. Epistaxis. 90. Haematuria. 87. Haemoptysis. 91. Menorrhagia. 88. 89. Hsematemesis. Hepatirrhoea. 92. Haemorrhois. * This class is formed upon the admirable arrangement of diseases of the skin, proposed by Dr. Willan, and improved by Dr, Bateman, 5 42 LECTURE II. 93. Ephidrosis. 94. Epiphora. 95. Otirrhoea. 96. Ptyalismus. 97. Galactirrhoea. 98. Cholera. Ord. II. Apocenoses. 99. Diarrhoea, 100. Diabetes. 101. Enuresis. 102. Leucorrhoea. 103. Blenorrhoea. 104. Gonorrhoea. CLASS V.— SUPPRESSIONES. 105. Icterus. 109. Dyspermatismus. 106. Obstipatio. 110. Amenorrhoea. 107. Ischuria. 111. Dyslochia. 108. Dysuria. 112. Agalactia. CLASS VI.— NEUROSES. Ord. I. Dysesthesia. 113. Asphyxia. 114. Apoplexia. 115. Paralysis. 116. Amaurosis. 117. Caligo. 118. Dysopia. 119. Pseudoblepsis. 120. Strabismus. 121. Paracusis. 122. Anosmia. 123. Agheustia. 124. Paraphonia. 125. Psellismus. 126. Dysphagia. 127. Anaesthesia. Ord. II. Adynamia. 128. Syncope. 129. Dyspepsia. 130. Satyriasis. 133. Tetanus. 134. Neuralgia. 135. Convulsio. 136. Chorea. 140. Sternalgia. 141. Pleuralgia. 131. Nymphomania. 132. Anaphrodisia. Ord. III. Spasmi. a. In functionibus animalibus. 137. Epilepsia. 138. Catalepsia. 139. Cephalalgia. b. In functionibus vitalibus. 142. Asthma. c. In functionibus naturalibus, 143. Colica. 144. Nephralgia. 145. Hysteralgia, 146. Hysteria. 147. Hydrophobia. DR. hosack's classification. 43 148. Amentia. 149. Oneirodynia. 152. Marasmus. 153. Plethora. 154. Polysarcia. 155. Emphysema. 156. Tympanites. 158. Hydrops cellularis. 159. Hydrops cerebri. 160. Hydrops spinas. 161. Hydrops thoracis. 162. Hydrops abdominis. 167. Physconia. 168. Rachitis. 169. Fragilitas ossium. 170. Moilities ossium. 171. Lithiasis. Ord. IV. Vesani.se. 150. Melancholia. 151. Mania. CLASS VII.— CACHEXIA. Ord. I. Marcores. Ord. II. Intumescenti^. a. Sanguinece. b. AdiposcB. c Flatuosce. 157. Physometra. d. Aquosce. 163. Hydrops uteri. 164. Hydrops ovarii. 165. Hydrops testis. 166. Hydrops articuli. e. Solidce. Ord. III. Vitia. 172. Scrofula. 173. Syphilis. 174. Scorbutus. 175. Plica. CLASS VIII.— LOCALES. Ord. I. Tumores. a. Hcematici, 176. Fungus hsematodes. 177. Aneurisma. 178. Varix. 181. Scirrhus. 183. Polypus. 184. Ganglion. 186. Sarcoma. 179. Ecchymoma. 180. Hematocele. b. Adenosi. 182. Carcinoma. c. Gelatinosi. 185. Hydatis. d. Adiposi. 187. Encystis. 44 188. Exostosis. 189. Hernia. 190. Prolapsus. 192. Vulnus. 193. Laceratio. 196. Enthesis. 197. Venenatio. LECTURE II* e. Osteosi. Ord. II. Ectopia. 191. Luxatio. Ord. III. Dialyses. 194. Fractura. 195. Ulcus. Ord. IV. Tychica. 198. Verminatio. Ord. V. Deformitates. We are now prepared to enter at once upon the description, causes, and cure of diseases. To-morrow, then, we shall be- gin with fevers. " To-morrow," in the language of the shepherd swain, Ly- cidas, " Te-morrow to fresh fields and pastures new.' 45 LECTURE III. OF FEVERS IN GENERAL. The term fever, or febris in Latin, has been variously derived. Some derive it from ferveo, to burn, or fervor, heat. Others derive it from februo, a verb signifying to depurate or purify — believing fever to be an effort of the system, by which it throws off any impurities which may be received or engen- dered in the body. The Greeks denominated it irugei-is, and wyga/ro?, from w^ fire. Fever is one of the most common, and one of the most dangerous affections of the human frame. It is common to both sexes. All ages are subject to it. It is found in all coun- tries and in all climates. None are exempt. Sydenham sup- posed fever, strictly so called, to constitute two-thirds of the diseases which prove fatal to the human species ; and he has calculated that eight out of nine of all who die, are cut off by febrile diseases. This computation is too high, considering fever in the limited sense in which we employ it. But, consi- dering it as comprehending every affection in which the febrile state exists, it certainly makes up a very large proportion of the diseases fatal to mankind. Indeed, fever is so universal a disease, that it may be said few either live or die without it. Few go out of the world or remain in it without fever. By Hesiod, fevers are hence denominated by the general term, " disease." And Horace in emptying Pandora's box, calls all diseases, " fevers." " Post ignem setherea domo Subductum macies, et nova febrium, Terris incubuit cohors." 5* 46 LECTURE III. Its importance, therefore, to the physician, and consequently to the student, becomes very apparent, especially when we view it as one of the great outlets to human life. Indeed, a physician is or is not entitled to that distinguished appellation ; he is or is not skilful, successful, or eminent, in proportion as he is or is not acquainted with this important class of diseases. And as he is well instructed in the nature and treatment of fevers, he will be successful in the treatment of diseases in general, as all diseases occasionally assume a febrile character. Hence Dr. Gregory used to devote the greater part of the six months' session to this subject, and the phlegmasia? ; for he very rarely reached the second class of diseases in the arrangement of Dr. Cullen, which, with all its defects and errors, is adopted in the university of Edinburgh ! What is fever ? It is difficult to answer this question. It has become almost a proverb, that the wisest man knows not the nature of a fever. Notwithstanding the long experience of mankind on this subject, and the investigation which has been bestowed upon it by physicians, much yet remains to be done in the investigation of this intricate subject. The only safe mode of procedure in arriving at a knowledge of this condition of body, will be carefully to note the facts which have presented themselves on this subject : for as that great practical observer, Sydenham, justly observes, " If we se- riously attend to what nature actually performs, and observe what instruments she uses in her work, we may be able to dis- cover her operations ; but," he adds, " the manner in which she operates, if I am not mistaken, will always be concealed." It is therefore proposed first to notice the symptoms of fever. Symptom is a Greek word, derived from the verb , to happen — to occur. It signifies thence, an appearance or occurrence. It is a term, moreover, appropriated to disease, but not to health. We say phenomena of health, but we say symptoms of disease. Another term made use of as adjective to symptom, is pathognomonic, derived from tt^oc, an affec- tion, and yivocnto, to know ; meaning thereby those peculiar symptoms by which the affection or disease may be known, to distinguish it from all others. Diagnostic is another adjective, frequently made use of by the physician, as expressing the OF FEVERS IN GENERAL. 47 quality of symptoms, and signifies those symptoms by which any two or more diseases may be distinguished from one an- other — i. e. by which two or more diseases, having a close resemblance, may be separated from each other — as plague and yellow fever. The term pyrexia, made use of by Dr. Cullen, (the febris of authors) was first introduced as synonymous with fever, by Sauvages. But Dr. Cullen first used it as the name of a class. Read Cullen's definition of the pyrexiae, " post horrorem pulsus frequens, calor major, plures functiones lsesge, viribus presertim artuum hnminutis." Of the post horrorem, Dr. Cullen was very tenacious in his description of fever. Not one, says he, of a thousand occurs without it. Boerhaave also considers chilliness essential in all fevers arising from internal causes. By internal cause, he meant that which existed in the body, before the fever appeared ; and that whether generated within the body, or introduced into it from without. The bile vitiated, is an example of the first ; the pestilential contagion of small-pox, of the last. Yet both exist in the system before the fever makes its appearance ; and, therefore, are considered as internal causes. But shivering, Boerhaave observes, is not present when fever proceeds from external causes, as sudden anger — violent and long-continued exercise. Then " no coldness, (he remarks,) is perceived to precede fever." Nor is it true of cases arising from internal causes that the chill is always present. It is an objection then to Dr. Cullen's definition of pyrexia, that some fevers are not preceded by chill or shivering. This fact was noticed as early as the time of Celsus. " xilice protinus a calore incipiunt." De Med. lib. 3. cap. 3. The same has been ob- served by many moderns : as Gorter, Compend. Med. Tract. 52. § 3. Burserius Inst. Med. Pract. vol. 1. p. 83 ; by For- dyce, Diss, on Simp. Fever, p. 11; and by Dr. Gregory, who remarks, that in the common quotidian there is frequently no cold stage. Cases of yellow fever too have frequently occurred, in which the patients w T ere very suddenly seized w T ith all the violence characteristic of that disease, without the least preceding sense 48 LECTURE III. of coldness. So in plague also ; even in intermittents, I have observed the same fact. Hence, probably, has arisen the supposed distinction which is made by the vulgar between the intermittent and the fever and ague. In other respects, Dr. Cullen's definition of pyrexiae contains for the most part a correct character of fever, except that " viribus artuum imminutis," is not properly applicable as mere debility, but as the effect of irritation, depriving the pa- tient of an inclination for exertion and begetting a sense of lassitude. But Dr. Cullen doubtless intended to convey the idea of pure debility; for by this supposed debility, he intended to strengthen his favourite hypothesis of debility's constituting the proximate cause of fever. But when we come to look at his definition of fever, strictly so called, we shall find it exceptionable throughout — " prse- gressis languore, lassitudine et aliis debilitatis signis, pyrexia sine morbo locali." I assert, there is not one word of truth in this whole definition. On the contrary, the invasion of fever is frequently sudden, without any previous languor or] lassitude, without any precursor or premonitory feelings whatever, and most commonly, or at least very often, without any debility, previous to the symptoms of increased action. And sometimes fever is attended with local affections from the commencement ■ — as of the brain, showing itself in violent pain of the head, delirium, and even mania. Indeed, Clutterbuck would have you believe, that all fevers arise from and consist in an inflam- mation of the brain. Dr. Parr considers a tension of the ten- dons of the wrist to be a constant symptom of fever. Dr. Fordyce also considers some mental alienation to be present in every fever. Such local affection shows itself also in the lungs in cough- ing, as in typhus. The throat too, in the commencement of typhus, is frequently sore and even inflamed, owing to the state of the stomach. The stomach too is frequently affected from the beginning with vomiting, as in yellow fever ; and that too, in some cases is irrestrainable — such is the sensibility of that viscus to the operation of the poison of that disease. And in plague the glands of the groin and axilla are some- Or FEVERS IN GENERAL. 49 times among the first seats of irritation. It is accordingly re- marked by almost all writers, that in proportion as those local affections appear early in the plague, the disease of the whole system becomes mild. Dr. Russel observes, that some cases of plague he prescribed for from his window — the patient having nothing but local affections or buboes. This, there- fore, is a bad definition given of fever by Dr. Cullen. Galen considered fever a preternatural heat generated in the heart, and from thence diffused throughout the body. It is true, that the greatest source of heat is in the neighbour- hood of the heart, viz. in the lungs, the fire-place where, by the constant condensation of the oxygen, the caloric which gave the oxygen its gaseous state is disengaged. It is now, however, considered that the lungs are not the only source of the heat of the system ; but that the various processes of di- gestion, chylification and assimilation, indeed, that all the de- compositions and new combinations in our system, are attended with an extrication of caloric, besides that arising from the process of respiration. Sennertus and Vogel following the ancients, Galen and others, made increased heat alone the essence or proximate cause of fever. There is great error in this respect. In the first place, the feelings of a physician mislead him, for the sense of feeling like all the other senses is frequently falla- cious. The sense of heat must necessarily too be relative, accord- ing to the temperature of our own bodies, or that temperature to which we had been previously exposed, or have just come from : and before the time of Van Helmont (who was born 1577, and died 1644,) we had no measure of heat by the glass and mercury. Indeed, this measure was only made use of within the last hundred years. Van Helmont first invented a measure of heat by the ex- pansion of air in a glass globe, pushing up when heated a fluid through a small cylinder, and allowing, when cold, the fluid to descend. By this instrument, as it was afterwards improved, we now measure the apparent heat of bodies. But besides the fallacy of our feelings, in some instances the heat of the pa- tient is not increased, it is even lessened, as in the first stage of fever ; yet the pulse is, perhaps, increased in frequency. Dr. 50 LECTURE III. Cullen admits this to be the case, as you will find by consulting his notes. His notes he finds very convenient to relieve him- self from the difficulties in which he becomes involved in his text — " neque calor major, &c. to negere nolo." See Noso- logia, p. 43. Heat being the result of quickened circulation and quickened respiration, must necessarily be absent in the first stage of most fevers, as it requires time to produce that effect, and therefore it is not to be looked for as a pathognomonic or es- sential characteristic symptom of fever : on the contrary, in some cases it is even reduced below the natural temperature. Fordyce found it less in fever by actual measurement, and yet all other appearances denoting fever were present. He found it at 96°, 95°, and even at 94°; and that too under the tongue, (the natural temperature of the body in health is 98, or rather 97J under the tongue.) Dr. Currie states, that he has found the heat under the tongue and in the axilla as low as 94°, 93°, and even down to 92°, (see Med. Reports on cold and warm water in fevers, 2d ed. p. 168,) and in other cases Dr. Fordyce remarks, that the patient feeling cold, his heat was up to 104° and 105° — indeed 110° and 112°, are mentioned by authors. The experiments of Dr. Fordyce frequently show no increase of cold, though it is felt and complained of by the patient. But the heat of the body is also very variable, and that too frequently in a few minutes, depending on accidental circumstances. It will de- pend somewhat upon the temperament of body, upon the con- dition of the nervous system, as well as the circulation. Hence the heat of some persons is greater than that of others. I have oftentimes met with this extraordinary degree of heat in persons of the nervous temperament, in which a great quantity of blood circulates upon the more sensible parts of the body. This is the case with myself. In very fat persons the temperature of the surface of the body is deceiving — for the skin in very fat persons is to a degree insulated and relatively cold, from the mass of fat be- neath, which is a non-conducting medium ; as is the case in some children as well as adults. The elder Dr. Bard was hence in the habit, when prescribing for children, of feeling the forehead, not trusting to the extremities to ascertain the heat OP FEVERS IN GENERAL. 51 of the body — for where the limbs are disproportionately large, they are generally cool. In ascertaining the temperature of the body, you will there- fore recollect, that feeling the limb is not a test of the degree of caloric present. To obviate this difficulty, the thermome- ter must be applied to some other part of the body for this purpose. Dr. Currie had a curved thermometer purposely con- structed, that it may be introduced into the mouth, or in the axilla, or any other part of the body that possesses a pretty uniform degree of heat. Heat, therefore, is not a pathognomonic symptom of fever. Heat too is frequently partial in its operation, as in typhus fever ; and frequently in convalescence shows itself in the more sensible parts of the body, as in the temples — the cheeks —palms of the hands — soles of the feet — and yet there is no fever present. Celsus, therefore, may with great propriety say of heat as of the other supposed characteristics, that it is " asque fallax." Sylvius and Boerhaave were no less in error, in making the velocity of the pulse one of the essential characters of fever. The pulse has in all ages been referred to, as an evidence of fever. The pulse, before the time of Celsus, was not much no- ticed. Galen says, that Hippocrates was the first who mentioned the pulse — he however did not place great dependence upon it. Hippocrates certainly examined the pulse, and judged of the violence, of fever by it : — thus, he says, the pulsa- tions in lethargic patients are slow — that he found the pulsa- tions slow and trembling in Zoilus the workman. In the case of Polycrates too, he observes that the fever was so gentle, that the pulse seemed to stand still, except in the temples. And again, he remarks, that in the most acute diseases, the pulsa- tions are the largest and hardest. — (See his Prognostics.) The pulse was more noticed afterwards by Herophilus and Erasistratus, and particularly by Aretaeus. But in the time of Celsus, it became an object of considerable attention. Yet Celsus, speaking of it as a criterion of fever, has well called it, " fallacissima res." " In every fever," says Boerhaave, (I mean Herman, the 52 LECTURE III* sun of the medical world,) " arising from internal causes, there is always a shivering, a quick pulse, and heat varying in de- gree at different times of the fever." This observation is cer- tainly incorrect, for though great heat may be present, the pulse sometimes is in fever not quicker than natural. Nay, in some cases it is slower, for we may observe that quickness of the cir- culation and the degree of heat are not invariably proportioned one to the other, although they are generally so. The ge- neral standard of the pulse we know to be about seventy-three, with men of active habits; and while actively engaged, it is somewhat quicker. In truth, we may say it is rarely less than seventy, nor more than seventy-five. It is not so more than once in a thousand cases, excepting in old age, or when the constitution may possess some peculiarities or idio- syncrasies, as in the charter-house man, noticed by For- dyce, whose pulse did not exceed twenty-six. I have also had a patient in this city, whose pulse did not exceed forty- five, though he enjoyed good health. He died in his 80th year. In early and active life it never exceeded sixty, and even during fever it was not very perceptibly quickened, yet every other symptom of fever was present. In infancy the pulse is more frequent than in the adult, oftentimes exceeding a hundred in a minute, and that too in health. Dr. Gregory related to us a case in which the pulse during fever was always diminished instead of being increased in frequency. In that case the constriction attendant on fever, it appears, was not confined to the smaller vessels, but extend- ed to the heart and larger vessels also. The subject had been a patient of his father and himself.* Sydenham has observed of a malignant fever (febris hye- malis,) that during the first days, the pulse was that of health. " Sanorum pulsui non admodum absimilis." — Tractat. de hy- drope postcripto. 7 I have oftentimes seen the same in yellow fever, and that * My original note taken in 1792. Pulse.— Instance of a man by Dr. Gregory, whose pulse in health is 120 — also of one whose pulse naturally did not exceed 50, and when at 70 or 72, the natural standard, he was dangerously ill. Of a man also, whose pulse in health was quick and irregular, viz. 120 per minute, but in fever, became both slower and regular. OF FEVERS IN GENERAL. 53 too throughout the whole course of the disease. The same fact has been observed in small-pox. Greding has observed the same in a contagious epidemic fever, as you will see in Ludwig Adversar. Med. vol. I. pt. 1. cap. 1. p. 22. That the pulse is slower than natural, has frequently been observed in malignant fevers, especially those proceeding from contagion. In typhus fever the pulse is frequently observed to be less than the natural standard, down sometimes to sixty, fifty, forty-five, and even to thirty, while other symptoms of fever are present. Even in inflammatory complaints, the pulse in some cases is very small and difficult to be perceived. Similar facts are stated by Burserius, p. 84 , by Russel, in his Diseases of Aleppo, p. 230 ; by Sauvages, torn. 2. p. 307. De Haen in his Rat. Medend. pt. 12. cap. 2. p. 50 et 117. The last mentioned author observed, that in a particular case, as in Dr. Gregory's clergyman, it was not only slower during the continuance of the fever, but became quicker during convalescence and health ; nothing is more common than the quick pulse and a corresponding degree of heat in convales- cence, though the patient is free from fever. Home also states 5 that he has lost patients of typhus fever, in whom the pulse was not quickened. The depressing or se- dative effects of the contagion producing typhus, is not unfre- quently exhibited in this manner on the arterial system. — (See also Pringle, Lind, and Fordyce, for similar facts.) The latter, in St. Thomas's hospital, frequently called his pupils' attention to this irregularity of the pulse — this almost capriciousness as it might be denominated, in malignant fevers. In diseases too of no danger, the pulse is sometimes very inordinately accelerated. In a common catarrh, it is often as high as 120; in cynanche tonsillaris, 130 or 140 or 150 ; but the same frequency in continued fever is generally attended with great danger. Again, we frequently find no fever, even when the pulse is quickened beyond the natural standard — because it is much influenced by the state of the nervous system. Let me tell you the case of Mr. Boyd, a pupil of mine, who was ill of the yellow fever in 1795. I did not feel very confi- dent as to his safetv, and called Dr. Bard to visit him. The 54 LECTURE III. Doctor, upon feeling his pulse, without giving much attention to his other functions, instantly turned on his heel, and walked out. " Hosack," said he, " this man will die." " I hope not. sir." " Did you feel his pulse ?" he added. — I returned to make a more particular inquiry as to his situation, and found his pulse quite as tranquil as I had done before Dr. Bard's visit. I also found he had been out of bed on his chair, and hearing us coming to his room, hurried to his bed, which excited his circulation at the moment. In that moment of agitation, Dr. Bard felt his pulse — he recovered. Getting out of bed in ordi- nary cases, or any other bodily exertion in this irritable state of the system, accelerates the circulation. The same thing occurs during the exercise of walking, run- ning, dancing, or even the exercise of gestation, as riding on horseback, or in a carriage. Yet, with this temporary acce- leration of the heart or vessels, no fever is produced. In like manner in spasmodic affections, as of the intestines, the pulse is sometimes quickened to a hundred, yet no fever exists. In palpitation of the heart also, the pulse is very rapid, but it does not constitute fever. The pulse is no less affected by the passions of the mind, than it is by other impressions made upon the nervous system, or the peculiar irritation, which is the cause of the disease. When the fair one meets her intended, her heart may be lite- rally said to leap with joy. But her arteries are also excited and her pulse is quickened, not by their own vis insita, but by impressions made through the medium of the mind upon her nervous system. There was a case during my attendance in the Pennsylvania Hospital, in 1789 : a poor man was ill of dropsy — bed-ridden and debilitated, of course irritable and alive to every impres- sion. The approach of the physician and a retinue of pupils, as you will suppose, (for they did not observe that decorum in the wards of the sick, that they do at this day,) agitated him — his pulse was greatly excited, and in that increased action vene- section was prescribed by Dr. Rush — the poor man died within four hours after the operation. It is a good rule, therefore, not to feel the pulse of your pa- tient immediately upon your entrance into the sick room ; for the very opening or shutting of the door, the appearance of OF FEVERS IN GENERAL. 55 a new object before your patient, excites the heart and vessels to more frequent action, which may deceive you. Celsus, speaking of the effects of fear, anger, and the other passions and emotions of the mind — the effects of heat and exercise, &c, on the pulse, has well observed, " Quam facile mille res turbant;" " how easily is it affected by a thousand things." Neither the pulse, nor the temperature then can be considered as pathognomonic symptoms of fever ; nor consequently, respi- ration ; for it, like the pulse, is much influenced by the state of the nervous system, as well as the circulation. Boerhaave used to tell his pupils, that he had been at great labour to assemble from different authors, the symptoms of fever ; and that from this catalogue he blotted out all those symptoms which he did not find to be present in all fevers. He found of all the catalogue he had collected, but three re- mained — shivering, a quick pulse, and heat. But upon the same principle, he might have blotted them all out, for no one, as we have seen, is invariably present : no one is to be considered as a characteristic or pathognomonic evidence of fever. I have thus endeavoured to show you, what fever is not. Dr. Rush has well observed, that before we can arrive at truth upon any subject, we must first exhaust it of all its errors. Some of these we have endeavoured to clear away as preparatory to a more distinct view of this important sub- ject. In our next we shall show you, that in every fever there is a concourse of many symptoms, in some more, in others less. 56 LECTURE IV THE SYMPTOMS OF FEVERS IN GENERAL. Agreeably to the plan announced to you yesterday, it is now proposed to call your attention to the concourse of various symptoms which enter into, or constitute fever. And in doing so, we shall detail the various symptoms in the order in which they usually take place, noticing not only those ap- pertaining to a particular species of fever, but those which belong to fever in general, under whatever shape or form it may appear; whether intermitting — remitting, or continued, reserving the peculiar symptoms of each specific form for future and distinct consideration. This plan has an advantage as subservient to practice. For after the general view we propose to take, we shall be prepared for every deviation or change which may occur in any particular species. We shall not only readily know the various grades of malignancy which may occur, but we shall also be prepared to apply the general principles of treatment, and to adapt that treatment to each particular case that may present itself, and to the various grades and modifications which may occur even in the same case. Cullen, Fordyce, and others, take as their standard the pa- roxysm of an intermittent ! This is certainly incorrect, to make the peculiar form of an intermittent the standard for all! An intermittent for a continued fever ! Dr. Cullen doubtless found it very favourable to his peculiar views relative to the nature and proximate cause of fever, in which unfortunately he has been blindly followed by others. I say blindly followed, for there is certainly not that affinity between SYMPTOMS OF FEVERS IN GENERAL. 57 the intermittent and continued form of fever that writers have imagined — nor that unity which our countryman, Dr. Rush, supposed: the one, therefore, cannot stand as the prototype of the others. The paroxysms of the one are not found in the others, as they have been represented. Many believe that every continued fever consists of the paroxysms of an inter- mittent running into each other ; that all fevers are originally intermittents — to use a chemical expression, that they all have an intermittent base. This idea is too absurd to call for a se- rious refutation, although it is the error of two of the most celebrated practical physicians. The whole of the symptoms which occur in fever in all its various forms, will now be presented to you, as preferable to the partial view which each specific fever exhibits. Know- ing the whole, we shall afterwards readily recognise the parts which compose it. Much labour too will be saved, in- asmuch as after the general description now to be given, we shall in describing particular fevers, more especially confine ourselves to their characteristic symptoms, omitting altogether those they possess in common. Fever I define to be, an affection of the whole system. Some affect to say, that this definition is too extensive — they ask, how is it possible that fever can affect the whole system ? What effect can fever have upon the bones 1 upon the carti- lages or the ligaments 1 But when Hippocrates in his seventh aphorism states, that a wound penetrating into the cavity of a bone, may produce a delirium, we find no difficulty in ad- mitting the connexion between the bones and the brain — why, therefore, should not a similar connexion exist when the brain or blood-vessels are primarily affected'? And do we not oftentimes find the bones affected with disease as the conse- quence of fevers'? viz. rheumatism, white-swelling, necrosis, &c. My definition, that fever is " a disturbance of all the func- tions," is adopted by Dr. Wright — (see Med. Chir. Journal, new series, p. 311. vol. 1.) lately too by Prof. Jackson of Boston, and by Dr. Potter of Baltimore ; and, indeed, the same is now adopted substantially in the Philadelphia school. We shall now proceed to show you, that fever is a disease of the whole system — a disturbance of all the functions ; that it 6* 58 LECTURE IV. appears no less in the faculties of the mind, than in the func- tions of the bodily structure — that it shows itself in every organ of our frame, and affects every nerve and fibre of the system. That the absorbing, the circulating, and the secerning systems of vessels are all affected by it ; that it shows itself in the fluids as well as the solids. In a word, that it is omnipresent — that it has no one pathognomonic symptom, but is constituted by a concourse of symptoms. Yet it is to be understood, that all the symptoms which are met with in fever, are not combined m every case. In this respect, there is an endless variety. As for example — the state of the tongue, which is generally considered by phy- sicians as an index of the presence and state of fever, yet a very fallacious one. In inflammatory fever it is for the most part white, furred, and dry ; but in plague and in yellow fever, and other contagious fevers, it is frequently moist and clean throughout the whole course of the dis- ease. In the bilious remitting fever, as it ordinarily ap- pears in this country, the tongue is uniformly foul and loaded, not with a white fur, but with a yellow sordes ; and in typhus fever it is dry, red, brown, and black. So with regard to headach, this is sometimes present, at other times absent ; and so with pain in the back, loins, and limbs, chill, affections of the stomach, — in some persons, one of these symptoms occurs — in others another, and in a third, a different symptom. We may, indeed, observe of fever, that there is no one symptom but is occasionally absent, and no one but is occa- sionally present. Nor in fever are all the parts of the system equally or uniformly affected. Sometimes one part, sometimes another is more affected ; depending upon temperament, season of the year, climate, and a thousand other circumstances. Fevers differ in their duration and violence, as well as in their character, from the ephemera or fever of a day (occasion- ed by a feast or a debauch,) to a six weeks' typhus fever, or the long nervous fever, as it was formerly denominated. Seeing then that there is no one symptom or circumstance to characterise fever — neither chill, nor pulse, nor heat, nor state of the respiration — Dr. Cullen has added to his " calor major," and " pulsus frequens," the " functiones lsesse," — the deranged or disturbed state of the functions with which he SYMPTOMS OF FEVERS IN GENERAL. 59 should have begun, instead of the " progressis languore." But, as I have already intimated, he had his peculiar reasons for it — he had a theory, a peculiar doctrine to support, or rather the baseless fabric of a vision. Let us respect the memory of Dr. Cullen ; but let us respect truth more. " Amicus Plato sed majus arnica Veritas," is our motto. The services of Dr. Cullen to his profession have been great, they are invaluable. They, however, chiefly appear in his description of diseases : this is the best part of his works. But although much of that was taken from Hoffmann, and from Sydenham, and without the due acknowledgment of the sources from whence he derived such details, yet he himself also collected much from the book of nature at the bedside. And it is to be remarked, and to the honour of Dr. Cullen, that he never suffered his own hypothesis to accompany him to the bedside. His treatment of diseases was ever the result of his cautious and judicious experience and observation. Like Galen of old, he had too much good sense to be governed even by his own peculiar doctrines. In proceeding to give a description of fever, I observe, first, That the invasion of fever is frequently sudden. Dr. Fordyce remarks, " that he has known several instances where persons sitting down at the table with a strong appetite, an attack of fever having suddenly taken place, in less than two minutes they have been seized with perfect aversion even to the smell of food." p. 93. 2. Fever occurs most frequently at night, when the body is most susceptible of irritation, especially those fevers which take place after exposure to cold, — as all inflammatory fevers, and especially in' children, owing to the greater sensibility of their system. Indeed this is the case in most inflammatory com- plaints. The same thing occurs in most nervous affections ; so with worms and other irritations of the bowels. So also with parturition. In like manner with fever proceeding from contagion, its operation is not perceived in the day, when the system is under other impressions, but shows itself at night when other stimuli are withdrawn. Dr. Fordyce remarks that in London, ten to one attacked with fever, are seized between 8 a. m. and 8 p. m., compared with those attacked at 60 LECTURE IV. night, or from 8 p. m. to 8 a. m. This is certainly not the fact in this country. But we shall have frequent occasions to call in question the correctness of many of the opinions and obser- vations, even of that excellent observer, Dr. Fordyce. He may, perhaps, be correct in recording the phenomena of fever as they appear in Great Britain. But in America, in this in- stance, they are not applicable. 3. Fever occurs too frequently under predisposition, arising from the state of the air, changes in its temperature and quality, and the condition of our fluids. We thereby frequently acquire a combustible state of body that is readily lighted up into fever. The northern man is readily inflamed by the rays of a tropical sun, and especially so when great numbers are con- gregated in small confined apartments, and the fluids of the system partake of the vitiated state of the air, produced by such confinement and want of ventilation. In such a fermenta- ble state of body, our fluids, like an impure atmosphere, are easily assimilated to the taint that may be introduced into them. The first symptoms of fever denote irritation in the nervous system, producing restlessness and uneasiness, both in the mind and body. In some the passion of anger is excited — the pa- tient, though originally of good temper, now quarrels with his best friends — takes offence even at every act of kindness. The mind becomes impatient, peevish, restless — passes rapidly from one object to another, and is incapable of steady mental exer- tion — the patient cannot think or reason even upon ordinary subjects with his usual ease ; and as the disease advances, the mind also becomes excited, and not unfrequently exhibits a character never known before. Senac informs us that he once knew a woman who, just before the paroxysm, became very loquacious, nor was the approach of the disease announced to the bystanders by any other sign — see Senac on Fevers, p. 29. During the excitement of fever, in the case ofa lady, which occurred in this city, the imagination became so highly excited, that it displayed itself in a talent for poetry. Every thing she said during her paroxysms, was uttered in couplets, many of which were very correct and very beautiful. Yet she had never in health exhibited any extraordinary predominance of the imagination over the other faculties of her mind. In SYMPTOMS OF FEVERS IN GENERAL. 61 another lady who, upon other occasions, had never been accused of wit, the mind was so powerfully influenced by the excitement of fever, that she uttered some of the most pointed expressions that the strongest intellect could have conceived. In one of those paroxysms, I requested her to put out her tongue. She did so. I requested her to put it out still farther — a little farther ma'am. — " Why, I believe, Doctor, you think there is no end to a woman's tongue," was her reply. Yet on no other occasion did this lady ever show the sudden and un- expected combination constituting wit. In the advanced stage of fever, it is known that delirium and even mania are not unfrequently among its attendant symptoms ; but in the very commencement of fever, the mind is similarly affected, though in a less degree, showing itself in great impatience and anxiety. Perception, memory, judgment, reasoning, are all more or less disturbed by the invasion of fever. The mind becomes hurried in all its movements, and acquires the same febrile state with the body. In some, the agitation is very considerable and very apparent, and attended with great anxiety — frequently analogous to that which appears in women at the approach of labour, and which irritation is of the same febrile character. But fever produces also, in other respects, an affection of the brain and nervous system, showing itself in the bodily organs as well as the mental. It produces pain of the head ; sometimes the forehead and eyes are more especially the seat of irritation. This is frequently the case in yellow fever and the plague. In other instances the nerves of the ear are pecu- liarly and violently affected, and in some instances the pain is exclusively seated in the posterior part of the head, the cere- bellum, producing stupor. Dr. Fordyce makes a distinction on this subject. He consi- ders the pain to be external in the first stage ! — but in the se- cond stage internal, which last he believes to be entirely the effect of the increased circulation in the carotids, and both occasionally producing delirium. His distinction is certainly not a just one ; the true explanation appears to me to be, that in the first stage, one cause is operating, viz. the impressions made upon the nervous system chiefly, if not exclusively. But in the second, two causes are co-operating to produce the 62 LECTURE IV. same effect, i. e. the increased impetus of the blood is now added to the primary impressions made by the invasion of the disease on the nervous system — but which first impressions are in some instances so violent as to produce all which have been ascribed to both combined. The pain, therefore, attendant on the invasion of fever, cannot be considered as external in its operation. Pain also appears in the back, and that too, whether the patient be lying down or sitting up. Not, however, like the pain occasioned by debility after a fever, in which the patient is unable to sit up without an increase of it ; but like that which attends upon parturition — upon excessive venery, or is occasioned by self-pollution, which peculiarly affects the loins, and chiefly consists in irritation exclusively showing itself in the nervous system. So with fevers also : the irritation manifests itself upon the spinal marrow, and the principal nerves proceed- ing from it. Hence, too, the patient complains of pains in the limbs following the course of the larger nerves analogous to the pains of rheumatism. Sometimes, this pain is in one limb — most usually in both. This is especially the case in yellow fever and plague, and other fevers arising from contagion. The pain in some instances is so severe that- the patient feels as if his bones would be broken by it, (constituting the break-bone-fever, as Dr. Rush has denominated it,) attended in some cases with such distressing feelings as to be more appropriately called by the name given to it by a fair patient of the Doctor's, the break- heart-fever. A lady who was attacked with the same fever, experienced a very unusual degree of depression in her spirits. In her the disease vented itself upon her more tender feelings. She accordingly was thence led to give it the name of break- heart-fever. These pains denote frequently too the returning paroxysm of an intermittent, — pain of the back especially, though no other symptoms are present. Fever also produces a disinclination for bodily, as well as mental exertion. This has been very improperly called de- bility* by Dr. Cullen ; for the power of exertion is not lost, but suspended. And it applies equally to mind and body — for * It is a common error and often a fatal one, to mistake oppression for de- bility. SYMPTOMS OF FEVERS IN GEJfERAL. bS the paroxysm of fever being removed, the tone and vigour of both are restored, and at the time too when the debility is greatest, or should be so, i. e. when the paroxysm is ended. The nervous system manifests this invasion of fever in va- rious ways. In infancy and childhood it frequently shows itself in tremor, starting, dreams, talking in sleep, (somniloquism) walking in sleep, (somnambulism) subsultus tendinum, grinding the teeth, chattering of the teeth, rigours and convulsions. Dreams are not only the common attendants on the very first stage of fever, especially in children ; they are not only often- times premonitory of fever; but they also very frequently, in the process of fever, constitute the first degree of delirium in adults. In some cases, the adult is thus attacked. A patient of mine, upon the attack of an intermittent, was seized with con- vulsions, indicating the symptoms more of an apoplexy than of an intermittent fever, constituting what Alibert calls the apoplectic form of intermittent. Indeed, some old persons are thus seized with apoplexy, occasioned by the first invasion of fever. Hence it is said, that when an intermittent proves fatal to old persons, it does so during the first attack, and especially during the chill. Dr. Bard, senr., was thus affected in the first invasion of the disease which proved fatal to him. In every epidemic yellow fever with which the United States have been visited, some have suddenly died from this cause, and have dropped in the street, or have been found dead in their beds. The same thing has been observed of the plague. Lucretius tells us so in his description of the plague of Athens. Sydenham observes that during the first months in which the plague raged in London, people dropped down dead every day. In others, the invasion shows itself in stupor. These inflammatory symptoms attendant upon the first stage of typhus, I have many years since been apprised of — long before the publication of Dr. Armstrong's book. In other cases again, the patient becomes instantly maniacal from a state apparently of perfect health. It is recorded by Diodorus of the fever of Syracuse, that the sick instantly be- came delirious, and beat all who came in their way. A case is related by Dr. Gregory, in which a quartan was thus regularly announced by delirium, instead of the usual chill or rigor. 64 LECTURE IV. Delirium we know to be the frequent attendant in every stage of fever. More commonly, however, the first stage of fever affects the nervous system by pain, tremor, and rigor, especially in children. In some I have seen it exhilarate the patient exceedingly. Children in hives frequently manifest this symptom before the disease shows itself in the blood-vessels. In other persons again, I have seen the invasion of fever produce hysteria, not only in women, but in men ; only, how- ever, in those of the nervous temperament, or who have created that temperament by intemperance. I have known an old gentleman thus attacked with hysteria, threatening convulsions. He was agitated, and sobbed like a young girl. In all persons you will observe great restlessness — the patient tossing from one side of the bed to another, except when stu- por is produced. Indeed, the whole frame is agitated and hur- ried ; it manifests itself in every act the patient performs. Upon giving him his drink, he receives it from you in haste — he takes it from you rapidly — he swallows it with the same hurry and agitation. If you ask a question, he answers you in the same impetuous manner. His respiration too partakes of the same hurry, and is frequently attended with great impa- tience, anxiety and heavy sighing, particularly in fevers arising from contagion. And let me add, that under such circum- stances, this is frequently a fatal symptom. The external senses are no less affected in the first stage of fever. The sense of vision manifests the irritation of fever — the patient complains of a degree of heat and burning in his eyes, attended with a great sensibility to light. In some in- stances it shows itself in an instantaneous and extraordinary redness of the eyes, attended with an inflammation of the glands, and an effusion of tears, and those of an acrid saline quality. These circumstances are frequently met with in the plague, yellow fever, influenza, measles, scarlatina, and other diseases proceeding from contagion. The state of the retina is also sometimes so much impaired, that the patient believes he sees a variety of objects passing before him which have no existence, the muscse volitantes, as they are thence denomi- nated. Motes of this kind are constantly created by this state of the nerves. In other instances the irritation shows itself in SYMPTOMS OF FEVERS IN GENERAL. 65 producing an irregular action of the external muscles of the eyes. Strabismus or squinting is the consequence, and perhaps only exists during the irritation of fever. One of my own fa- mily is thus affected whenever any strong impression is made upon his nervous system, whether from fever, fear, or anxiety, but never squints at any other time. The sense of hearing is also affected. The patient hears imaginary sounds; the sensibility of the ear is so much quickened to real impres- sions, that he hears even the pulsations of the arteries of the ear. But this symptom occurs, as it regards both real and imaginary objects, more commonly in the advanced stage of fever, constituting what practical writers hence denominate tinnitus aurium. But where the sensibility of the constitu- tion is great, or the irritation of the disease is strong, this symptom exists from the first. The taste is in like manner de- praved and vitiated, insomuch that the patient scarcely distin- guishes his medicines from his food .or his drinks. Whereas, before, his sense of taste may, perhaps, have been very acute. The sense of smell is also frequently impaired or even sus- pended. The feeling is especially affected. In some instances the patient supposes he feels insects creeping over his skin, or hairs pricking him : some are insensible to heat. A case once occurred to me of a person who was severely burnt, by the application of a hot iron in the commencement of fever. The same patient was confined three months by an ulcer thus produced. More commonly, however, the patient complains of great coldness, when the body is even preternaturally heated ; and this too to a degree of shivering, called horripilatio, mak- ing the papillae of the skin and the very hairs erect them- selves. Hence the origin of the term. As an evidence of this sense of coldness, although the patient may be unusually co- vered, he complains that he wants more clothes, or wants to approach the fire — calls for hot drinks — takes them much hotter than he could possibly do in health ; and all this time the body is perhaps preternaturally heated, as shown by the thermo- meter. Frequently, however, the heat is actually reduced by the first irritations of the nervous system — and the circulation diminished in the small vessels upon the extreme parts of the body — and the extremities become cold, especially when the 7 68 LECTtffiE V, communis choledocus, or the urinary calculus in the ureter- sometimes excites the most severe rigours. A catheter in the bladder — an enema in the rectum— caustic applied for stric- ture of the urethra — strangulation of the intestines — hemor- rhagic affections— pus in the blood-vessels, I have known to produce similar rigours without any peculiar affection of the stomach. A case is related by Senac, of a soldier who died of a ri- gour that lasted two days, induced by a krge abscess in the liver. The rigours, therefore, in an intermittent, upon the same principle, may be accounted for as the result of an analogous irritation of the nervous system, occasioned by the usual causes of intermittents, particularly marsh effluvia. But we may easily account for the mistake of Dr. Fordyce, when we take into view the extensive connexions which the stomach holds with the nervous system* T)y means of its ganglions— its nerves — -the cseliac plexus — the great intercostal, and its immediate correspondence with the brain through the intervention of the eighth pair or the par vagum, constituting the stomach, as I have already expressed it, a sort of second brain in the system. By referring to Whytt's experiments, and still more recently, those of Wilson, the tying of the eighth pair in a dog, you will see the injury it occasioned in impairing the functions of the sto- mach. It is certainly surprising that Dr. Fordyce, with bis long ex- perience, his talent for investigation, and his acquaintance with pathology, should have had so limited, so short-sighted a view of this subject, as to refer those phenomena to a single organ- The whole body should be looked at. The body, like a build- ing, should be surveyed in toto, and all its parts io connexion taken into view. They should be viewed, too, at a proper dis- tance — every object has its focal distance — we should not merely see the fly on the castle. Clutterbuck, in like manner, saw nothing but the brain amidst all the phenomena which fever produces ! ! His doctrine traces all fever, forsooth, to inflammation of the brain ! It would be wasting your time, gentlemen, to notice the absurdity of Dr. Clutterbuck's whims on this subject — you may read his book if you please, to see to what ridiculous lengths a man will suffer himself to be carried by a favourite notion. OF FEVERS IN GENERAL. 69 The same remark will apply to the fanciful theories of some recent writers of the French school, who refer all fever to in- flammation of the mucous lining of the alimentary canal. Every thing with these new-fangled pathologists, is gastroente- ritis! Risum teneatis, amici '? But a Frenchman, you know, is very apt to think a great deal about his stomach ! The truth is, these new-fashioned theorists mistake the effect for the cause. The post-mortem appearances to which they so triumphantly appeal as evidence of their doctrine, are generally nothing more than the results of the disease ; often they are the effects of acrid medicines, and other injudicious prescriptions ; frequent- ly, the changes produced by the very act of dying, or con- sequent upon death ;* and perhaps, even more frequently, nothing more than the proofs that the patient has perished be- cause his physician has, instead of properly cleansing the pri- mcevicB, permitted the vitiated secretions and offensive contents of the bowels to overload them, and remain pent up to be an additional source of irritation to their highly sensitive surfaces, and to, the system at large. And yet, this is the doctrine so vaunted among us in the present day, and which threatens to become the popular theory of fever. So long, however, as the wretched, temporising practice which must result from it, is , pursued, there will not be wanting abundant post-mortem proof? j that fever is nothing more than g astro-enteritis. If you wouli 1 be enlightened physicians, and successful practitioners, yo u must take more general views than those which will lead you to look only at the internal coat of the stomach and bowels for the causes and phenomena of fevers. But fever also shows itself in the muscular fibres of the vas- cular system. Not only the heart is in general excited to more frequent contractions, but the arteries also. — The natural standard of the pulse in the adult, in health, is seventy-three. You will recollect that the circulation differs at different ages — that in a new-born infant the pulse is about one hundred and forty — towards the end of the first year, about one hundred * Upon the inspection of dead bodies, there has been repeatedly observed a remarkable turgescence of the vessels of the stomach and intestines, when the individual has died suddenly, without having ever manifested in life the least in- dication of disease in these organs. The vessels I have seen strongly injected even in cases of death from casualties occurring in perfect health 7* 68 LECTCfku V, communis choledocus, or the urinary calculus in the ureter- sometimes excites the most severe rigours. A catheter in the bladder — an enema in the rectum— caustic applied for stric- ture of the urethra — strangulation of the intestines — hemor- rhagic affections — pus in the blood-vessels, I have known to produce similar rigours without any peculiar affection of the stomach. A case is related by Senac, of a soldier who died of a ri- gour that lasted two days, induced by a krge abscess in the liver. The rigours, therefore, in an intermittent, upon the same principle, may be accounted for as the result of an analogous irritation of the nervous system, occasioned by the usual causes of intermittents, particularly marsh effluvia. But we may easily account for the mistake of Dr. Fordyce, when we take into view the extensive connexions which the stomach holds with the nervous systenfby means of its ganglions— its nerves — -the casliac plexus — the great intercostal, and its immediate correspondence with the brain through the intervention of the eighth pair or the par vagum, constituting the stomach, as I have already expressed it, a sort of second brain in the system. By referring to Whytt's experiments, and still more recently, those of Wilson, the tying of the eighth pair in a dog, you will see the injury it occasioned in impairing the functions of the sto- mach. It is certainly surprising that Dr. Fordyce, with his long ex- perience, his talent for investigation, and his acquaintance with pathology, should have had so limited, so short-sighted a view of this subject, as to refer those phenomena to a single orgam The whole body should be looked at. The body, like a build- ing, should be surveyed in toto, and all its parts in connexion taken into view. They should be viewed, too, at a proper dis- tance — every object has its focal distance — we should not merely see the fly on the castle. Clutterbuck, in like manner, saw nothing but the brain amidst all the phenomena which fever produces ! ! His doctrine traces all fever, forsooth, to inflammation of the brain ! It would be wasting your time, gentlemen, to notice the absurdity of Dr. Clutterbuck's whims on this subject — you may read his book if you please, to see to what ridiculous lengths a man will suffer himself to be carried by a favourite notion. OF FEVERS IN GENERAL. 69 The same remark will apply to the fanciful theories of some recent writers of the French school, who refer all fever to in- flammation of the mucous lining of the alimentary canal. Every thing with these new-fangled pathologists, is gastroente- ritis! Risum teneatis, amici '? But a Frenchman, you know, is very apt to think a great deal about his stomach ! The truth is, these new-fashioned theorists mistake the effect for the cause. The post-mortem appearances to which they so triumphantly appeal as evidence of their doctrine, are generally nothing more than the results of the disease ; often they are the effects of acrid medicines, and other injudicious prescriptions ; frequent- ly, the changes produced by the very act of dying, or con- sequent upon death ;* and perhaps, even more frequently, nothing more than the proofs that the patient has perished be- cause his physician has, instead of properly cleansing the pri- mcevifz, permitted the vitiated secretions and offensive contents of the bowels to overload them, and remain pent up to be an additional source of irritation to their highly sensitive surfaces, and to, the system at large. And yet, this is the doctrine so vaunted among us in the present day, and which threatens to become the popular theory of fever. So long, however, as the wretched, temporising practice which must result from it, is , pursued, there will not be wanting abundant post-mortem proof* j that fever is nothing more than g astro-enteritis. If you would be enlightened physicians, and successful practitioners, yo u must take more general views than those which will lead yc >xx to look only at the internal coat of the stomach and bowels for the causes and phenomena of fevers. But fever also shows itself in the muscular fibres of the v;as- cular system. Not only the heart is in general excited to more frequent contractions, but the arteries also. — The natural standard of the pulse in the adult, in health, is seventy-three. You will recollect that the circulation differs at different agetf — that in a new-born infant the pulse is about one hundred and forty — towards the end of the first year, about one hundred * Upon the inspection of dead bodies, there has been repeatedly observed a remarkable turgescence of the vessels of the stomach and intestines, when the individual has died suddenly, without having ever manifested in life the least in- dication of disease in these organs. The vessels I have seen strongly injected even in cases of death from casualties occurring in perfect health 7* 70 LECTURE V. and twenty-four — in the second year, one hundred and ten — in the third and fourth, ninety-six — -at puberty, eighty — in manhood, seventy-three — at sixty, about sixty. Instead of se- venty-three or seventy-five pulsations, they are quickened from that number to ninety, one hundred, one hundred and ten, one hundred and twenty in a minute — occasionally to one hundred and forty or one hundred and fifty strokes, depending upon the habit of body, the sensibility of the system, the type and cha- racter, as well as the cause of the fever, and the depletion the person may have undergone. This greater frequency of the circulation, though it does not take place in all instances, is generally present in fevers of the continued form ; i. e. in the second or hot stage ; but even then, it sometimes happens, that although all the other symptoms of fever may be present, the pulse, and in continued fevers too, is not more than seventy- three, the natural standard of health. Indeed in some cases, as before observed, Fordyce has seen it below seventy-three, yet all the other symptoms of the second stage of fever were pre- sent. From which it appears that the heart and vessels are in some cases not so much acted upon as the other parts of the body. So with yellow fever; the patient dies with black vomit, yet the pulse throughout is calm, soft, full and appa- rently healthy. A pupil of mine, (Dr. Marx,) informs me that the same fact has been noticed by Dr. Glover of Charleston, S. C. in a patient of his who died with the yellow fever, that the pulse had been na- tural throughout his disease, and that Dr. Glover has related the iase to the Medical Society of that city, noting this peculiarity. This disease frequently operates, I had almost said exclusively jpon the nervous system, affecting not only the brain but the nerves of the stomach, and other branches of the cseliac plexus. Indeed the stomach has been very properly denominated by Dr. Warren, of Barbadoes, the " seat and throne of the dis- ease," in yellow fever; for frequently other parts of the system remain relatively undisturbed. Even the muscles, in some cases, retain their power to the last moment of life ! They are so little affected by the irritations of that fever, that I have known the patient to rise from his bed, dress himself, and walk about his chamber until his hearse was at his door, ready to receive his body. Such was his muscular power that he could dig his own grave ! OF FEVERS IN GENERAL. 71 Analogous peculiarities have been remarked in the plague and in the spotted fever : but they are not found as the attend- ants on fevers in general, as they rather constitute exceptions. But to return to our subject. In the first stage, or the inva- sion of fever, the smaller arteries of the surface of the body are preternaturally contracted and diminished in their diameters. Less blood flows into them — the surface becomes pale ; and with less blood there is also less heat ; for heat is generally in pro- portion to the quantity of blood carried to a part — this fact we must all have witnessed. The hands, after riding in the cold air, and coming into a warm apartment, or suddenly exposing them to the intense heat of the fire, are not only attended with swelling but great increase of heat also, in proportion to such in- flux. So in fever the heat accumulates with the blood ; and the quantity of blood being diminished in the first stage, the extre- mities are cold. This, it is to be observed, occurs much more frequently in fevers arising from marsh miasma, as intermit- tents or remittents ; but less so in yellow fever ; yet it is not unfrequently the case in small-pox, typhus fever, and the phleg- masise. The exhalent, as well as the circulating arteries, are also ex- cited to preternatural contraction ; their extremities, in particu- lar, are contracted or spasmodically affected. This is so fre- quently the case that Dr. Cullen considers spasm the cause of the fever. Is it not more probably the effect of the fever, or of the irritation producing fever, analogous to the small pulse in gastritis, enteritis or phreiitis, and other membranous inflam- mations, or inflammations seated in very sensible parts of the body? Dr. Rush calls fever a convulsive action of the blood-vessels. This is but another expression to show the irritation which fe- ver produces in this as well as other parts of the system. This stricture, spasm, or convulsed state, of the exhalent vessels, shows itself throughout the system in the excretions. 1. The saliva is diminished in quantity, and the mouth be- comes parched and dry. The tongue, too, is dry ; its papilla? are erected by the retraction and stricture which take place upon the intermediate pirts ; and usually is attended with great thirst. 2. The urine is limpil, pale, white, and diminished in quantity 72 LECTURE V. — the bladder, as well as the vessels of the kidneys, manifests the effect of this irritation by its contraction and. disposition to eva- cuate itself frequently during the invasion of fever ; and that irri- tation will produce this effect we have an illustration in the effects of hydrophobia. In a dissection made of a person who died of hydrophobia, by the late Dr. Andrew Marshall, of Lon- don ; and by whom I was informed of the fact, in 1793-4 ; the urinary bladder was found preternaturally contracted. (See the same as related in his life, published by Mr. Sawyer, one of his pupils.) The same thing has been stated in accounts of other dissections, where death had been occasioned by that disease. 3. The skin is contracted in fevers — exhibiting the cutis an- serina — the constriction is even manifest to the eye, like a muscle wrinkled as well as contracted — almost the same con- striction is apparent in the human body as takes place in the skin of horses, which is supplied with a distinct muscle, the pan- niculus carnosus. Whenever that animal is diseased by fever, this muscle becomes affected, and the horse is said to be hide- bound. The skin, in fevers, also becomes dry and harsh, losing its natural softness, and no evaporation taking place, the circu- lation at the same time being increased, the heat of the body accumulates ; for the fluid secreted by the skin in health being converted into vapour, necessarily takes off a portion of the body's heat. In this way cold is produced by evaporation. Upon the same principle the atmosphere is cooled on a hot day by a shower of rain — the heat or caloric being absorbed in the con- version of water into vapour — in the practice, too, of cooling liquors by moistening the bottles containing them, the heat of the liquor is communicated to the surrounding moisture, which it converts into vapour, leaving the contents of the bottle rela- tively cold. In this way the human body might be frozen in the month of July. Upon the same principle, perspiration going on, Sir Charles Blagden, Dr. Fordyce and others, were enabled to bear the extraordinary degree of heat (300°, 400°) to which they were exposed in their experiments ; and which was great enough to broil beef-steaks, or to cook eggs. The use of the fan, instead of cooling them, burnt t;hem by bringing a new stratum of hot air into contact with the surface of their bodies, which had been cooled by the abstraction of heat that took OF FEVERS IN GENERAL, 73 place in converting the perspirable fluid into vapour. The want of this cooling process, therefore, as already observed, occasions our heat to accumulate, and thereby to become an additional source of febrile excitement. 4. The lungs, too, undergo a corresponding change in their functions. In phthisis we see expectoration diminished during the paroxysms of the hectic fever attendant upon that disease — in pneumonia the same thing occurs. We see the same in fevers in general. 5. The stomach, as is to be expected, manifests the evidences of the same irritation in loss of appetite— a morbid appetite — nausea, vomiting, suspension of the digestive process, as is evident from the food being long retained. — The gastric liquor is also probably both diminished in quantity and altered in its quality, analogous to the changes we see take place in the se- cretions of an ulcer. Hence it appears that intermittents and diseases cf contagion are ushered in most generally by nausea and vomiting because they make strong impressions on the nerv- ous system. The great semi-lunar ganglion and the numerous nerves of the stomach cannot escape the commotion produced by fever upon the nervous system. 6. The liver is no less affected than the stomach in the first stage of fever ; but in the hot and sweating stages its secretions are oftentimes increased, showing this effect in a catharsis or increased evacuations ; and those, too, exhibiting the appearance of bile recently secreted. 7. As to the pancreas, we have no evidence of such change, but the presumptive. 8. In the intestines the secretion of fluids is obviously dimi- nished ; hence costiveness is the usual attendant. The thinner fluids, that had been secreted, are also probably reabsorbed. Accordingly in the first stage of fevers the faeces are not liquid, but come away in a solid form, as we see upon giving an enema at this time. This is not all ; it frequently happens that even after a cathartic or an enema, we find very unexpected discharges of scybala to take place, which had been long pent up probably by some irregular and partial contractions of the intestinal canal itself. This event frequently occurs in fevers ; and especially in the advanced stage ; oftentimes just before death, when such stricture may be removed by the universal 74 LECTURE V. relaxation of the frame. In dysentery, where evacuations have not been sufficient in the first stage of the disease, such dis- charges frequently show themselves just before dissolution, and to the great reproach of the physician. In diseases of the in- testines themselves, we know by dissection afterwards, that such stricture or preternatural contractions have taken place ; and that lodgments of faeces have thus been formed. (See Baillie's Morbid Anatomy.) In fevers we also see this con- traction by the small discharges that take place, and that the same irritation contracts the bowels that we know to affect the bladder. 9. Uterus. The menses are in like manner checked by fever, when they may have been flowing at the time of the patient's attack, and the lochia in puerperal fever are in the same way diminished. Indeed this diminution is among its first symp- toms, and proves an additional source of malignancy in that peculiar form of fever that follows parturition. 10. The milk, too, is diminished, sometimes totally dried away ; not only during the paroxysm, but frequently this aga- lactia remains after the fever has terminated. 11. Ulcers are dried up and their colour changed during the action of fever. Blisters become pale and cease to discharge — hence it is a bad symptom to see blisters rapidly healed — it being an evidence of the diminished secretion from the surface and the accumulation of great heat in the part. 12. The extremities also shrink — rings which before were tight now drop off. The wedding ring is frequently dropped on this occasion, and this by the superstitious is considered a bad omen. The pulse also partakes of the changes going on in the sys- tem. In the first stage the pulse is small — it is small from an- other cause than the preternatural constriction of the artery ; probably there is less blood to dilate it ; i. e. the irritation, the cause of the disease, occasions the artery to contract upon less blood, and its contractions are more frequent — the heart and larger vessels consequently become in proportion full. The pulse, I should here remark, is of different kinds; and conveys different sensations to the physician, which are ex- pressed accordingly. I shall not amuse you with a recital of the numerous varieties of the pulse noticed by some nations, as OP PEVERS IN GENERAL. 75 the Chinese, who count three thousand pulses : nor even the variety described by Dr. Rush. I distinguish at the bedside ten varieties of pulse — 1. The full pulse, which dilates itself unrestrained. 2. Small pulse, scarcely to be perceived. 3. The soft pulse, readily yielding to pressure. 4. Hard or chorded, terse, wiery or quilled pulse ; i. e. not easily compressed, but making great resistance under the finger, 5. The frequent or quick pulse, in which one pulsation rapidly succeeds to another. Some distinguish between the frequent or quick pulse, referring in the last to the quickness or jerk with which the artery contracts, and not the rapidity as it re- gards the number of pulsations. This is an useless distinction, for they both show the same irritation operating upon the heart and vessels. 6. The slow pulse — one beat slowly succeeding to the other, 7. The regular pulse — the intermission between the beats being the same. 8. The irregular pulse — the intervals being irregular. 9. The intermittent — where some pulsations are wanting — This is common in hydropic affections of the chest — also com- mon in gastric and hepatic affectkwis, and is more frequently symptomatic of those diseases than of any mal-organization of the heart or its valves — in angina pectoris — in organic af- fections of the heart, and also in nervous affections — palpi- tations. 10. The gaseous pulse — giving the idea of air instead of blood filling the vessel — the soap-bubble pulse of Dr. Rush, as it was unfortunately called. The manner of feeling the pulse merits a moment's attention. 1. Do not feel the pulse too soon after you have entered the room. Allow the first impressions made upon your patient by the approach of a new object to subside. 2. Let your patient's arm lie in an easy position, so that the pulse may not be excited by the action of the muscles, as would be the case in extending the arm to the physician. I 3. For the same reason, if your^. patient has just been getting out of bed, or has been moved in bed, wait for the subsidence of the effects of such movement. 4. Do not exclusively confine yourselves to the pulse at the 76 LECTURE V. wrist — sometimes the carotids or temporal arteries manifest the chief irritation of the disease. 5. In feeling the pulse, make use of two fingers instead of one — they correct each other's sensations — and as the fingers have nicer sensibility than the thumbs, the fingers are preferable for this operation. It is a good rule, too, to feel the pulse in both arms — for fre- quently you meet with a great difference, particularly as it re- gards the size and strength of the artery. 6. This leads me to observe that for this purpose it will be important for you to cultivate a nice sense of feeling at the extremities of your fingers. This you will best do by the prac- tice of wearing gloves — at the same time that you thereby preserve your hands at a proper temperature, so as thereby to ascertain the temperature of your patient. The physician need not frighten the women and children by wearing a muff, as was the practice of the elder Dr. Shippen, of Philadelphia, and of the elder Dr. Bard, of this city ; but every physician should protect his fingers by wearing gloves, that their sensibility as well as their proper temperature may be preserved. Upon many occasions, too, let me tell you, that you require all the sensibility you can command in the extremities of your fingers. You want it, in some instances, to detect the presence of pus when deep seated — or of water in the cavity of the belly — or in the ovarium. We also require a nice sense of touch in feeling a vein for the purposes of venesection, especially in young and fat children. The late Rev. Dr. McDonald, of Albany, came one hundred and sixty miles for the purpose of getting bled. The physicians of the town where he resided could not effect the operation. They could not perceive the vein under the stratum of fat that covered it. So in cases of croup it is very difficult, unless you are habituated to the sen- sation, to find a vein. For these purposes then cultivate this sensibility — this know- ledge at our fingers' ends is highly important — you will find it upon many occasions no less useful to the physician than to the surgeon. In the practice of midwifery, this nice touch is peculiarly necessary, not only in conducting labour, in ascer- taining the presenting part of the child, and the dimensions and condition of the organs concerned, but in directing the OF FEVERS IN GENERAL. 77 introduction of the catheter, which the accoucheur is frequently called upon to perform. Another good rule in feeling the pulse is, to concentrate our sensations in the fingers. This is done by closing the eyes, and thereby excluding impressions received by the other senses. Noise or even music, at our meals, we well know, impairs, if it does not destroy the sense of taste — so does a variety of objects upon the eye diminish and divert the sense of feeling. Noise in the bystanders, at an operation, frequently disturbs the operator. The cries of the patient have, upon some occasions, very much interfered with the sensations of the person performing an operation. I once, when operating for aneurism upon a lad, for a few moments found it diffi- cult to feel even the pulsations of the femoral artery that I wished to detach, to put a ligature around it, until I could ab- stract myself by concentrating my sensations in my fingers. I make but one remark more on this collateral, but certainly not unimportant matter. Never time the patient's pulse by a watch. It alarms, without communicating any information w T orth having. It may prove a death-watch to the sick ! — But to return to ihe subject. As fever advances to the second stage, the pulse becomes more frequent and tense, hard, chorded, communicating to the fingers a sense of sharpness, more especially when fever is at- tended with inflammation seated in sensible parts of the body, as the intestines ; or with inflammation of the surface, as in erysipelas and other cutaneous diseases, and inflammation of the uterus, &c. ; or of parts which become highly sensible when inflamed, as the dense membranes, the serous mem- branes, as Bichat calls them — such as the membranes of the chest — those of the liver, and those of the brain. The pulse manifests the irritation, not only by its frequency, but by its hardness, in the first and second stage. It is an observation, as before remarked, made by Hippo- crates, that sometimes while the arteries at the wrist are weak and small, the carotid and temporal arteries are strong, and the case is attended with coma ; and in some cases by acute, deep-seated pain in the head. These dangerous symptoms, as remarked by Sir J. Pringle, in some cases denote inflammation of the brain, and abscesses are sometimes the consequence. Another observation worthy of your notice is, that the irritation 8 78 LECTURE V. in the pulse is sometimes perceptible to the physician, while the patient is not conscious of any departure from a healthy state in his feelings. I have, in this way, oftentimes known in the morning, from the indication manifested by the state of the pulse, whether my patient would have a return of an intermittent, and have predicted it ; while in other instances I have thus been enabled to prevent its recurrence. 79 LECTURE VI OF FEVERS IN GENERAL. The phenomena which have been noticed as the attendant symptoms of fever, appear not only in the paroxysm of an intermittent, but also in an ephemera, in synocha, typhus, the phlegmasia?, and many eruptive diseases, as small-pox, measles, &c. They appear even in tetanus and in hydropho- bia, when inducing fever by the irritation of the nerves, the primary seat of those diseases. For irritation, thus applied and continued, will produce fever. Not so, says Fordyce ! — But we do see it even in tetanus and in hydrophobia. — See Dr. Rush's las^ publication on the hydrophobic state of fever, as he denominates it, in a letter which he did me the honour to address to me. Also, see Dr. Shoolbred's valuable paper on that subject, in which he relates some cases cured by treating it as fever, i. e. by venesection, and other depleting remedies. See Med. Phil. Register — Eclectic Repertory of Philadelphia. See also, Dr. Andrew Marshall's Observations on Hydrophobia, in which the effects of fever and inflammation are manifest in various parts of the system. I refer you to these cases, not for the purpose of showing that they are necessarily febrile diseases, but that nervous irri- tation will extend itself to the blood-vessels by its continuance. Pain alone, if long continued, will also produce fever, as in cases of calculi of the gall bladder, kidneys, urinary bladder, the pain from spasm of the uterus, intestines, &c. The pains of labour are frequently attended with fever, which in some instances is of considerable duration. Indeed, in the process of labour you recognise the symptoms of a paroxysm of an BO LECTURE VI. intermittent. The first irritations beget a chill; the hot and sweating stages succeed. So far as irritation begets fever, we may say with Dr. Rush, that fever is unit ; but assuredly the character and duration of the disease are changed, influenced, and varied by the causes producing il ; and, as has already been pointed out, by the parts of the body becoming affected. I say, by the causes pro- ducing fever, and the structure and sensibility of the parts affected by such fever. Thus, synocha arising from the sensible qualities of the at- mosphere affecting the mucous membrane, produces catarrh, or cynanche tonsillaris ; and these are afterwards frequently renewed by the consequent irritability of those parts upon the least change of dress, of air, or both combined. In this way we see some of the most alarming diseases induced. Our families in their attendance upon our dancing assemblies, by their sudden exposure at first to the air of hot rooms, and afterwards to the cool atmosphere, when heated by the violent exercise of dancing, and sometimes from other causes, with their bodies half naked, frequently thus ensure catarrh, he- moptysis, and pulmonary consumption. These causes first excite general fever ; but pain and excite- ment in the irritable part are also among the first symptoms, the effects of such general fever upon the system. In some persons the same synocha or general fever locates itself in the lungs, producing pneumonia. In others, the liver becomes affected, and hepatitis is produced. The skin sometimes becomes the seat of irritation, producing erysipelas. Nothing is more common than these eruptive dis- eases at the approach of winter, in consequence of the check of perspiration and a general febrile state of the system; while in others it shows itself upon the muscles and joints, in the form of gout and rheumatism. Hence the common ex- pression that the gout cures all other diseases, or takes the place of all others. If I could get a fit of the gout, says the free-liver, I should be a well man : that is, all his disagreeable feelings which affect him in different parts of the body, would be concentrated in his great toe. In other words, he would have one seat of irritation instead of many. In some again, the bowels are the irritable organs, and enteritis is the consequence.. OF FEVERS IN GENERAL. 81 In like manner the breasts, the uterus, or the lower extremi- ties of lying-in women, are easily affected at the time of partu- rition, and inflammation of those parts of the body is frequently then produced by causes which, under other circumstances, would perhaps only occasion a slight indisposition or a com- mon catarrh. Accordingly, then, as the part is more or less irritable, either from its greater sensibility, natural or acquired, or from its previously having been the seat of disease, it becomes again the seat of irritation — the place of rendezvous. A fellow student of mine at the University of Edinburgh, Decastro of Vienna, informed me that his mother had suffered twenty-one attacks of pleurisy, and ten of hives; and Dr. Ferdi- nand Ludlow, a student of mine, I am sure I attended for croup nearly as often : not a season passed until his twelfth year, that he had not several attacks of it, such was the irritability of his trachea and bronchiae. Mr. T P 1, jun., also, in his infancy suffered many attacks of croup, attended with symptoms of asthma. He now suffers bronchitis upon every exposure to cold. Fever, therefore, varies in its character according to the causes producing it, and the condition of the part affected. Let me here call your attention to the error of Fordyce, (p. 19, 20,) who makes those local inflammations the primary disease, instead of the effects of general fever occasioned by the sensible qualities of the atmosphere ! He even considers phlegmon and sphacelus, as primary affections in diseases ! — When occurring in fevers they certainly in many cases are not so. The bubo and carbuncle that appear in plague and yellow fever, although they appear early, are unquestionably the effect of general not local irritation, and that too in the first instance. So also the sore-throat in the commencement, and local inflammation or sphacelus which occasionally super- venes in typhus, are ascribable to the same general affection of the system. I have seen a case of an affection of the ankle joint in typhus fever prove fatal. I know another who is now suffering severe local disease proceeding from rheumatism, the effect of sea-bathing when heated by previous exercise* Hydrocephalus is also thus produced, in some instances, as the result of general fever. And you have seen in the present sea- 8* 82 LECTURE VI. son, 1822, a case of fever ending in carbuncles, filled with purulent matter, and which in that case terminated fatally. Riverius (see his Prax. Med. lib. 27. cap. 2. Appendix,) ob- serves, that acute and dangerous fevers very rarely occur with- out producing some local congestion or inflammation of some of the viscera — " Rarissime fieri sine interna et peculiari vis- ceris cujusdem affectione et plerumque inflammatione ; quare nunquam omittenda cura hypochondriorum, capitis, thoracis, uteri, renum, et vesicas ; ut omni ratione investigamus quse harum partium insigniter laboret, et ei, quoad fieri potest, subvenietur." Dr. Donald Monro observes, that in fatal or malignant fevers, " the febrile matter is apt to fall on particular parts, and there to create abscesses, particularly in the brain, the lungs, and in the glands and organs." Diseases of Military Hospitals, vol. i. p. 237. Affections of the brain are frequently noticed by authors as the consequences of general fever, as showing themselves in inflammation, in effusion of serum, or in suppuration, espe- cially in the cerebrum, and indeed in the cerebellum occasion- ally. The cerebellum is said to be comparatively little affected. Two cases, however, of abscesses in the cerebellum are no- ticed by Pringle, as produced by remitting fever. Eisfield, in his account of the yellow fever of Leipsic, in 1799, mentions a case of abscess in the brain thus produced. In the epidemic fever of Geneva, in 1805, congestions of the brain were fre- quent occurrences. A similar condition of the organ was also observed by Jackson, to be the effect of yellow fever. And in examinations made in this country, this engorged state of the brain was also frequently observed, and occasionally a rup- ture of the vessels producing sudden death. There was a case at Bellevue, prescribed for by Dr. Rayley, in which the patient, apparently convalescent and sitting up in bed, sud- denly fell back dead — an effusion of blood upon the brain was found upon dissection. De Haen also mentions inflammation and sphacelus of the bowels as the frequent attendant on remitting fever, as disco- vered upon dissection. Pringle too states, that in northern climates rheumatism was an attendant upon intermitting fever. In 1822 and 1823, a case of this compound character occurred OF FEVERS IN GENERAL. 83 in the New York Hospital, in which the intermittent and rheu- matism appeared alternately. When the one appeared the other yielded — in this manner too, frequently changing places. In like manner fever, after exhibiting its idiopathic character, sometimes fastens on the lungs and terminates in pneumonic inflammation. Many years since a case of this nature occur- red under the care of Dr. Richard Bayley. The disease began as an intermittent, and preserved its character a long time as such, but ended in pulmonary inflammation and ulcer of the lungs. A case of this nature was also presented in the hos- pital, in which it began as rheumatism, but in a little time manifested a tendency to phthisis ; and another of an intermit- tent ending in a similar manner. Inflammation of the stomach is recorded by Bartholin, as attendant upon the remittent fever of Copenhagen. The same fact was noticed by Silvius de la Boe, in the epidemic of Leyden. Fordyce even asserts that fever does not give a tendency to sphacelus, p. 21. Had he seen either of the cases I have al- ready referred to, of the fever falling upon the ankle joint, or upon the knee, and ending in rheumatism and abscesses, he would probably have expressed himself differently on this sub- ject ; or had he seen the black man in the hospital in 1822, in whom the sacrum was laid bare by inflammation and ulcer supervening, in a typhoid remittent, he would have changed his views upon this important subject. Dr. Fordyce farther errs, when he says, that by removing the local inflammation, you remove the general fever. This is indeed taking a nar- row, contracted view of the subject, not to observe the in- tervention of the whole system in producing the phlegmasia?. I say, by removing the general febrile symptoms, you re- move the local inflammation, unless it be far advanced towards the usual terminations of inflammation. But even then you moderate it ; and again I assert, that the most effectual reme- dies are those which act on the whole system, and not upon the part affected. Dr. Fordyce himself mentions, p. 24, a case of fever Conti- nuing and going through a long course of typhus, after pneu- monic inflammation had been removed by venesection and other remedies. And he might have found many similar cases in practice. Therefore, I again say, remove the general 84 LECTURE VI. symptoms, and you will remove the local affections connected with them ; but not vice versa, as he himself by this very case shows. For in this case, although the local disease was re- moved, the fever was not cured, but proceeded in its course even to the typhoid t} 7 pe. The doctrine I contend for, is far- ther confirmed by Dr. Fordyce's own observation, see p. 25, that general fever disappears and is entirely cured by the ap- pearance of local disease ; — whereas, upon his principle, the general fever should be increased instead of being diminished. But the contrary is the case. The general fever is very ge- nerally lessened by such local irritation, except for the time that such cause of irritation may be applied — during the ac- tion of a blister in a very sensitive system, the excitement is frequently very much augmented, but subsides in a short time. In like manner the local inflammation produced by mercury upon the salivary glands, frequently converts a general into a local disease. We observe the same fact upon the eruption of small-pox, measles, and chicken-pox, that the fever subsides upon the eruption taking place. So in like manner when erup- tions spontaneously take place in diseases not of an eruptive character, the same relief is afforded. I know a young woman in whom an eruption appeared on the limbs, in all respects resembling the small-pox, as the attendant upon acute rheumatism, affording relief to the general symptoms. An- other case occurred to me in a young child, in which an eruption appeared in the progress of a remitting fever. Erup- tions of this nature occur frequently in various parts of the body, and generally afford relief. They appear about the mouth, the lips, the nose — from their salutary nature they are hence called critical eruptions. Not from any peculiar virus or humour that is thus discharged, as was formerly supposed to be the case, (my views of the humoral pathology, I trust, do not extend to this ridiculous extreme !) but from the local irritation they produce, translating the general irritation from the blood-vessels and other parts of the system. Upon the same principle, blisters remove instead of increasing general fever, and are accordingly oftentimes prescribed for this very purpose, and with the best effects. I therefore am inclined to believe, that synocha will beget the local phlegmasia?, but that OF FEVERS IN GENERAL. 85 the phlegmasia? are not, as Fordyce and others suppose, the primary diseases, at least generally speaking. At the same time, however, it is well known that local in- flammation will sometimes produce general fever, especially when seated in very sensible parts of the body and in habits of great irritability of nerve, as in females and in children. A wound, a surgical operation, a blister, teething, generally pro- duce fever. But it does not follow from this, that the phleg- masiae are in general the primary diseases, because they may be so in some instances, and are so under peculiar circum- stances. The physician of the Fever Institution, (see art. Fever. Rees,) observes, that in the advanced stage of fever, " inflammatory congestions are of not unfrequent occurrence, as in the stomach, lungs, intestines, and other organs," as al- ready noticed by Riverius, who also has remarked, in most distinct terms, that we ought to recollect that all those fevers w T ith which local inflammation is conjoined, are not sympto- matic, but often idiopathic, and that the inflammation super- venes, not being the cause, but as the consequence of the fever, — " qua? febrem istam non afficit sed illi potius succedanea est." He adds, " we frequently observe in practice, that patients labour under continued fever for a day or two before pain of the side and other symptoms of pleurisy appear ; thus also many persons, on the third or fourth day of fever, fall into in- flammation of the brain, &c, " sic nobis frequenter in usu practico videre licet asgrotantes, ab initio febre continua labo- rantes per unam aut alteram diem, antequam dolor lateris et alia pleuritidis signa appereant ; sic multi tertia vel quarta febris die in phrenitidem incidunt," &c. Riv. Prax. Med. lib. xvii. cap. 1. Speaking of pneumonia, Dr. Cullen observes that pyrexia is frequently formed for some hours before the local symptoms become considerable, and particularly before the pain is felt. And Boerhaave has justly remarked, vol. v. p. 4 — that pleurisy is rarely observed without a fever preceding it. So of the phlegmasia? in general. The second stage of fever now appears — no vis medicatrix is necessary to account for the phenomena which follow those of the first stage — no previous cold to beget the heat which succeeds. Attention to those symptoms will teach us that 86 LECTURE VI. there is but one continued, direct irritation, from the beginning to the end of fever, whatever may be its source. True — the spasmodic constriction of the smaller arteries, and espe- cially of the exhalents, must necessarily, as I have already observed, accumulate the blood in the heart and larger ves- sels, including those of the brain, as well as of the chest. And this accumulation necessarily proves an additional stimu- lus in producing the excitement that succeeds, thereby adding to the fever ; but which fever, as w r e have seen, already exists. The cold stage doubtless must be considered as an additional source of excitement or irritation. We see this frequently ex- emplified. We see it in a person immersed in a cold bath — he generally experiences soon after a temporary degree even of febrile heat — the hands and face after exposure to cold, glow w r ith the increased action that succeeds. — And if the cold stage be induced by cold, such cold of itself becomes in some in- stances, even a direct source of irritation ; I mean to say, that it is a direct stimulus — there is no truth in medicine in my opinion better established, that is, if it is the property of a sti- mulus to excite or to increase sensation and motion, than that cold is a direct stimulant or excitant. That a current of cold air will produce a glow on the cheek by exciting the action of the arteries, I think you will not dispute ; nor I be- lieve will you question the fact, that a lump of ice or a snow- ball, applied to the sensible parts of the body, will awaken a person from a sound sleep. Immersing the hand of a person sleeping in cold water, we know to have the effect of exciting even the distant bladder to contraction. To return to our subject. — In consequence of the irritation so applied, the circulation accordingly becomes increased, and the pulse quickened; the skin becomes hot, dry, and glowing with blood, except when local determinations take place to the viscera, as in enteritis, and prevent or counteract the circulation to the surface. The cheeks especially, from their great sensibi- lity, become florid during fever — the ears also show the same excitement — the eyes too become red — the serous vessels of the adnata being now enlarged from the impetus given to them, carry red blood instead of serum. At this time, hemorrhagies not unfrequently take place from the vessels of the nose, espe- cially if the fever proceeds from a cause operating on the fluids, OF FEVERS IN GENERAL. 87 as typhus. I have my three children at this time, in this very situation. The hands and feet also become hot and flushed — that is, the most sensible parts of the body become loaded with blood. In this respect a local, as well as a general fever, may be said to exist. Sometimes, indeed, as before remarked, a local fever exists without a general febrile excitement, (as in the cases of White and Smith of Whitehall; enteritis is their disease, yet there is no pulse, or heat, or state of the tongue indicating their condition;) but this excitability of the system from local causes greatly de- pends on the constitutional sensibility of the nervous tempera- ment. In some persons a common bile or whitlow, will beget a violent fever of the whole system. Besides this excitement in the blood-vesse|s during the second stage of fever, the respiration also becomes harried and anxious, in proportion as the blood is more or less rapidly conveyed to the lungs. The heat of the body, too, is in correspond- ence with the rapidity and irregularities of the circulation. The natural standard, as before observed, ife 98° of Fah. or rather 97^, to speak very accurately, the measure of heat being applied under the tongue. In this stage of fever it is increased even as high in some instances, according to For- dyce, as 105°. As I have already remarked, 110° or 112° have been noticed by authors, but their correctness becomes very questionable after the repeated, and, doubtless, accurate experi- ments of Drs. Fordyce and Currie. Perhaps the statement may be true of scarlatina, in which certainly the heat is more intense than in any other febrile affection. Dr. Willan says, that in that disease he has known it to be as high as 112°. Owing, too, to the partial determinations in the action of the blood-vessels, we also find the heat to show itself in some par- ticular parts of the body more than in others. Thus one ex- tremity of the patient is sometimes hot and of a florid colour, while another is cool and even pale. Senac states the same fact of a patient of his, who felt a coldness only in one arm. He also refers to another case, where ihe person had one side cold and the other hot, p. 25. As before observed, it is the effect of respiration to increase the heat of the body — the lungs are the fire-place ; but it is the province of the circulation to distribute that heat : hence, accordingly, we find it directed to 88 LECTURE VI. particular parts, producing the effects which have been no- ticed. It is also worthy of remark, that the heat of the body, now increased and accumulated, becomes a great additional source of irritation and fever ; operating upon all the functions, vital, natural and animal. The disturbance of the brain and nervous system now be- comes increased by the additional irritation and excitement which has taken place, especially in the vascular system ; and as in the first stage, so in the second, we perceive its effects in all the faculties of the mind ; in the external senses, and the organs of motion — producing delirium— an increased confu- sion of thought — distressing dreams — insensibility to external objects — inability to distinguish them ; and in some instances, a total alienation of mind, amounting to mania. It is also ob- served, that when the patient dies in this stage of disease, the brain is frequently found to exhibit the evidences of great con- gestion and inflammation. The effects of the second stage are also manifest in the or- gans of secretion. The urine now becomes high-coloured, be- ing hurried through the kidneys half formed, almost partaking of the blood from whence it has been so recently separated. The same observation applies to the bilious secretion, which is also increased in quantity in consequence of a similar rapidity of circulation through the liver, as we see by the immense discharges of bile — and bile, too, just secreted — which often- times are observed to take place when vomiting or diarrhoea is excited. In like manner, the small vessels upon the surface, and indeed in every part of the system, become highly injected, for they are acted upon by a very powerful engine, the heart and its larger vessels. But although this impetus be given to the vascular system, the exhalents are not completely unlocked in this stage of fever. The absorbents partake of the same excitement that influ- ences the exhalent vessels. They also are quickened in their operation, as appears by the rapid diminution of the flesh and fat of the body, which is the consequence of fever, as we see exemplified in the hectic fever attendant upon phthisis, in which the very nails become curved around the fingers, such is the irritation attendant upon that disease. OF FEVERS IN GENERAL. 89 We see the same loss of flesh in typhus fever, and in the fe- brile irritation of pregnancy. This increased excitement of the absorbent system also shows itself in the rapidity with which blisters are healed and disap- pear, owing not only to the strictured state of the exhalents, but to the excitement in the absorbents, which take up the effused fluid as fast as it is poured out Hence, too, the use of blisters in dropsy. The fluids of the intestines are in like manner rapidly carried away ; and this is probably the first cause of that costiveness which is so invariably the attendant upon fever. Hence the scy- bala and hardened fasces which are afterwards created. For this reason it is important to procure early evacuations in fevers, as we thereby guard against a great additional source of febrile excitement, arising from the materials so absorbed. Thus, too, we account for the dry and parched state of the tongue, as partly occasioned by the thinner fluids being taken away, as well as by diminished exhalation. Hence the secretions of the mouth become viscid and clammy, adhering to the surface from which they are secreted, as after the excitement of the system occasioned by too much wine. The discharge from the salivary glands, in the same manner, becomes thickened and adhesive. The fluid of anasarcous swellings accumulates after fevers have terminated, from want of energy in the absorbents ; but during the continuance of febrile action that fluid is sensibly diminished. Hence it is that febrile commotion, in whatever way excited, in many instances proves a cure for dropsy. Hence, too, the most active means that are prescribed in passive dropsy are such as produce a powerfully stimulant effect and excitement in the vascular system — mercury and squills — cantharides — horse-radish — mustard, and other stimulating ingredients, composing the fashionable diuretic decoctions. This accumulation in the blood-vessels makes evacuations more necessary, for by the neglect of them fever is aggravated, more especially by the reabsorption of the foul materials from the bowels. Not that it is necessary that such evacuations should be by venesection, but by the natural excretions of the body. Therefore not only retention of the noxious matters ordinarily evacuated, adds to the malignancy of fever, but an increase of 9 90 LECTURE VI. foul materials in the blood-vessels, carried thither from the in- testines and other sources by the absorbents. We should therefore also be prepared to expect from violent fever, or fever long continued, a vitiated state of the mass of circulating fluids, both from those materials which are retained as well as those which are absorbed from the intestinal canal and other sources. These various vessels of the system, having their action continued a certain time, at length the body be- comes relaxed either by a remission or abatement, or by a total intermission of the symptoms of the disease, depending on the causes creating the irritation and the duration of those causes. In consequence of this general relaxation, ihe vessels on the external surface of the body become more patulous — the spasm, or stricture, or convulsion — call it what you please, ceases to exist, and the fluids are again discharged by the ex- halents in the form of sweat. Hence this stage of fever is denominated the third or sweating stage of fever. This too is to be considered as the effect of indirect debility, as opposed to that which is the direct effect of weakness, as occurs in the last stage of fever or during convalescence. The sweating stage may take place spontaneously, or it is the effect of art employed to relax and unlock the vessels of our system. When this stage has arrived, it displays itself in all the secretions and excretions — the excreting vessels of the tongue, mouth, fauces, and membrane lining the nose, all pour forth from their surfaces the fluids that had been pent up. Accordingly such discharges indicate a favourable change in the character of the complaint, and are an evidence that the irritation of the disease is subsiding. In like manner the excretion from the lungs is restored by this general solution of fever, as we see in phthisis to take place at the termination of the paroxysms of the hectic form of fever attendant upon that disease: and in ordinary pneu- monia, the same discharge by expectoration denotes the abate- ment of the general fever, as well as of the local inflammation, and hence constitutes one of the most favourable symptoms that can occur in pleurisy or peripneumony. The skin too, in the sweating stage of fever, changes its temperature not only as the effect of a diminished circulation at this period of fever, but as the consequence of evaporation and the absorption of OF FEVERS IN GENERAL. 91 caloric by the conversion that takes place of the fluid discharg- ing from the surface into vapour. The skin, I may remark, generally manifests this favourable change first about the fore- head, and thence it becomes apparent over the other parts of the body. In the excretion from the kidneys an analogous degree of relaxation is apparent — the urine, instead of being pale as in the commencement of fever, or of a high colour as in the second stage, now deposits a large sediment, and is of more consistence : — this sediment consists of the earthy and saline materials of the blood, which the emulgents and their exhaling terminations permit readily to pass in this relaxed condition of the system. This sediment, from its resemblance to brick-dust in its colour and character, is hence denominated the brick- dust or lateritious sediment, so called from later — lateris, a brick. After the fever of gout and other diseases attendant upon a full habit of body, this deposite is uniformly observed to be very abundant. The discharge of bile from the liver, and of serous fluids into the intestinal canal, is in like manner restored, as we infer from the liquid stools and the bilious colour of them that some- times take place in this stage of fever. Indeed, in some in- stances diarrhoea takes place at this period. The uterus too experiences a degree of relaxation corre- spondent with the general condition of the system. The ves- sels of that viscus, which were surcharged in the second stage, now empty themselves by profuse menstruation — fluor albus reappears if it had been suspended — the lochia if suppressed are again restored. In some cases such is the determination to the uterine organs by fever, that the discharge amounts to haemorrhage. Even clots I have known discharged under such circumstances, and from a person too, whose womb had never been called upon to perform other duties — contrary to the opinion of those who consider the menstrual discharge to be a peculiar secretion, and not possessing the properties of blood. This doctrine of the discharge from the womb being sangui- neous I have long taught. I find it also to be the opinion of Sir E. Home, Cruikshank, Bichat, and others, as well as of Rhuysch, Hunter, and a host of others. The milk in a similar 92 LECTURE VI. manner is restored, and ulcers again secrete their natural and healthy fluids. After the fever is terminated, if of short duration, the natu- ral feelings are all revived — the various appetites return, and in some instances acquire new vigour. The snuffer returns to his box, the smoker to his cigar, and the seminal secretion and appetite among others, is perhaps preternaturally acted upon by the now greater sensibility of system. The wife too, in this season of convalescence and returning vigour, is now some- times got with child that was never before pregnant. Such is the effect of the impulse that has been given to his system, that it becomes also a source of new impressions to the wife. To proceed. The functions are all restored, mental and bodily. The vital, natural, and animal functions, except where the system is much debilitated by the long continuance of febrile action, as in typhus and other continued fevers ; in which case the degree of debility is in proportion to the degree and duration of the existing irritation. But in this case, the debility not only shows itself in those parts of the system we have hitherto pointed out, it also displays itself in its effects upon the fluids of the system. 93 LECTURE VII. OF FEVERS IN GENERAL But fever not only operates, 1st, upon the nervous system; 2d, it not only operates upon the muscular fibre, as it shows itself upon the larger muscles, upon the circulating, the exha- lent, and the absorbing vessels ; but it has also a third opera- tion: — it acts upon the fluids of the system as well as upon the solids, more especially when the fever is of considerable dura- tion and violence ; and that too, whatever may be the charac- ter of that fever, whether belonging to the class of febres, the phlegmasia?, or the cutanei. Allow me here to protest against the prevailing disposition among the medical teachers and practitioners of this day, and which has existed from the days of Dr. Cullen, to trace the seat, origin, and proximate cause of disease to the nervous system exclusively, totally disregarding the condition of the fluids and the vessels from whence the brain and nerves derive their powers, and upon which they constantly depend for the performance of their functions. When we look at the formation of the various parts of the body in the earliest stages of existence, we see the immediate dependence of vitality upon the globules of fluid circulating upon the part that may be the object of our examination. The fetus in the womb holds connexion with the mother, not through the medium of nerves or by sympathy, but by means of the fluids that circulate through an insensible tube, in which the anatomist, with all the aids he can derive from his glass or his knife, has not hitherto discovered the least evidence of a nervous fibril. Yet through this very conveyance do we see 9* 94 LECTURE VII. not only lie and health, but numerous diseases of the mother communicated to her offspring. In what does this change of the fluids consist ? I call it a putrid or putrescent state. — What is putrefaction ? I answer, it consists in a decomposition of the materials undergoing such process, and new chemical combinations or compounds taking the place of the materials so decomposed. In this process the solids lose their cohesion — the fluids lose their combination, and are divided into more minute molecules, from which again new chemical compounds are formed. In the ordinary process of putrefaction or decomposition too, there is usually an extrication of air towards the latter part of such process — that is, when such putrefactive process is com- pleted ; or in other words, some of the new products which are formed assume a gaseous or aeriform state. Not so, however, in all cases — for such extrication of air is not essential to the putrefactive process. Some say this extrication does not take place during life, and that the vital principle is the great anti- septic which counteracts the completion of the putrid stage : — but the vital principle being destroyed, surely that organization which is dependent upon it is destroyed. So it is during life : the vital principle being impaired, the organization is accord- ingly impaired. The vital principle partially destroyed, the organization becomes to the same extent destroyed or suspend- ed. But in some cases it may be renewed by the regeneration of parts so destroyed — as after gangrene or sphacelus. As far, therefore, as the vital principle may be destroyed or lose its controlling influence, so far putrefaction may take place, even in the living body. But this will especially be the case in those parts of the body in which the vital principle has the least in- fluence, — as in the fluids, which are certainly less dependent on the condition of the principle of life, than either the nervous or the moving fibre constituting the solids. Admit that the blood possesses vitality, (and some you know extend vitality to all the fluids of the body, not excepting the excretions,) I say, admit that the blood possesses the living principle, and it follows that in proportion as such power is impaired or destroyed, the fluids are liable to those changes they would undergo out of the body. But this tendency to the putrefactive process in any body, will also depend upon the number of articles making OF FEVERS IN GENERAL. 95 up the compound. Out of the body, it is a fact established by chemists, that articles consisting but of one or two ingredients, as oils or resins, will not putrefy ; — that this process requires an aggregation of materials. In like manner, if such condi- tion exists in the fluids of the living body, — that is, that a great variety of materials be taken into the system, or those retained which are usually evacuated, or a new ferment be introduced, putrefaction may be expected when the vital principle is im- paired and loses its controlling influence over those fluids. It is of all things most strange, that Dr. Cullen and Dr. For- dyce, when describing the phenomena of fever, should have been so silent, at least so sparing in their observations on the effects which fever produces upon the fluids of the system ; — for they both, upon other occasions, were compelled to admit, though involuntarily, the changes which we contend for. As practical physicians and as candid men, they could not pass by those changes which the fluids undergo in dis- ease. Dr. Cullen in his Nosology, admits it in the following expression. See note to p. 72. " I suppose that the humours have a tendency to putridity in every typhus — but this only in different degrees — and a greater or. less tendency to putridity only varies, but does not change the species." " In omni typho humorum in putredinem proclivitatem adesse puto ; sed vario tantum gradu adest, ita ut major minorve putredo speciem variare, nequaquam mutare, potest." In his Materia Medica, vol. i. p. 62, 63, &c, in remarking upon the conversion of vegetable substances into the animal fluids, he says, that this conversion is best illustrated by the putrefactive process they undergo. Again; after the animal fluids are so formed or perfected, he observes, " they do not long remain stationary, but are conti- nually advancing towards a putrid state, and that these dege- nerated parts, i. e. putrescent materials, are constantly passing out of the body by the several excretions." p. 63. Speaking of the acrimony of the fluids, he says, " It is very possible it may be so ;" and adds, " that upon many occasions it certainly is so." p. 63. Again he remarks: " To conclude, I will not deny that the state of the fluids may have a share in distinguishing the dif- ferent states of the body both in health and in sickness — but at 96 LECTURE VII. the same time I must maintain, that we know little of the manner in which it may have this effect : that our theory of the human fluids is still very incomplete and imperfect." p. 65. In his First Lines, (Rotheram's edition, p. 45,) he says: "From the dissolved state of the blood, as it presents itself when drawn out of the veins, or as it appears from the red blood being dis- posed to be effused and run off by various outlets, and from several other symptoms, I have no doubt, how much soever it has been disputed by ingenious men, that a putrescency of the fluids, to a certain degree, does really take place in many cases of fever." p. 45. Again, speaking of the causes of fever, he admits in p. 49, " that they arise from a putrescent matter; that their production is favoured, and their pow T er increased, by circumstances which favour putrefaction ; and furthermore, that they often prove putrefactive ferments with respect to the animal fluids." In his cure of fevers, his third indication, too, is expressly formed upon the existence of this state ; — for the object of it is " to obviate or correct the tendency of the fluids to putrefaction." The means of fulfilling this indication con- sists, — 1st, in avoiding the new application of putrid or putre- scent matter, — 2d, in evacuating the putrid or putrescent matter that may already be present in the body, — and 3d, in cor- recting what may remain by means of fixed air and other antiseptics, p. 88. See also his observations on scurvy, dia- betes, and hEematuria, pp. 328, 466, 573, et sequel. Yet Dr. Cullen in his preface, speaking of the doctrines of his great predecessor Hoffman, observes, that they were disfigured by intermixing the humoral pathology ! The system of Boerhaave, too, he pronounces on this ac- count to be fallacious, and apt to mislead — denominating the humoral pathology hypothetical, p. 17. But, as I have before observed to you, Dr. Cullen had powerful inducements to offer some new doctrines, whether ill or well founded. A strong current had been setting to Leyden. Boerhaave's merited ce- lebrity must be counteracted. To do this a new standard must be raised : and as he expressed himself to Dr. John Gregory, — " a tub must be thrown out to amuse the whale."* From what has been said, it is evident that he possessed a * See Gregory's Memorial. OF FEVERS IN GENERAL. 97 perfect knowledge of the facts on this subject ; but it is no less certain that he wanted candour to promulgate them — because, forsooth, they are calculated to overthrow the favourite fabric that he had erected. In concluding his preface, after stating his intention of extending the doctrines of Hoffman, founded on the nervous and moving power, he also observes, " that he avoids the hypothetical doctrines of the humoral pathology, which disfigured his and all the other systems which had hitherto prevailed," and hopes to be excused for attempting a system which may appear new. p. 22. But Homer himself sometimes nods. Fordyce, who is no less inconsistent, you will also find falling into a similar error on this subject, in his description of fever. Yet in page 117, he has this expression: "True, it appears not uncommonly that very evident appearances of putrefaction take place in fevers which are very infectious ; yet in a great many fevers that are so, there are no appearances of putrefaction." Here the admission is given very grudgingly, (yet it is given,) that the putrid state may exist during life, though he does not specify the fluids which may undergo such putrid process. Armstrong, a bold writer, whose work on typhus fever, (third edition, p. 118,) has lately attracted the notice of the me- dical world as a work of great practical merit, thus expresses himself on the subject of the fluids as the seat of disease. " The humoral pathology no doubt abounded with absurdi- ties, yet I am fully satisfied that there are several diseases to which it might in some degree be justly extended ; and there- fore believe that its almost entire abandonment has been preju- dicial, by leading us from the investigation of various morbid states of the fluids, and of the means best fitted to correct them." And then he applies his remarks to haemorrhages and to petechias, as connected with a dissolved state of the blood. In like manner, some of the professors of the medical colleges of our own country have lately adopted the doctrines which have been taught in the New York school. I rejoice that these are, in general, the doctrines embodied in Dr. Eberle's excellent system of practice, which has now become the po- pular text-book in therapeutics.* * See also Gregory's Practice, with Notes by Drs. Potter and Calhoun, 98 LECTURE VII. What, then, are the evidences of such condition of body exist- ing in fever ? The fluids of the body become changed from their healthy state, — 1st, by the causes of the disease. Fever occurs in such situations as are peculiarly favourable to such vitiated state of the fluids, as on ship-board, in hospitals, in camps, jails, &c, where the air becomes putrid and often si ve. Fever has been produced by putrid animal substances, — as the putrid whale in Holland, spoken of by Forestus. Parasus, in his Tract de Peste, cap. iii., observes also, that in his time the same thing took place on the coast of Tuscany. Septic effluvia, from putrid animal bodies, constitute the chief causes of putrid fevers. Sir John Pringle mentions a fever of this kind in the camp hospital, which was caused by a person lying in one of the wards with a mortified limb, at a time when the weather was very hot, and the place very close and badly ventilated. He mentions the fact also of his having known a dysentery (which is nothing more nor less than a fever, and often a very putrid one too,) to be occasioned by experiments on putrid blood. A fever of a most putrid sort was engendered from the pu- trefaction of cattle in the island of Nevis, from hides, &c, affecting the crew of a French ship, producing in the sick all those symptoms which are usually considered as indica- tive of such deranged or putrescent condition of the system, such as hsemorrhagies, purple spots, and carbuncles. Fevers are also recorded by Sir John Pringle, as the effects of the state of the air, induced by the putrefaction of dead bodies re- maining unburied on the field of battle. See Pringle's Dis. of the Army, p. 321. To these he adds, that the decomposition of vegetable sub- stances producing miasma, also gives rise to intermitting and remitting fevers, the last of which especially frequently run on into the typhoid type of fever; while others arise from ferments of a contagious character, introduced either by exposure to the diseased body or by art — as small-pox, measles, plague, and even the yellow fever. And in other instances again, we see fevers generated from the very condition of our system, independently of a materia ab extra — traceable to colluvies in the intestinal canal, the OF FEVERS IN GENERAL. 99 effect of the excessive use of fish and other forms of animal diet — from putrid provisions, or from the contents of the bowels being rendered more than usually offensive and acrid from ne- glect — from the influence of season — change of climate, or other cause. Dysentery is thus not unfrequently lighted up in the individual, and afterwards, like typhus or yellow fever, assuming a contagious character, becomes communicable to others in a similar frame of body. 2dly. The fluids of the body become changed from their natural and healthy state by the retention of those materials which are, when in health, ordinarily passed off by the skin, the lungs, the kidneys, and the bowels. The nature of those materials, and their peculiar qualities, will be noticed in an- other place. 3dly. The fluids become changed by the absorption of the materials contained in the bowels, and these become more vi- tiated by the fermentative process which takes place in the stomach and small intestines when diseased, viz. the acetous fermentation ; and by the putrefactive fermentation of those contents that succeed in the lower tract of the intestinal tube, more especially in hot climates and in hot seasons of the year. By neglecting to evacuate the bowels in the first stage of fevers, practitioners not only lose the advantage of removing an ag- gravating cause of fever, but they absolutely protract it into a very tedious disease, that otherwise would have been little more than an ephemera : — and frequently too they thereby convert a simple fever into one of a malignant character. 4thly. The fluids become changed by the reabsorption of the secreted fluids of the system ; at the same time, perhaps, that the whole of those secreted fluids had already undergone some change, previously to their secretion, by the morbid con- dition of the system existing in fever, as we see to take place in the ulcerated surface, as in the bowels, and in the quality and properties of the urine, all of which vary according to the state of body at the time of such secretion. The gelatin, the albumen, the fat, the saline materials of the body may be, and are probably thus reabsorbed, and contribute to those changes which are manifested in the circulating mass. Hence it is, that we see the blood in fevers exhibiting the buffy coat, that too of various characters ; and frequently too in the 100 LECTURE VII. last stage of fevers, but not in the first. See Rush on Yellow Fever. Hence it happens, that in pregnancy the blood usually exhibits the buffy coat, owing probably to the absorption of the fat and other materials that are taken up, and produce the irritation so characteristic of the pregnant state. I may here just remark, that it is favourable to this explana- tion, that the buffy coat consists of this compound, that it putrefies some hours sooner than the other parts of the blood, as has been ascertained by repeated experiments made by Sir John Pringle, as you will see in the valuable appendix to his work on the Diseases of the Army, p. 75. I shall notice this subject upon another occasion. 5thly. When diseases of this character occur, the body is under circumstances peculiarly favourable to such putrefactive process. The greater heat of climate and season in which such diseases are most prevalent, and the increased tempera- ture of the body itself in fever, are calculated to favour this change. What are the evidences we derive from the phenomena the body exhibits under such circumstances 1 The streams depend upon the fountain. If the source be pure, so are the streams ; but if the former be foul, so also will be the latter. The fluids manifest these changes in the excre- tions of the system. As, 1st. In the urine, which becomes turbid, and oftentimes muddy, like beer. In some instances, again, it is bloody, re- sembling coffee-grounds. " I have seen," says Dr. Huxham, " several times the urine rendered almost quite black, de- positing an immense quantity of matter, nearly of the colour of coffee-grounds." Similar cases of black urine may be found in the books. — Treatise on Fevers, p. 38. In other cases, again, the urine is foetid, and so acrid that it affects the blad- der itself, exciting it to frequent evacuations. When you look at its saline ingredients, which are now so readily discharged, you are not surprised at the irritation it excites in the bladder. 2d. The intestinal discharges show this condition of the fluids. In this state of body the discharges from the bowels are fre- quently frothy, like yeast, thereby indicating the fermenting or putrefactive process. The materials, too, evacuated, are highly offensive and acrid, exciting the bowels even to tenesmus and OF FEVERS IN GENERAL. 101 diarrhoea, a frequent occurrence in fevers of the typhoid cha- racter. 3d. The lungs, too, emit a peculiar effluvium, in fever, which is sometimes highly offensive, particularly in typhus; and indeed I may say, in the advanced stage of most fevers. It is to the acrid quality of the excretions from the surface of the lungs, in typhus fever, that we see that disease so uniformly at- tended with coughing. The tongue and the teeth also display this condition of the humours. The tongue is covered with a slimy, dirty, blackish matter. The gums are, in like manner, loaded with foul sordes, like that on the teeth. The lips par- take of it ; i. e. the secretions which take place about those parts are changed from their original and healthy state, analogous to similar changes in the other excretory organs of the body. A new and peculiar set of glands, situated in the gums, have re- cently been discovered to be the source of those peculiar secre- tions constituting the tartar on the teeth. The secretion from them no doubt adds to the offensiveness of the breath under these circumstances. At the same time, however, let me remark, that these symptoms are also attended with an impaired state of the vital powers in other respects, manifesting itself by hemorrhages, great depression of spirits, sighing, subsultus tendinum, &c. 4th. The skin also excretes an offensive discharge. Instead of the natural smell of the perspirable matter, its smell is simi- lar to that of urine ; at the same time that it is exceedingly acrid and irritating to the surface, and frequently attended with petechias and vibices.* " Frequently," says Armstrong, " they not only arise from h> creased arterial action, or from relaxation of the extreme ves- sels, but oftentimes from a dissolved state of the blood, which undoubtedly occurs in the last stage of many fevers," He far- thermore subjoins, that " petechias, from increased action, are of a bright red colour — from relaxation, generally of a darkish brow# From a dissolved state of the blood, they have an inky appearance, always accompanied with effusions of very dark blood from other parts of the body, as the nose, bladder, or in- * See Richerand's Observations on Urinous Fever. See Armstrong on Ty- phus, p. 119. 10 102 LECTURE VII. testines." p. 119. Indeed he believes, from repeated reflection, that the cause of death is some peculiar change in the blood itself, rendering it unfit for the purposes of vitality, p. 117-18. " Sometimes," says that minute, precise observer, Pringle, p. 313, " petechias are not seen till after death, i. e. after a still more complete decomposition ; but they are also frequent in the advanced stage of fever. The complaints attendant upon miliary fever are in this way produced," In the last stage of typhus, yellow fever, dysentery, and plague, these evidences of such change in the system are fre- quently met with. The eruptions, the blotches, and ecchymoma, of scurvy ; the hemorrhages from the nose, gums, lips, ears, bow T els and kidneys; the sphacelus from blisters, ulcers, and ichorous abscesses, all which occur in the advanced stages of fever, (as recorded by Lind, Pringle, and others,) are in this way only to be accounted for. The doctrines of Hoffman, Cullen, Brown, and others, who look exclusively to the nervous system for their principles of pathology, are very insufficient and unsatisfactory on this subject. The putrid, offensive sweats, and the cadaverous smell of the whole body, are also indicative of this putrescent condition of body. The colour of the skin is changed even during life, in the same manner as we observe to take place after death ; i. e. what occurs after the total extinction of the vital principle, to a ma- nifest degree, takes place during its partial extinction in the state approaching dissolution. After death from yellow fever, or from the bilious remitting, and in some instances from typhus fever, the body becomes yellow, and of a brownish, tawny hue. A similar change is apparent in the advanced stage of those fevers, and announces their fatal termination. In like manner the skin changes its colour by poisons introduced into the sys- tem ; such as laurel water, and the bite of a serpent, particu- larly about the parts bitten, as stated by Huxham. Some sup- pose the yellow colour that appears, to be produced by bile. This resort is not necessary. We see in dropsy, and especially in hydrocele, the serum effused to be frequently of the same yellow colour, when the liver has not manifested the least disease. Nor does the general aspect of the body exhibit the peculiar appearance of bile in those very cases in which such yellow serous effusions may have taken place. I some- OP FEVERS IN GENERAL. 103 time since drew off from the vaginal sack, in a case of hy- drocele, nearly a pint of serous fluid, as yellow as fresh bile, yet the patient was otherwise in health. Dr. Warren, in his account of the yellow fever of Barbadoes, offers the best explanation of the change of colour that takes place in that disease. He accounts for it as dependent on the state of the fluids, and especially of the serum, which becomes altered in its properties, as the effects of the poison in impairing or de- stroying the vital principle that he supposes to exist in the fluids of the system ; analogous to the changes which the blood un- dergoes when effused or extra va sated, when it is out of the reach of the vital principle, as in a part that has been bruised ; or as we see it in an ecchymoma after venesection, or in the analogous effusions under the skin, attendant upon scurvy, in which a similar yellowish colour of the part is produced. We have a familiar example of the same appearance in a bruise of the eye, vulgarly called a black eye. The small vessels are broken, and the blood diffuses itself throughout the whole loose texture of the eyelids that are affected. Sir J. Pringle, in his Experiments upon the serum, Ap- pendix, p. 79, observes : " We are not always to ascribe this to inflammation, but to a solution of some of the red globules, mixed with the serum; for the serum is tinged with a small quantity of red blood when putrefied." In the very sanguine complexion, the skin is yellow ; in the dark, swarthy sailor, the red disappearing, the body assumes a dark nut-brown. It is not improbable, too, that the numerous sebaceous glands of the skin may have their secretions changed, which may aid in pro- ducing those changes of colour which the skin undergoes from febrile disease. The appearances after death, we know, in- stantly bespeak this change of the system. After death from fevers, that have been of long continuance, and have been at- tended with the malignant symptoms referred to, a rapid de- composition immediately ensues — much more so than after death from any other diseases. This change, this decomposi- tion or putrefactive process, I assert, must necessarily have begun before death But where do these evidences of dissolu- tion or decomposition first appear? I answer, in those parts of the body where fluids abound, viz. the brain, the eyes, nose, mouth, throat, abdomen, stomach, intestines, uterine organs, 104 LECTURE VII. &c. This fact is observable in every dissecting-room. It was long since noticed and recorded by Dr. Hunter and others, as you will perceive upon consulting the appendix to the work of Sir John Pringle, in which you will find Dr. William Hunter's letter to Sir John Pringle, stating his observations made in the dissecting-room. — I add, it is in consequence of this rapid de- composition in the more fluid parts of the body, that anatomists, in dissecting the body, always begin with the brain, as decom- position soon takes place there, rendering it soft, destroying its texture, and confounding the various organs and tissues of which it is composed. They next proceed to the abdomen, and so on to the other cavities, w r here fluids abound ; and in the fluids, as before observed, the putrefactive process takes place more ra- pidly than it does in the relatively solid muscular fibre, which for many weeks remains unaltered, for the anatomist to pursue his dissections and demonstrations. But appearances, before death, no less indicate the com- mencement of the decomposition or putrefactive process, than that we observe so instantaneously to follow dissolution. The same state which has been described as the attendant upon the total extinction of life, is no less apparent before death, viz. the distended state of the abdomen, constituting tympanites.* The blotches on the belly, the offensive effluvia from the excretions, the cadaverous smell of the body, all indicate the same condi- tion that succeeds to the total extinction of life. In the case of a lady who died of scarlet fever, six months advanced in preg- nancy, there was, during life, tympanites ; and an offensive, cadaverous smell, and discolourations of the belly took place before death. She, herself, became conscious of the cadave- rous odour emitted from her own person ; for in this case the intellectual faculties and the senses were relatively undisturbed. In fifteen minutes after death the air of the room, and indeed of the adjoining apartments, became so intolerably offensive, that it was necessary to employ artificial means to purify the atmosphere, as recommended by Guyton de Morveau and * This distention of the belly is doubtless owing to the extrication of air from tlie decomposition of the fluids contained in the cavity of the belly, as well as those more immediately contained in the intestinal canal, and which we see so sensibly to increase immediately afler death. Or FEVERS IN GENERAL. 105 Carmichael Smyth. In such cases, after death, the body is only to be preserved by artificial means, as immersing it in spirits, enclosing it in a tarred sheet, covering it in oil, or wash- ing it with the acetous or pyroligneous acid, the application of powdered charcoal, covering it with ice, or other means of con- trolling decomposition. Another evidence of such decomposition or putrefaction is derived from the fact noticed by Baron Percy, (see Journal of Science and the Arts, No. 23, p. 180,) that wounds in a malignant state have been known to manifest the same phosphorescent appearance, the same emission of light, that is known to take place from organized bodies when putrefaction takes place, as from putrid meat. But these are not all ; many other cases I have witnessed, in which this tympanites and change of colour took place. In ordinary cases we see the pulse to cease in the extremities, which become cold and rela- tively dead. Blistered surfaces, too, evince the loss of the vital principle, by the dark and black appearance which they fre- quently assume. Ulcerations, from whatever cause, exhibit, at this stage of disease, the same change. Even before death, and in cases, too, where the patient recovers, it is not unusual to observe this partial loss of the vital principle, when at least its operations are suspended. It ceases to have control over the extremities of the body ; the pulse ceases ; the hair drops out; the feet become insensible, and relatively dead, and per- haps remain so for weeks after general recovery. The remedies that are necessary to counteract this vitiated state of body bespeak its putrid condition. Stimulants, tonics, but especially that class of remedies denominated antiseptics, are in a peculiar manner called for in this condition of the sys- tem. We use acids, fixed air in yeast, (see Dobson on Fixed Air,) sudorifics, serpentaria, and particularly the acescent ve- getables — and such means only can restore the body to its natu- ral healthy state. (See an excellent note on the subject of the fluids in Lewis's Translation of Cullen's Nosology, p. 147, art. Tabes. Cabanis, p. 130.) 10* 100 LECTURE VIII. OF FEVERS IN GENERAL, AND THE EVIDENCES OF A VITIATED CONDITION OT THE FLUIDS. But we are not limited to the facts which have been enu- merated. We have others that furnish the evidence of such a putrescent state of the body actually existing — proofs that the blood itself circulating in our vessels, undergoes a change ap- proaching to this process, as well as the fluids secreted from it. Fernelius, one of the most respectable authorities in medi- cine, (see Cabanis, p. 130,) and who is always spoken of as a philosopher as well as a physician, and in terms of the highest approbation, in his work on Fever, chap, vi., expressly states, that the blood drawn in putrid fevers (for the ancients always divided fevers into putrid and non-putrid,) is not only foetid, but that it has arrived at that condition that it will not coagu- late, its fibrous texture being destroyed by decomposition or putrefaction. — " Sanguis qui per febres putridas detrahitur ssepe animadvertitur non solum fostidus et graveolens, sed et putridus ; adeo ut nee sibi coheerere nee concrescere queat, omnibus sci- licet ejus fibris putredini consumptis." Fernel. de Febr. cap. v. Morton, another celebrated physician, in his Pyretologia, states the case of the blood drawn from a female in malignant fever, being so offensive that it not only greatly annoyed the ope- rator, but was perceptible to the bystanders. The same author (see Prolegomena, p. 26,) observes, that in petechial fever the blood when drawn emits a foetor as well as the urine. Swenc- kius (see Haematologia, p. 90,) also states, that in putrid dis- eases, and especially in plague, the blood is found in a putrid state. Pringle remarks, " that besides numberless observa- EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. 107 tions of the corruption of most of the secretions as well as the excretions in diseases, we have frequent instances of the tawny colour of the serum, the resolution of the crassamen- tum, and even of the offensive smell of the blood recently drawn." Huxham, in his work on fevers, (chap, v.) in a chapter expressly written on the dissolved and putrid state of the blood, states many facts corroborative of this condition existing even during life — not only as manifesting itself in the discharges which take place from the body, but by the sensible properties and changes wrought in the blood itself. See Cleg- horn, p. 101. In the " General Considerations" prefixed to Bichat's " General Anatomy," is the following passage :* " I cannot forbear relating a fact, which contradicts all that has been lately advanced relative to the incorruptibility of the blood in diseases. Engaged a short time ago in opening a body at the Hotel Dieu, with MM. Peborde, L'Herminier, and Courder, I found, instead of the black blood that is common to the abdomen, a sanious grayish fluid, which filled all the divi- sions of the splenic vein, the trunks of the vena porta and its hepatic branches, so that, on cutting the liver in slices, we could perceive, by the oozing out of this matter, the various ramifications of the vena porta and vena cava, which contained common blood. The body was so remarkable for its obesity, that I do not recollect ever having seen one like it. This state of fluid certainly did not proceed from the effects of dissolu- tion ; so that the blood must have been, while circulating, if not vitiated to this degree, at least very different from its natu- ral state, and absolutely decomposed." The reason why we do not so often meet with this state of the blood as might be expected, doubtless is, that we so rarely draw blood from the body in the advanced stage of fevers. Physiologists consider the blood not only to be kept from putrefaction by the vital principle, but also by its constant mo- tion ; as the constant movement of running water and the agi- tation of the sea preserve rivers and the ocean pure. Motion, in these last cases, certainly serves to exhale both from sea and river water its most putrid particles. * Vide p. 41. — London edition, 1824, 108 LECTURE VIII. At the same time that its movements interrupt to a degree the fermentative process that otherwise would take' place; for rest is necessary to fermentation, and so far such motion con- trols its putrefaction ; but when it ceases to flow in the distant vessels, this preservative power is diminished or lost. So secretion and excretion convey out the noxious materials from our system, and new materials take their place : but when those noxious excretions are retained, and these new materials are withheld, the effects are very soon perceived. Dr. Lind remarks, that he has always observed that the Romish clergy, who are in the habit of frequent fasting, become scorbutic, and remarkable for a foetid and offensive breath. He asks, " Can we ascribe this sudden effect of fasting to a disorganization in the solids ? Is it not more consonant to the laws of the eco- nomy, that the blood, being deprived of regular supplies of mild and nutritious chyle, should be first affected by this loss, and that the solids suffer in a secondary way only ?" Lind on Scurvy, p. 328. But, independently of the fresh supplies of chyle, these secretions being stopped, the putrefactive process soon succeeds. So with the ocean itself — in calms of any du- ration, it soon becomes highly offensive, and its surface is covered with the results of such putrid process. After three days' calm in the month of August, 1794, I witnessed this fact on the Atlantic Ocean. The sea for miles around us was co- vered with a scum that became exceedingly offensive, (the heat at the same time being great,) and very soon after our whole crew and passengers became sick with typhus fever. A simi- lar fact I have met with either in Cook, Clark, or Humboldt, Silliman, or some other voyager equally respectable, though I cannot now verify the authority. The moderate motion of the sea, therefore, does not of itself prevent that process from taking place even in the waters of the ocean. So it goes on to a certain extent in the blood-vessels. We see fermentation, (for we have no better term by which to de- signate the assimilating process which takes place in fevers,) I say, we see fermentation in small-pox, in measles, in the yellow fever, in jail fever, and in plague, and indeed in all diseases arising from contagion. We even see this fermenta- tive or assimilating process in various parts of the body. We see it in the processes of secretion and assimilation going on EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. 109 in the intestines, in the lacteals, in the blood-vessels. We see it in all the secreting and excreting vessels. What are these but decompositions and new chemical combinations 1 Putre- faction is an analogous process. I know no distinction between fermentation and putrefaction. Indeed, fermentation is deno- minated in this stage the putrefactive fermentation, to distin- guish it from the first stages of the same process, the vinous and acetous fermentations. Sir John Pringle used to observe, w That from the Greeks down to the present time, medicine was a science in which there was a great deal of reasoning upon a small number of facts ;" and justly adds, " that in future, on the contrary, there ought to be little reasoning upon a great number of facts." Upon the subject before us, there has been a great deal of discussion, (especially since the fashionable re- jection of the humoral pathology,) but these speculations I trust, must yield to the numerous facts which we have now assembled, and which all lead irresistibly to the conclusion, that a putrescent state of the fluids occasionally takes place even in the living system. Such at least is the conclusion I draw from them. But whatever may be the speculations we indulge, however unsa- tisfactory may be our explanation of the phenomena which have been enumerated, the facts themselves can never be in- validated relative to such change, let that change be called by whatever name. And, as subservient to practice, they are all important ; for without giving attention to the use of those means that are peculiarly calculated to resist this putrescent or vitiated condition of the fluids, we shall prescribe in vain. Dr. Cullen, the great but inconsistent opponent of the humo- ral pathology, admits that the bark is of no importance in the cure of scurvy, — that this is not merely a disease of debility, but of a peculiar vice of the system, to be otherwise corrected. In like manner, in the cases related to you in my clinical lec- tures of the scurvy and scorbutic eruptions which prevailed in the state prison, we might have gone on to the end of time with mercury and sulphur, without curing the disease, which ripe acescent fruits and other vegetable antiseptics, immediately effected. So in fevers of the typhoid type. It is uniformly urged as an objection to this doctrine, that if putrefaction existed in the blood, air must be extricated, and 110 LECTURE VIII. consequently the texture of the vessels must be immediately destroyed. Putrefaction, as I said before, is fermentation, i. e. decomposition, or a change in the compounds and new combi- nations formed out of the same materials. In the processes of chylification and the formation of blood — in the assimilation of that blood to the purposes for which it is destined, we have such decompositions and new compounds formed without the extrication of air. But we see actual fer- mentation or change go on without the extrication of air. We see it in every bottle of wine, however carefully it may be sealed, (for the ripening of wine is no other process.) And, as Walker observes, we see it in the living body in small-pox, the multiplication of which in the body he calls a fermentative process, and in which Dr. Cullen concurs. Dr. Cullen in his First Lines, (vol. v. p. 597,) says, " It is evident that the contagion of small-pox acts as a ferment with respect to the human fluids, and assimilates a great part of them to its own nature.'' Cruikshank, one of the most en- lightened of our profession, also expresses the same opinion still more amply. (See Dyckman's Pathology of the Human Fluids, p. 185.) This species of fermentation is hence called silent fermentation, as having some laws peculiar to itself; as opposed to that which takes place in the open air or under other circumstances. But, allowing for a moment that air should be extricated in the blood-vessels, I ask, must it neces- sarily prove fatal? I say yes, if it be suddenly introduced into the blood-vessels, and in large quantities. So of pus, and indeed water, in large quantities. Even blood itself in transfu- sion, if suddenly introduced, proves immediately fatal. See an excellent paper by John Hunter, on the inflammation of the veins after venesection, in the Chirurgical Transactions, vol. i. Yet pus taken gradually into the system by absorption, is not immediately fatal, and perhaps not so at all. But it produces a peculiar form of fever called hectic fever ; and this, I believe, is the only way in which hectic fever is ever formed. I have never seen a hectic fever but from this cause. Remember the peculiar characters of hectic fever. It is not every waste of the body from weakness, but much more, as its name imports. It comes from the Greek word «£/?, which signifies a habit. EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. Ill Some, by the by, contend that hectic fever is formed without the presence of pus in the blood-vessels ; and they will give you as an example a caries of the bone, or a diseased joint, as attended with such fever, and yet without pus. Is this so 1 Is there no absorption of matter 1 I ask what is a caries of the bone but an ulcer of the bone 1 And where is the ulcer with- out secretion? Where is the ulcer without matter? And what is this matter but pus 1 True, the pus of bone is one thing in ap- pearance, the pus of flesh is another — yet both are nevertheless pus, and will produce all the effects of pus in the blood-vessels. Although the muscular fibre of fish is different from that of other animals, they are muscular fibre; although, as the scrip- ture tells us, the flesh of fish is one, and the flesh of birds is another, they are nevertheless flesh. So the pus of bone may have some appearances differing from that of the soft parts ; it is nevertheless pus. To return from this digression. — The ex- periments of Redi, and other eminent naturalists, show that air, like pus, may be conveyed into the veins slowly and in small quantities, without killing the animal. " Pauco aere injecto neque necatis animalibus." — Redi, vol. iv. p. 223. See also Pringle, Ap. p. 89. But this part of the subject may now be put at rest, since the observations of Mr. Home and Mr. Bauer, lately published in the Philosophical Transactions, showing the presence of air circulating in our vessels, and that the very qualities of that air have been ascertained, viz. fixed air, given out in coagulation* p. 463. But we do not contend for absolute putrefaction in the living body, while influenced by, and under the control of, the vital principle ; or say that it proceeds to the same extent that takes place after death ; but that so far as the vital principle is de- stroyed in the part, or in the whole system, so far putrefaction may take place during the life of the body. But do we see this grade of putrefaction, this commence- ment of the process, exhibited by experiments out of the body 1 Yes we do. — See Pringle's experiments on flesh and upon blood. Before air was extricated in such quantity as to be percepti- ble, putrefaction began. The specific gravity of the material, the subject of the experiments, was changed ; the substance floated before such air could at all be detected by the senses; 112 LECTURE VIII. yet a separation, to a certain extent, had taken place between the integrant parts of the substance undergoing such change. Similar decomposition may certainly take place in the living body, especially in the blood and other fluids, in which there is less of the vital principle, and where it exercises less control than in the solids. And it is farther to be observed, that from the experiments of Sir John Pringle, and of Dr. Hales, (See Veg. Static, ch. vi.) that much more air is extricated from putrid flesh than from putrid blood. The same quantity of air, therefore, is not to be expected from such changes in the fluids as would be looked for from the decomposition of the solids ; the fluids would be much more advanced in the putrescent state before they exhibited this evidence of such change. But w T hile silent fermentation can exist in other bodies, so also may that silent form of putrefaction, that putrescent grade, take place in the less vital parts even of the living system ; for all the chemical changes which occur in the body are assuredly controlled, and more or less modified, by the influence of the vital principle. Hence, therefore, it is certainly possible that a degree of the putrefactive process may take place during life, in as far as the vital principle itself is impaired, and its con- trolling power diminished. It is even possible that putrefaction itself may have some peculiarities — some limits in the living body, which it has not after death, under different circum- stances. Without admitting this result in a certain extent, as before remarked, we cannot possibly in any way account for the rapid decomposition which so instantaneously takes place after dissolution, as well as many other facts which have been no- ticed. Whatever may be our reasonings or our speculations, our facts themselves must stand uncontradicted. We may cloud them in words, or obscure them by sophistry ; they are never- theless the same ; and so far the humoral pathology must be received. But fever, in the last stage of disease, is not confined to these effects upon the fluids ; the solids also become, in turn, affected by their reaction. As the heat that is accumulated by fever becomes in turn a new and additional source of excitement, so the fluids, being vitiated in the manner that has been stated, become a new source of irritation and of exhaustion to the EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. 1 13 nervous and moving fibre — a sort of secondary fever, as it may be called, ensues. In the last stage, the typhoid state of fever, now to be no- ticed, the solids, I observe, are in turn reacted upon by the fluids, which have become vitiated. Such vitiation is produced by long-continued action — whether the fever in which it occurs be induced by cold ; by marsh effluvia ; by human effluvia ; or the materies morbi of diseases acknowledged by all to be con- tagious, as small-pox, measles, scarlatina, &c. We occa- sionally see cases of pleurisy from cold, exhibiting a similar malignancy. Rheumatism, in 1797, prevailed in New York to a great de- gree, and exhibited a great tendency to assume the typhoid type, in which venesection was injurious. Analogous cases are no- ticed by Sydenham, as influenced by peculiarity of season, state of the air, &c. Intermittent fevers, from marsh effluvia, in some cases run into that type ; and are especially malignant on alternate days — particularly those fevers occurring in the heat of summer, or in hot climates — thence they readily become continued and contagious, as noticed by Cleghorn, in Minorca, and by Russel, in his history of Aleppo. See also Senac. And on the same account remittents still more frequently terminate in typhus, as they are a nearer approach to the uninterrupted or continued form of fever. Even hectic fever, I believe, would become so, if regular intermissions did not occur to counteract the putre- scent tendency, by the sweat and other natural secretions and excretions being restored. In small-pox too, that is, in natural small-pox, which is generally the confluent form of it, there is always a secondary fever, from the reabsorption of the matter from the surface ; and this secondary fever, very generally, as- sumes the typhoid type. Measles also, in some cases, exhibit the evidences of putrescency. — See Watson's account of what he denominates putrid measles, in the London Observations and Inquiries — see also Willan's Rubeola Nigra. I witnessed several cases of typhoid measles in 1795, in New York, particularly in a family that had recently arrived from the West Indies, and probably with their systems more or less influenced and changed by the heat of the climate they had 11 114 LECTURE VIII. left. It assumed a malignancy which I have observed but once since that period. I saw another case in the hospital in 1819, during the prevalence of typhus in the same ward. In scarlatina this condition of body is also of very common occurrence. In a family in this city, it was a very fatal dis- ease ; and it will ever be so if active measures be not taken to guard against this condition of body, and attention be not paid to the different stages of that disease, which you will find very much neglected even by the best practical writers. Dr. Heber- den himself, distinguished as he is for his practical observations, does not appear to recognise these different stages. In like manner, the ferment of concentrated human effluvia produces this typhoid form of fever, and is propagated by con- tagion. This is perhaps the only idiopathic form of typhus fever ; the others being symptomatic of long-continued excite- ment. I call jail, camp, or ship fever, idiopathic, because the dis- ease has a tendency to assume that character, notwithstanding all the exertions; that may be made to counteract this tendency. The predisposition is in the previous state of the fluids. I call ■the poison: or ft^iot communicated by jail and other fevers, of a 'contagiousiinaiture, a ferment, because it acts as such upon the 'circulating i fluids. That " a little leaven leaveneth the whole lump," is as true in fevers as in making bread, or in the conversion of acescent fluids into the acetous acid — and that upon the same principle of assimilation. That one spoiled her- ring will taint the whole cask, is well known to every house- wife or fish-monger ; hence the great care of the Dutch in their herring fisheries to salt down their fish as soon as they are taken. They never permit the sun to rise upon them. Sir John Pringle's experiments with an egg, a living body, illus- trates this principle very happily. The same assimilating pro- cess I believe to take place in small-pox, in syphilis, and other diseases which are universally admitted to be contagious dis- eases. It is called by Walker, the assimilating fermentation. The same process, I believe, takes place in fevers ; and that the ■peculiar taint formed by the excretions of the system repro- duces in others precisely the same disease, whether it be dysen- tery, yellow fever, plague, ship or jail fever. EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. 115 Hewson, the celebrated anatomist, died of typhus fever, induced by a wound received in dissecting a diseased body : the poison conveyed proved a ferment and source of morbid excitement to the whole system. During the winter of 1827-8, a fatal and much to be lamented case, of a similar nature, occurred within these walls, in which such local irritation was followed by an excitement that appeared in every part of the system ; at first operating upon the stomach, intestines and brain ; and thence diffusing its deadly effects throughout the frame. Numerous cases of fatal fevers have been produced in London and Edinburgh by this cause, among the young men attending the dissecting rooms. But in some instances, such poison vents its force upon a single gland, producing perhaps a bubo in the axilla, as in the case of my own brother. We see, then, two distinct causes of this typhoid state of body. 1. A worn-out state of the excitement ; and, 2. A fer- ment introduced. But the first is of itself sufficient in fevers to induce this derangement -of the whole system, without the last, by wasting the nervous energy and that of the moving fibre ; and thence the impaired state of the functions of circu- lation and excretion which succeeds. I xlo not, however, mean that merely a long-continued action, if it did not operate by its effects on the secretions, would of itself create typhus ; (that alone would produce symptoms of simple debility, a worn-out state of the nervous system and the muscular fibre, as manifested in the impaired strength of the body ;) but that it also acts on those vessels of the system upon which the state of our fluids depends. I mean the secreting, excreting, and absorbent systems of vessels. This typhous state of body is accordingly sometimes mani- fested, as before observed, in pleurisy, or in an intermitting fever ; but in those fevers arising from contagion or putrid fer- ments, added to the materials already existing in our circulating fluids, typhus is more readily produced ; sooner manifests itself in the progress of the fever by depression, sighing, and other affections, denoting an impaired state of the nervous system ; and more rapidly proves fatal, as in yellow fever, plague, spot- ted fever, than it is when generated under the circumstances before stated. This vitiated state of the fluids, combined with 116 LECTURE VIII. debility, constitutes the typhoid type of fever : hence then, we see two classes of symptoms manifested in cases of this nature. First, those which are ascribable to an exhausted state of the nervous and muscular powers ; and, secondly, those depending upon the condition of the circulating and the secreted fluids. So that this debility appears in all the functions of the system^ the vital, natural and animal 117 LECTURE IX. THE TYPHOID STATE OF FEVER We observed yesterday, the typhoid state of fever to be made up of two classes of symptoms. 1st. Such as are referable to an exhausted state of the gene- ral excitement — that is, independently of any change in the condition of the fluids or of the system in any other respects. And, 2dly. Those symptoms which arise from a deranged state of the fluids, as manifesting themselves both in the circu- lating and secreted fluids. This impaired state of the nervous system shows itself in all the functions both of the mind and body. It appears in the imagination ; it discovers itself in an impaired state of the judgment ; in the reasoning faculty, and in the memory. We see it in the imagination or perception of things, which is ge- nerally false at this advanced period of fever. The sick man imagines things which have no existence. The external senses, too, are impaired. He sees supposed objects constantly before him. He now exhibits a perfect pseudoblepsis imaginaria, ana- logous to that, state of the brain which is induced by spirituous liquors ; or similar to that state of mind which is intoxicated by passion or deranged by the consciousness of crime or guilt; as Macbeth, when about to commit murder, sees the air- drawn dagger, which, in his eyes, is so palpable, that he draws it from its scabbard. In fever, sometimes, those objects appear to him in one shape — then in another ; — he sees men — flies, (hence called muses volitantes.) So strong is the impression that he catches at them — he rises up in bed, in pursuit of them ; in some instances his fears are excited, and he endeavours to fly from them. His 11* 118 LECTURE IX. eftrs are no less affected in the sense of hearing ; — in some in- stances the sensibility is so great that the patient is disturbed by the very pulsations of the arteries ; in other cases the nerves of the ear, like those of the eye, are acted upon by imaginary impressions, the effect of the creative power which they acquire in this diseased state of the nervous system — well denomi- nated paracusis imaginaria, similar to that sometimes attend- ant upon dyspepsia. In like manner, the patient, in fever, hears drums beating to battle — or a person calling him, — he hears the bell toll — he sees his coffin — they are about to take him off for burial — he springs up — gets out of bed — wishes to go out •^—conceits himself not at home — (he wants to go home ;) and, if not prevented, runs into the street, or leaps from a window. He is unconscious of his family and friends — talks incoherently — mutters to himself — is with great difficulty controlled — ten thousand thoughts rush upon his mind in rapid succession — every pulse almost brings with it a new impression ; so sensitive is the condition of his brain, with regard to internal impres- sions. Not so to external ones ; to these he is comparatively insensible; and sometimes altogether unconscious of what, is passing around him ; but by loud speaking he is roused from this reverie, and for a moment is perhaps consistent ; but his mind is instantly disturbed again by the same phantasms, and he relapses into the same maniacal delirium as before. During this condition of body, and which perhaps continues for seve- ral days and nights, especially if mismanaged by the physician* he is constantly watchful ; or if he sleeps, he is in continued agitation : you see it in every muscle of his body — his cheeks — his lips — -his eyes — (they are all in motion) — his extremities also are in continual change from place to place ; and each muscle in exercise. A subsultus tendinum, or an irregular ac- tion of the muscles, as in chorea, pervades his frame ; if he awakes, he awakes confused — or is roused by a distressing dream — or perhaps imagines himself upon a precipice, or fall- ing from a great height. The memory, too, like the other faculties of the mind, is also affected, not only during the con- tinuance of fever, but even long after recovery. This I expe- rienced after scarlatina, in 1801 — my memory was impaired for six weeks after my recovery. On that occasion I was obliged to carry a memorandum of my patients, and of my THE TYPHOID STATE OF FEVER. 119 prescriptions for their complaints. In other fevers again, as in the plague and yellow fever, the animal functions, as they ap- pear in the senses and in the muscular organs, sometimes re- main undisturbed to the last of life. In those cases the disease appears to vent itself upon the fluids of the body; or upon some particular organ, as the stomach or liver. In all these cases the patients consider themselves well at the very moment that their graves are prepared for them, and the hearse is wait- ing at the door for their dissolution. This is not an imaginary picture, but drawn from the facts which have come within my own knowledge. For the most part, these walking cases, as they have been very properly called, are fatal cases. I have seen, however, two exceptions ; and strange to tell, both grog drinkers ; yet both recovered. The one was the late Mr. J. H. — he was thought by his physician, Dr. Tillary, to be dying — his skin was yellow — he had a violent hiccup, and was far advanced in the disease — he got hold of his can, and soon drowned the fever. Met by a friend, he cried out, " I have killed it — I have killed it." He was a man of fine talents, and of a finished education, received under Beattie and Campbell, in Scotland. But he became intemperate, and sunk so low as to be a wanderer in our streets. The second case was that of a Mr. T. I found him sitting on the floor, with a blanket about him, and his mug of stiff brandy and water at his side. He accosted me thus : " There is my physician, Doctor, I shall live or die by it." He too recovered. I lately treated a case of typhus fever upon the same principle — of preserving the excitement of the system by brandy. Finding that, in health, my patient had been in habits of indulgence in the use of spirituous drinks, the indication was apparent to adjust the degree of stimulus to the condition which the previous habit had produced. In other fevers, again, the patient is affected by stupor or coma, at this period of the disease, instead of the irritations of the brain which have been mentioned. For the most part, coma or stupor appears late in the disease. The jaw falls ; the mouth remains open ; and symptoms of apoplexy ensue. Stupor, how- ever, in this stage, does not arise from an active fulness of the vessels, but from a worn-out excitement of the brain, which in some cases shows its loss of power by this torpor, or from di- minished action in the absorbents, or in retarded circulation of 120 LECTURE IX. the venous system of vessels ; and hence patients frequently recover without the usual consequence of apoplexy, from pres- sure produced by an overloaded state of the vessels, from increased arterial action of the brain — as Dr. Bard justly ob- serves, " They sleep away their disease." But, in some cases, this stupor appears very early in the disease, from accidental determinations to the brain, or effusion taking place from the exhalents. The brain, in such case, soon becomes so engorged, that if it is not instantly relieved, an apoplexy follows. This mode of attack constitutes the congestive typhus of authors. Frequently, in fevers, partial determinations of this sort take place, owing to peculiarity of temperament ; and perhaps ori- ginal make of brain, as well as the pursuits of the patient, when in health. Hence literary characters soon become delirious in fevers, whatever may be their type ; and in every stage of them, the first, as well as the last. With regard to delirium, too, it is important to distinguish between that which arises from the first or inflammatory stage of fever, and that which occurs in the advanced stage. This may generally be known by the duration of the disease — the evacuations the patient has undergone — the degree of abstinence which has been observed — the causes of the disease ; but more especially by the ac- companying symptoms, such as the state of the circulation, the pulse, heat, respiration, and the state of the secretions and ex- cretions. It is important to ascertain the character, nature and origin of the delirium, because this knowledge must be the guide of our practice. For example : — Delirium in the first stage, as it proceeds from an active current of blood to the brain, calls for one class of remedies, such as are calculated to diminish excitement. While that of the last, requires a treatment totally opposite ; to excite the system by tonics, and the most powerful and diffusi- ble stimuli. In this stage of the disease the pulse is small, fre- quent, and oftentimes irregular. The circulation being rapid, the respiration is also in proportion hurried and irregular, at- tended with frequent sighing and sense of oppression. The heat is also in correspondence with the quickened action of the heart and lungs. The blood, I told you, is the vehicle of heat * — but the fluids themselves are now changed in their condition ; THE TYPHOID STATE OF FEVER. 121 you have not merely heat, but a modification of heat, de- rived probably from the quality of the fluids that convey it. It is accordingly intense, and of that peculiar sort that leaves an impression on the hand of the physician. The French call it " chaleur d'acrimonie." Wright calls it a biting heat. The same has been noticed by Huxham, Dr. Moore, and most prac- tical writers. Dr. Frank describes it as " acer, digitosque urens" comparing it to the impression produced by the sting- ing nettle, the urtica urens : — while others again, compare it, with more propriety, to the sensation excited by hartshorn ap- plied to the hand or other sensible parts of the body. This sensation appears to arise more from the peculiarly acrid nature of the discharges from the surface, in the advanced stage of fevers, than from the mere temperature of the body— for that effect is sometimes noticed when the heat itself is moderate — and it appears chiefly in those fevers which are of a contagious nature, as in jail fever, cynanche maligna, yellow fever, scarlatina, and dysentery. Pringle has noticed it particularly in the last mentioned disease. This typhoid stage of fever shows itself in the secretions and excretions. The tongue, on this occasion, as in the preceding stages of fever, shows the condition of the system in this re- spect. I should here first remark, that the tongue, upon being put out, manifests the same tremor and loss of power that is exhi- bited in the hand, or in other muscles of the body ; but the patient sometimes is incapable of putting it out, though he un- derstands you when you request him to show it ; and if he has strength to put it out, such is the state of his mind, that he perhaps keeps it out until you direct him to withdraw it. In this stage of fever, you now find the tongue of various colours ; sometimes of a dark crimson red, and perhaps effusing blood from its edges. In other instances black, and even coated with a dark, dry crust — in others, of a dark brown, with a black line along the middle of it ; and occasionally I have seen it exhibiting even a greenish hue. But we must except from this description the plague and yellow fever, in both of which diseases the tongue is frequently clean and moist throughout the whole progress of the disease. 122 LECTURE IX. The tongue too, at the same time, will perhaps be found ulcerated, having aphthae, which also are of different colours, whitish, brown, ash coloured, and occasionally almost black. These aphthae or ulcers frequently extend to the gums, cheeks, and fauces ; and for the most part are fatal symptoms, especially in dysentery. The breath is also highly offensive. The urine is muddy like beer, depositing a heavy cloud of mucilage and earthy matter. The stools are acrid and frequent, and exceed- ingly foetid. The skin is hot and dry : — or, if moist, a slimy sweat appears to cover it, attended with petechiae, small spots resembling flea bites or the sting of mosquitos ; and these some- times, says Huxham, are of a dun colour : and according to Armstrong, in some instances they are black, resembling ink. Vibices, like the appearances left after the strokes of a whip, effusions of blood, and extensive discolorations, also appear at this period of fever. This vitiated state of body, showing itself in the state of the fluids as before intimated, may exist even without fever or the waste of the nervous excitement, as in scurvy, and the disease hence denominated petechiae sine febre, the effects of a bad diet. See Adair, and the Edinburgh Journal. In the Medical Repository, vol. ii. p. 147, you will see a case of scurvy produced by the excessive use of hickory nuts. According to Beddoes, scurvy is owing to the want of oxygen. Hickory nuts we know to consist chiefly of oil, that is, of hy- drogen and carbon. Upon these the child was fed for three or four weeks. The consequence was, as perfect a case of scurvy as is produced at sea by the exclusive use of animal food. It was cured by the use of fresh acescent vegetables. The author of that communication proceeds to remark most justly, that the humoral pathology is too much neglected. In typhus fevers, not only the fluids are affected, but this vitiation is conjoined with a general expenditure of the excite- ment of the solids. In this state too, as I have already re- marked, the vitiated fluids create a new fever in the system, a secondary fever. The excretion from the lungs is also changed in this stage. Instead of the natural sputa, the mucus becomes viscid and glassy, with great loss of power in the muscles to expectorate it ; especially if the lungs have been the seat of irritation, as in peripneumony. In some instances the dis- THE TYPHOID STATE OF FEVER. 123 charges from the lungs are dark coloured. The disease pro- ceeding, the lungs become insensible to the effused fluids, until they may be collected in considerable quantities, when a vio- lent exertion is made to unload them of the matter oppressing them. The patient now becomes totally unconscious of exter- nal objects. This is not all : he is also insensible to those events which are ever going on in the system itself. He passes his stools and his urine involuntarily, taking no cognisance of them. The discharges themselves are changed in their quality, as well as poured out in an inordinate quantity. Diar- rhoea, at this stage of the disease, is a very common occur- rence, and generally proves fatal. A great flux of humours is sometimes at this period suddenly poured into the intestines, which as suddenly destroys the patient. I have recently seen a fatal case, in which destructive diarrhoea was induced by the use of porter, given in this irritable state of the intestines. The urine, too, is passed in considerable quantities, and some- times of a dark colour, resembling broken blood or coffee- grounds. In other cases the bladder becomes insensible, though full of water ; and is so much distended, that it is incapable of the contraction necessary to evacuate it — yet it proves a source of irritation to the patient, though he is unconscious of it. The catamenia also, at this period, in some cases become excessive, attended with a disposition to haemorrhage from almost every vessel of the body. Thus we see at this period, haemorrhages to take place from the nose, the gums, the ears, the lungs, tinging the expectoration, and even the saliva. Si- milar effusions of blood take place from the stomach and the liver, in the form of black vomit ; from the intestines, the kid- neys, and the bladder, resembling worms, — the blood taking the shape of the ureters or urethra through which it passes. In like manner, blood flows from the surface of blisters and of ulcers : veins too, that have been opened in the beginning of the disease, now bleed afresh ; wounds that had been long closed (for twenty or thirty years, says Huxham,) are opened anew. Even the sweat itself, is also occasionally stated, in some malignant cases, to be tinged or coloured by blood poured out from the relaxed vessels of the surface. This is certainly not surprising, after the ecchymoma or effusion under the skin, which we have noticed. Of the blood drawn in malignant 124 LECTURE IX. fevers, we have already spoken very largely, viz. its fetor, its dissolved state, the rapidity with which it runs into putrefaction. The disease advancing, the sweats become profuse, clammy, and cold. The evaporation is so great, and the powers of life so quickly diminishing, that the whole body rapidly loses its temperature, especially the extremities, viz. the hands, feet, legs, nose, and the ears. The same loss of contractile power existing in the vessels upon the different surfaces of the body, (I mean both the internal and external surfaces,) and the power of the absorbents being at the same time impaired, the fluids are consequently effused, and accumulated in most of the cavi- ties of the body; as in the ventricles of the brain, producing stupor; in the chest, creating an additional source of laborious respiration ; in the pericardium, showing itself in an oppressed state of the heart, and an irregular action of that viscus. In the abdomen also, large collections of water have been some- times found. And in the last stage of fever, such effusion has occasionally produced hydrocele. I have seen such a case myself. The eyes now become insensible to their natural stimulus, the light — they remain half closed, the patient winking very rarely. The thinner fluids become evaporated, leaving a glassy and viscid matter covering the balls of the eyes. The eyes at the same time remaining open, the vulgar suppose, as they express it, that the " strings of the eyes are broken." And as far as it regards the power of the muscles of the eyes to close them, they are right, for that power is now destroyed. The sense of hearing too is lost — for the patient is roused with the greatest difficulty. The taste and sense of feeling are also de- stroyed or greatly impaired. The lungs partake of the same insensibility — the fluids effused in the bronchia? and upon the cells of the lungs, collect in considerable quantity. Hence, the air passing and repassing through this fluid thus accumulated, occasions a rattling noise ; respiration becomes irregular, with a total inability to expectorate. The power of the muscles is also destroyed. The patient is unable to swallow— the muscles of the pharynx and oesophagus partaking of this inability, and losing their contractile power, the smaller vessels cease to beat ; the circulation in the smaller distant vessels ceases to be performed, or is not to be perceived ; the sphincters of the THE TYPHOID STATE OF FEVER. 125 anus and bladder are totally relaxed ; every exhalent vessel loses its contractile power. But this loss of tone is not con- fined to the muscular fibre, showing itself in the various systems of vessels ; but also in the organs of voluntary motion. The limbs sometimes become palsied ; a constant twitching or sub- sultus of the tendons and muscles takes place ; and occasionally general convulsions. And these, when they occur in the last stage of fever, are for the most part instantly fatal. But where the exhaustion does not show itself in this extreme, the debility is still manifest. The body slides down to the lower part of the bed, owing to the action of the flexor muscles, which retain their power of action a much longer time than the extensors. Hence old men have their bodies bent forward. The same thing is observed with debauchees, who, by their mode of life, induce a premature old age. You will read a very interesting chapter on this subject by Richerand, in his Physiology. He has given a very lucid account of the predominance of the flexors over the extensors, as displaying itself in great exhaus- tion of the system, and immediately before dissolution. Upon the same principle, in this advanced state of fever, when about to prove fatal, the limbs are bent, the thighs on the body, and the legs on the thighs, as in sleep, but the patient lying on his back. Hence this itself is an unfavourable symptom, (as well as the flexed state of the limbs, and the action of the flexors in dragging the patient from the upper to the lower part of the bed,) for it shows the incapacity of the muscles for the exer- tion necessary to sustain the body on the side, which is always done by the action of the muscles. I have known an excep- tion, however, in a gentleman of this city. The patient died lying on his side, owing probably to a paralysis of one side of his body. The position of the patient in sickness should be constantly attended to by the physician, as it leads to important infer- ences. Accordingly, Hippocrates observes that * the physician should find his patient lying upon his side, with his neck, his arms, and his legs a little bent, and his whole body in an easy posture; for persons in health generally lie in that manner;" and adds, that " if the patient cannot maintain his situation, and is apt to slide to the foot of the bed, it is a most alarming sign." Prognostics, sec i. Aph. 14, 16. Remember, then, that 12 126 LECTURE IX. the flexor muscles are the first to live and move, and the last to die, — as is seen exemplified in the foetus in utero, and the patient in death. The muscles of voluntary motion belonging to the face be- come relaxed. The natural expression of countenance being impaired in connexion with the emaciation that now takes place, produces that change which is denominated the fades Hippocratica^ from the admirable description given of it by Hippocrates in his Prognostics.* At this time, too, we often- times see in the patient a likeness to his relations, which in health was never observed — that is, it shows itself in the less changeable parts of the body, the bones, though not in the soft parts, which now have nearly disappeared in the emaciation that has been induced. The countenance, like the limbs, becomes of a livid pale colour, owing to the blood collecting about the heart, especially the right side of the heart — its force in throwing it to the ex- tremities being diminished. The cheeks become hollow ; the nose pinched ; the nostrils dilate at every inspiration; and death soon terminates even these imperfect efforts of the vital func- tions. After death, the body being examined, we find a variety of appearances which indicate the injury which particular parts may have sustained in the tumult and violence of the fever the patient has suffered. Sanious effusions are sometimes found in various cavities, as in the brain, in the chest, in the belly, and occasionally in the cellular membrane of the extre- mities. Where the patient does not die from typhus, dropsy accordingly is not an uncommon consequence or sequela of the disease. Sometimes too, purulent collections are met with in the brain, as noticed by Pringle. Similar collections also ap- pear in the liver and the lungs, particularly where a predispo- sition existed to those last mentioned diseases, especially to phthisis. Inflammation, or an engorged state of the vessels of the brain or stomach ; sphacelus of the latter organ and of the intestines, as in yellow fever and spotted fever, are some- times discovered after death. This last mentioned fever, I * See the Prognostics and Crises of Hippocrates, translated from the Greek, with critical and explanatary notes, by Dr. Ducachet, a graduate of this Univer- sity, p. 15, THE TYPHOID STATE OF FEVER. 127 may just remark, is denominated in the Medical Repository the new fever ; whereas, it is the old-fashioned petechial fever of authors, and is well described both by the ancients and mo- derns. A part of its virulence has doubtless been created by the improper stimulant treatment pursued in it. To this source of excitement too, probably many of the appearances found after death in spotted fever may be ascribed. Such are the general symptoms of fever, and which we have seen to manifest itself, 1st. By the irritation it excites in the brain and nervous sys- tem, affecting the mind as well as the body. 2d. In the excitement it produces in the muscular fibre, showing itself not only in the muscles of voluntary motion, but also in the heart and arteries, in the exhalent and secreting vessels, not only expending the power of those vessels, but vi- tiating their functions, and thereby changing the quality of the materials they secrete. 3d. In the absorbent system of vessels, embracing not only the lacteals, but the absorbents of the different surfaces and cavities of the body. 4th. Its effects upon the fluids of the body ; and 5th. The subsequent operation of the fluids thus vitiated upon the system, in exciting fever de novo, producing the ty- phoid form of fever, and this terminating in debility, putre« gcency and death. 128 LECTURE X THE CAUSES OF FEVER,— PREDISPOSING AND EXCITING CAUSES, Having taken a general view of the phenomena of fever, as it affects the various parts of the system, we are now led to inquire what are the causes from whence these phenomena pro- ceed ? It is to be observed that physicians, when treating of diseases, make use of the term cause with great latitude of meaning, and in a sense sometimes very different from its ordi- nary acceptation in the writings of philosophers. It is there- fore necessary for us to know the several medical applications of it, or at least those which are in most frequent use. The causes of fever are very properly divided into remote and proximate causes. By remote causes they understand such as are comparatively less nearly connected w r ith the disease, though they are the agents in the production of it ; whereas the proximate are essentially and immediately so. They are indeed so inseparably connected with the disease, that they constitute the very condition or manner of its existence. The proximate cause is that — " Qua? prsesens morbum facit, sublata tollit, mutata mutat" — which being present, the disease is present; which taken away, the disease is removed; and which being changed, the nature and character of the disease becomes changed. Hence this distinction has been made be- tween the remote and proximate causes. The remote causes are again subdivided into two kinds, de- nominated predisposing and exciting causes. What then are predisposing causes? They are such as prepare the body, or render it more fit to be acted upon, by those agents which more immediately excite the disease. In other words, they ren- CAUSES OF FEVER. 129 der it more combustible, while the exciting cause, the torch, lights the fire. Let us illustrate this subject by a few examples. In the production of a cholera morbus, we see these various causes exemplified — a debilited, irritable state of the stomach and intestines, is the predisposing cause ; an indigestible meal, as an oyster supper, is the exciting cause. These, again, pro- duce irritation, which, by inviting a great determination of bilious and other fluids into the intestinal canal, constitute the proxi- mate cause. In irritable bowels, a glass of cider will induce cholera or diarrhoea. Or in the debility induced by fever, por- ter will sometimes induce a catharsis, as in the case mentioned to you yesterday. 2d. In the production of a common pleurisy, a peculiar frame of the chest, or irritability of the part, the consequence of a former attack, is the predisposing cause. Cold, heat, intem- perance, or violent exercise, may be the exciting cause. Irrita- tion in the pleura, producing a determination of blood to that part, and inflammation of that membrane, is the proximate cause of all those symptoms that make up the disease. 3d. The convulsions of children furnish another example. Their sensibility of frame, at that period of life, or a peculiar nervous temperament, constitutes the predisposition; while worms, teething, variolous matter, or other causes of fever, are the exciting causes : but the proximate consists in the irri- tation so produced in the bowels, in the gums, or in the blood- vessels, as small-pox or measles, for either of these will produce convulsions. 4th. Intermitting fever. — Debility from a former attack, or from other diseases, is perhaps the predisposing cause — marsh effluvia, the exciting cause — irritation of the nervous, and hence of the arterial system, constituting the proximate. Or perhaps marsh effluvia may be the predisposing cause. While cold, or heat, as by riding in the sun, or an indigestible meal, may be the exciting cause — yet the irritation which either of these may excite, is the proximate : not debility, which is an effect instead of being the cause. The predisposing causes, for the most part, are internal — ■ inherent in the system, and appertaining to it, as the various temperaments of body. This predisposition, however, is not in all instances essentially necessary to the operation of the ex- 12* 130 LECTURE X. citing causes. The body may or may not be debilitated ; yet the exciting cause may operate, and disease nevertheless be produced. Nor is it indispensably necessary that the predispo- sition be inherent in the system, though generally this is the case, as in the example above mentioned, where marsh effluvia are the predisposing causes, — in these it is an external agent. The exciting causes, again, are for the most part external, but not always so. When seated in the intestinal canal, as worms, indigestion, biliary calculi ; a peculiar condition of the fluids, as lithiasis ; or an hereditary taint, as scrofula or syphilis, they are interna], yet they are exciting causes. The exciting causes, too, are by some called the occasional causes, because they may or may not be present : but this is a bad term, as it is not appropriate ; for the predisposing causes are also sometimes occasional causes. I might go on to illustrate this subject by numerous other examples, as gout, apoplexy, &c. in which this distinction be- tween the predisposing causes and those more immediately ex- citing the disease, is very obvious. It is highly important for us to ascertain the remote causes of disease, inasmuch as this knowledge enables us very often to prevent diseases, and some- times to cure them. For instance : to remove from marsh miasma on both accounts, both to cure the disease and to pre- vent its return. In what then does the proximate cause con- sist, and what is it ? It is that state of the system, or of the part, not only in which the disease resides, but which keeps up the disease — which present, causes the disease ; which being changed, changes the disease; and which, taken away, re- moves the disease. Our knowledge of the proximate cause, therefore, is derived from the structure and functions of the part or of the whole system, which is the seat of the disease, of the remote causes, and the effects they produce. From these, and from these only, are derived the great general prin- ciples upon which we proceed in the cure of diseases. And until we have a correct and definite knowledge of the proxi- mate, as well as of the remote causes, we shall never under- stand the cure of diseases upon principle : — until then, we shall indeed be mere empirics ; for the proximate cause is correctly defined by the late Dr. Gregory, and by Gaubius, and by Cel- sus before him, in the language I have already quoted. CAUSES OF FEVER. 131 Let me give you a few examples. — Dropsy, in some cases, arises from increased exhalation, the result of fulness and inor- dinate excitement of the arterial system: while in other in- stances it proceeds from a debilitated state of the arteries, the veins and absorbents ; i. e. the return of blood to the heart is retarded, and connected with it there is a diminished power in the absorbent system. Thus, then, dropsy arises from two oppo- site causes, and is of two kinds, sthenic and asthenic. The first occurs, perhaps, in a sanguine temperament, which is therefore the predisposing cause ; — intemperance, or other cause, pro- ducing plethora, is the exciting cause. In that case, increased action of the exhalents becomes the proximate cause. Here, then, you perceive, very clearly, the distinction between the proximate cause and the disease itself: — and we remove the disease by the means of diminishing such plethora and such increased exhalation. Again, the same disease, dropsy, arises from other circum- stances. It perhaps occurs in a phlegmatic temperament, or in feeble old age, as the predisposing cause. The patient has had a fever of some duration, which has left a debilitated state of body, particularly a loss of tone in the nervous system, and of the absorbents, which debility of the blood-vessels and of the absorbents constitutes, in this case, the proximate cause of the disease. This debility, as I have said before, may even exist in the smaller distant vessels of the arterial system, as well as the nervous and absorbent system of vessels. In either case, this debility constitutes the proximate cause; to counteract which, will effect the cure. Stimulants and tonics, the reverse of the means employed in the former case, are now our only resource. A second example that may be adduced, is nephral- gia, or spasm of the kidneys. Plethora is frequently the predis- posing cause of such an attack ; — cold feet the exciting ; — irri- tation in the part, the proximate cause. Our knowledge of the part, of the state of the whole system, and our knowledge of the causes, direct our remedies. In hysteralgia, plethora is the predisposing, excessive venery the exciting, irritation of the nerves the proximate. Lithiasis, or calculus, is another example. Here the predisposing, ex- citing, and proximate, are all united. The patient comes into the world with a redundant quantity of the lithic acid. It ac- 132 LECTURE X. cumulates in his kidneys and bladder from his mode of living, the free use of wine, &c. ; and thus becomes the proximate, as well as the remote cause. So in gout — a sanguine temperament and free living predis- pose the body to this disease. Cold is the exciting cause. A determination to the extremity affected, producing inflammation in the great toe, becomes the proximate cause of the disease. In all of these diseases, our knowledge of the causes alone directs our prescriptions. The structure of the part, or of the whole system, the seat of the disease, therefore, must be known, as well as the cause or causes from whence it proceeds, to know the remedies which will be indicated. A few remarks upon each of these classes of the causes of fever will be necessary in this place. Predisposition, we observe, is sometimes hereditary, and sometimes acquired. It is hereditary in the different tempera- ments, as the sanguineous, the melancholic, the nervous, and the phlegmatic. The sanguineous predisposes to fever and the phlegmasia? ; — the melancholic, to dyspepsia, hypochondriasis, &c. ; — the nervous, to convulsions, hysteria, and other diseases of the class neuroses : while the phlegmatic temperament is peculiarly predisposed to dropsy> and other diseases of direct debility, as already noticed. The first of these temperaments, the sanguineous, is more especially predisposed to fevers and febrile diseases ; accord- ingly, this temperament stands at the head of the list of the pre- disposing causes of fever, and of the phlegmasia?. Plethora, in like manner, is frequently the predisposing cause of fever, as in the northern man, in the hot latitudes of the tropics. The fulness of his vessels gives the predisposition to be powerfully operated upon by heat ; and then, violent exer- cise and intemperance readily become exciting causes. But in some instances, plethora itself becomes the exciting cause, and produces apoplexy or inflammation of the brain. More fre- quently, however, in these cases, plethora merely predisposes ; and cold, or a full meal, particularly a hearty supper, proves the exciting cause. Extraordinary exertion, as stooping, cough- ing, &c, not unfrequently becomes the exciting cause. This exertion, particularly in coughing, interrupts the return of the blood from the head. The effects of vomiting have the same CAUSES OF FEVER. 133 operation. Hence the obvious impropriety of emetics in such habit of body. I have known apoplexy thus induced more than once. Predisposition is acquired, as well as constitutional. 1. It is sometimes the result of previous disease, as in cy- nanche tonsillaris, croup, &c. I have already told you of pleurisy occurring no less than twenty-one times in one individ- ual. The same remark will apply to fevers. Persons who have had intermitting fever, are peculiarly liable to its return from the slightest causes, without being exposed to the original cause which produced it. Galen tells of its having been renewed by the imprudent use of vegetable acids. I have known it repeat- edly renewed by excessive venery in a young gentleman of this city. Hence, it was observed, during the plague of Marseilles, that newly married people very generally suffered from the pes- tilence. Those who suffer an intermittent in the fall, are very liable to an attack in the spring. 2. This acquired predisposition is often the effect of intem- perance in eating or drinking. 3. The various passions, such as grief, anger, love, fear — all predispose to febrile attacks. Fear, especially, prepares the body to receive contagious diseases. It is noticed by Thucy- dides, that those who suffered much from fear or anxiety, were first affected in the plague of Athens, and were the most likely to be cut off by it. Diemerbroeck makes a similar remark : " Confidentes utplurimum serventur; contra, meticulosi facile corripiantur." — De peste, lib. i. c. viii. s. 9. 4. Debility, the effect of a vegetable, spare diet, predisposes to intermitting and remitting fevers. This I had an opportu- nity of observing at my botanic garden at Elgin, on this island. The labourers employed there, suffered greatly from this cause; but my own family, who ate animal food, as usual, escaped. 5. Debility, the effect of water-drinking, especially in those accustomed to the use of spirits or wine, is another predisposing cause. I heard the late Dr. Gregory say, that Dr. Kuhn, of Phi- ladelphia, when in Holland, was severely attacked with intermit- ting fever. He used nothing but water as a drink : whereas his comrades, thirteen or fourteen in number, who drank wine — his own father, the elder Gregory, among the rest, all escaped. I found, too, that the water-drinkers among my workmen at El- 134 LECTURE X. gin, suffered from the prevailing fever, while the grog-drinkers went free. 6. But the excessive use of spirituous liquors no less predis- poses to febrile complaints, and often, by the prostration they induce, to the typhoid form of fever. Hence yellow fever is generally fatal to drunkards ; or if they survive, as in the cases related before, it must be by the continuance of potent draughts of their accustomed stimulus. 7. A vitiated state of the fluids predisposes to fevers, and fevers of the most malignant character. This state is frequently induced by salt meats, the want of fresh vegetables, and the excessive use of animal food. They produce a putrid colluvies in the bowels, and thence in the blood-vessels. Scurvy, dys- entery, and typhus fevers, are thus produced, as you will find by referring to Lind, Pringle, and Blane : and disease, once lighted up, soon destroys patients of this habit of body. 8. A moist atmosphere predisposes to fever. Catarrh, pneu- monia, and phthisis, are hence the common diseases of our sea- board, and of Great Britain. The Irish employed to drain the drowned lands of Orange county, suffered exceedingly from this source of disease ; and very many fell victims to typhus fever. Standing immersed in water, by the day and week, must necessarily have exposed them to disease ; and that, too, of a malignant type. 9. Climate predisposes to fevers. A hot climate, especially after a residence in a cold one, renders the stranger peculiarly liable to fever upon the slightest debauch or irregularity. A hot climate, too, of itself, begets great excitement, and is fol- lowed by debility, and consequently an irritability, which is easily acted upon by causes that, under other circumstances, would prove harmless. In like manner, the inhabitant of the torrid zone, coming to our colder latitudes, suffers febrile dis- eases, and especially the phlegmasia?, after the slightest ex- posure to exciting causes, which are innocent when applied to those habituated to our colder temperature. This fact should teach the youth who come from our southern states, to guard their persons by wearing flannel next the skin, and an addi- tional garment, to meet the frequent changes of weather they have to encounter in this climate. 10. A vitiated atmosphere is another very frequent and fatal CAUSES OF FEVER. 135 source of febrile diseases, by the predisposition it creates ; while, in other instances, it is an exciting cause of fever. Thus, if vitiated air, from putrid bilge-water on board ships — the air of jails and of hospitals — the confined dwellings of the poor — sail- ors' lodging-houses — of small, confined streets — the air of mar- ket-places — of docks — of privies, loaded with fermentable ma- terials, the product of decomposed animal and vegetable sub- stances, predisposes to fevers. And these, when thus produced, rapidly propagate themselves, as far as such atmosphere extends. In some instances, this vitiated air is said to be an exciting cause of disease, as in the manufacturing towns of Great Britain, and on ship-board, producing typhus fever. This we have seen frequently exemplified in Irish vessels. On board the Mohawk, with a hundred passengers, the disease broke out in the cabin and steerage. Though both occurred in the heat of summer, the fever was typhus fever, not yellow fever, which requires a greater degree of heat, and of longer continuance. It indeed requires the heat of the torrid zone, and that, too, must operate upon the northern man to beget that peculiar form of fever. Hence new-comers, not the natives of the tropics, are the subjects of it, both in the West Indies and South America. In our climate, such impure or vitiated air, doubtless may give birth to febrile diseases of the intermittent, remittent, and typhoid type. But the more malignant, and the more fatal form of tropical fever, I have never seen thus produced — though it is the belief of the majority of the physicians of this city, and of Dr. Rush and his disciples, in Philadelphia, that it is thus engendered in our own climate ! But whether begotten here, or introduced, such atmosphere as we have mentioned, during the warmer seasons of the year, readily multiplies and extends the poison engendered or introduced. But does it so multiply? and how does it multiply itself? We have already spoken of the assimilating fermentation, as it takes place in the human body, as in small-pox, and other diseases communicated by inoculation ; — we have also called your attention to the fact commonly observed, of the rapid dif- fusion of the putrefactive process among animal substances, when a taint of impurity, or foul materials may have been in- 136 LECTURE X. troduced among them — as we have noticed in the process of packing beef or fish ; and as illustrated by the experiments made by Sir John Pringle upon eggs. An analogous multiply- ing power appears in the atmosphere when once infected by the introduction of a contagious disease; as dysentery, yellow fever, and others. It is accordingly remarked, that the disease so introduced remains limited, for a certain space of time, to the spot where it first made its appearance. Accordingly, I have observed, (for I have been an eye-witness of the facts I give you on this subject,) that in 1791, 1795, 1796, 1797, 1798, 1805, 1819, and 1822, — the yellow fever appeared, not in the same part of the town, but at different parts, in every season of such visitation. It began in 1791, at Burling-slip. It did not appear at those constant deposits of filth, the Collect, (now "the Five Points") — the Fly-market — the Bear-market — Catherine-market, and other places proverbially filthy : but at entirely different spots of the city. In 1795, at Peck-slip ;■ — an- other year, at the Coffeehouse-slip ; — a fourth year, at the ship- yards; and twice at the Old-slip. At each of those places, the disease remained stationary for many days, (assuming the character of what would be denominated sporadic,) in- fluenced, in some respects, by the state of the weather, and the degrees of heat, moisture, and the state of the wind; but usually observing a definite period — insomuch that its subse- quent diffusion was at length uniformly anticipated by our citi- zens, as it had been in 1795, by that sagacious observer, the elder Dr. Bard. This is not all — it will perhaps appear to be totally suspended and gone, when, at the end of a certain period of time, (this, too, pretty uniformly, as it regards the period,) it again is sud- denly lighted up, and spreads extensively along in the vicinity, as an endemic ; but it is conveyed to other parts of the town, and forms new centres, from which it becomes extensively dif- fused. The epidemic, comparatively speaking, during the first few days perhaps, is confined to a single case, as in the case of Mr. Jenkins, in 1795; or in another year, 1791, when Gen. Malcolm was attacked. These cases die off. We hear no more of it. Some days (say from ten to fourteen) in- tervene — it re-appears in the same neighbourhood — many now CAUSES OF FEVER. 137 sicken, and a general fatality follows, creating alarm and con- sternation throughout the city.* In the history of the Plague of Marseilles, the same deceit- ful pause is frequently recorded by the historians ; after which new centres were formed, which scattered the pestilential rays to such an extent as to involve a whole city in distress and death. I must caution you against Dr. Miller's incorrect state- ment and false reasoning, the result of an error in his premises. I refer to his report as resident physician, in which he over- looks the first point where the poisonous material showed itself; — but most carefully enumerates all the second, sub- sequent parts of the city to which it was introduced from the first. On the contrary, the Board of Health, of which he was a member, In several years — in 1795, 1798, and others, (see Hardie's Reports, taken from the Minutes of the Board of Health,) stated distinctly and emphatically to the citizens, that the disease was so exclusively located ; and advised an aban- donment of such parts of the town. Many of the cartmen, carpenters, and masons, who worked at the new buildings at the Coffee-house slip, and returned to their respective homes, principally on the north side of the city, and Rutgers' grounds, sickened. The Board traced all their first cases to that source, and advised the abandonment of that part of the city. This was communicated to me by Dr. Douglass, a member of the Board at the time. But no — the citizens remained, tied as by a spell to the fatal spot. — It spread. — Its new lines of demarcation were again pointed out by the corporation, with threats to com- pel an abandonment, but without effect. Our citizens resorted to it still, conveyed the poison to other parts of the city, and thus involved a considerable portion of the city in one scene of mortality and distress. This assimilating process became al- most manifest to the senses, in this gradual extension of the disease/)- See my letter to Dr. Chisholm, and his criticisms on Dr. Miller's Report. See also Hardie's various reports, prepared under the direction of the corporation ; and in these you will * Rev. Dr. Smith, of Princeton College, N. Jersey, most wisely wrote me a let- ter, in 1805, cautioning me against the evils of neglecting those measures which are necessary to guard against the subsequent multiplication of the disease. t See my Discourse — Appendix to Thomas's Practice of Physic. 13 138 LECTURE X. find an ample refutation of the errors, both in the premises as- sumed by Dr. Miller, and in the conclusions he has deduced from them. 11. Contagion itself, like marsh miasma, in some instances becomes a predisposing, as well as the exciting cause of fever. The person under its influence is even conscious of a slight de- gree of febrile irritation in his system, but which is frequently counteracted by temperance and attention to his evacuations ; but is, however, readily called into action by an exciting cause, as fatigue, cold, heat, irregularity in diet, intemperance, loss of sleep, &c. During our epidemics, I experienced frequently the sensation of burning hands, a dry skin, and vertigo ; my whole sensations were disturbed. But by care in my mode of living, the liberal use of fruits and vegetables, with the occasional use of laxative medicines, I was enabled to resist the disease a long time. The same observations were made by Dr. Rush. (See his account of his own feelings and situation.) Nor, as I have said before, are marsh effluvia always an ex- citing cause of intermittent fevers. Like contagion, they also are sometimes the predisposing cause. For the most part, how- ever, the reverse is the case — that the fatigues of the camp, a hot climate, excessive exercise, and intemperance, by debilitat- ing, and thereby deranging the functions of the system, predis- pose the body to the action both of contagion and of marsh effluvia as the exciting cause. 139 LECTURE XL EXCITING CAUSES OF FEVER— EXERCISE, HEAT, COLD. We now proceed to take a view of the second class of the remote causes, viz., those which more immediately excite fever, or febrile diseases ; — they are hence called exciting causes. The first of these, is violent exercise. By the excitement it produces upon the nervous system, its effects are also extended to the moving fibres of the heart and arteries, and the other parts of the system. Stage riding, violent and long-continued exercise on horseback, are hence frequently the exciting causes of fever ; more especially when conjoined with the usual ac- companiments, spirituous liquors, and other stimulant drinks, which the traveller generally has recourse to, in some shape or other, instead of plain water or lemonade, which should be his only beverage during the excitement created by this inor- dinate exercise. On the contrary, the gin sling, the pot of gin- gered cider, the mint cordial, the glass of bitters, or some other form of alcohol, are the usual juleps of the traveller, in most countries, and rarely fail to excite a febrile state of body. Some years since, travelling to Albany, in company with a gentleman of high distinction, I drank water — he took his mug of cider, well powdered with ginger, at most of the houses at which we stopped. When we arrived at the end of our jour- ney, he was so much excited that he required two or three days to calm the commotion produced, while I felt compara- tively little or no effect from the journey, although it was in the winter season, and the roads were unusually rough. I am frequently called upon to prescribe for fever, thus induced by violent exercise, and this species of intemperance, combined. 140 LECTURE XI. Inordinate exercise of the mind, especially when not relieved by regular sleep, is also an exciting cause of fever. I am now attending a gentleman, who has been ardently engaged in preparing a work for the press, and who, in consequence of want of his accustomed sleep, in connexion with intense application, has been attacked with continued fever, and in whom the head is particularly affected. 2. Heat is another and a frequent cause of fever. By heat, I mean caloric, the matter, not merely the sensation, of heat — for heat, like cold, is absolute or relative. The absolute heat of a body denotes the quantity of caloric such body contains, as measured by the thermometer or pyrometer, while the relative heat only signifies its comparative temperature; i. e. compared with itself, or with other bodies, and refers itself more espe- cially to our feelings as our measure. We shall illustrate this directly, when speaking of cold ; and confine ourselves at pre- sent to the effects of caloric upon the body; more especially as communicated by the direct rays of the sun, or generated in the system by other causes. In either case, it occasionally becomes the exciting cause of febrile action. We perceive the effects produced upon our system by the direct rays of the sun, in the expansion which it gives to our fluids in the spring of the year, especially when its influence is suddenly communicated, as after a severe and cold winter. We then become sensible of its effects in all our feelings, producing headache, vertigo, numbness, and tingling in the extremities ; and if not counter- acted, these are frequently followed by inflammatory fever (synocha,) or by haemorrhages, in the form of haemoptysis, epistaxis, or apoplexy, (the hemorrhagia cerebri, as Hoffman calls it,) or perhaps palsy is produced by the same cause. In some instances, serous effusions in the cavities of the body are the result. Or we see its effects in the production of gout, or of some of the phlegmasia?, which are all readily induced in that season of the year. But the direct effects of heat are not only perceived in our feelings, or in its operation upon the ex- citement of the system. It shows its effects upon our secre- tions. The skin, the kidneys, and even the seminal vessels, show its operation in this respect. For in the spring of the year, the expansion of the fluids is no less manifest in the ani- mal body, than it displays itself in the rising of the sap in the EXCITING CAUSES OF FEVER. 141 vegetable structure. In like manner, upon a change of climate, from a cold to a hot one, we are liable to a coup de sole'd, a stroke of the sun as it is called ; that is, to phrenitis, and to apoplexy. A great number of such cases occurred here in the summer of 1811. In cold weather, also, apoplexy is a disease of frequent occurrence. The same effect is produced by ap- parently opposite causes. But, in truth, it is resolvable into the same as it regards pressure on the brain. The causus or ardent fever in hot latitudes in general, — the yellow fever in the West Indies and South America, the stran- gers' fever in the southern states, and indeed in New York, (foreigners especially, who are unaccustomed to our heat and our climate, suffer from this latter form of fever,) are all at- tributable, in a great degree, to the effects of heat. The effect of heat in aggravating the remitting fever of the southern states, which exhibits a much more inflammatory type than the same disease in the more temperate latitudes, you will see admirably described by Dr. Norcom, in his account of the fevers of North Carolina. This form of fever, in consequence of the inflammatory action which is superinduced as the effect of heat and habit of body, is very generally confounded with the yel- low fever of the West Indies! It doubtless, excepting the plague, is the nearest approach to yellow fever that exists : — but although they are thus nearly allied, they are asymptotes, which can never meet. There are some lines of discrimination between them, that are as fixed as those which .separate the small-pox from the measles, or the plague of the Levant from the ordinary bilious remittent of the United States. The heat of climate or season, .especially when blended with exercise, readily produces fever, as in the case of Dr. Rowe, a pupil of mine, who went to settle himself at St. Croix. But cases of fever produced by the heat of climate, and espe- cially when in co-operation with severe exercise, hard labour, and perhaps intemperance, are met with in every book of practice : I need only refer you to those of Blane, Pringle, and the Linds. Our own annual observation also furnishes constant testimony of the effects of heat, as an exciting cause of fever and of febrile diseases. 3. Cold is among the most frequent of the exciting causes 13* 142 LECTURE XI. of fever. It is with cold as with heat ; the term has two meanings. It denotes the sensation of cold- — it also signifies the real diminution of temperature, or the abstraction of caloric. These are two totally different things, and are not always connected. We feel hot, or we feel cold, when we are not really so, as we have already observed when describing the symptoms attending the first stage of fever. Our feelings not only depend upon the condition of the nervous system, but in this particular they also depend upon our previous sensa- tions, and upon our previous real degree of heat or cold, ac- cording as our temperature may be above or below the healthy standard. For example, immerse the hand in water at 100° — 97 A , which is the natural temperature, will in this case be cold to our sensations. Again : immerse the hand in a mixture as low as 50°. In that case, 60° or 70°, though below the natu- ral temperature, will still be hot to our feelings as the test. Our sensations, therefore, depend upon our preceding feelings and our preceding temperature. Heat and cold are conse- quently very properly called relative heat and relative cold. This distinction is of great importance, as applied to the va- rious states of the human body. For instance, it is of great importance in the treatment of asphyxia from cold ; because, with this distinction before us> we adjust or proportion the temperature of our applications to that of the body to be acted upon. We are hence taught to apply our heat gradually, be- ginning a few degrees only above the temperature of the frozen body. In such case we begin with snow, which is comparatively warm. We next apply cold water, that is, water at its ordinary temperature, which is still warm enough to be a stimulus to the still colder body. We thence proceed to the use of water moderately warm, &c. Upon the same principle the application of spirits of wine, spirits of turpen- tine, and other spirituous and highly stimulating applications to burns are recommended, inasmuch as they constitute the next grade of stimulus to the part. Hence, the absurdity of cold applications, especially when conjoined with the sedative effects of lead, in the form of saturnine solutions, frequently prescribed by physicians who do not advert to this principle. Without observing these grades of temperature in our several applications, we may waste the small portion of excitement EXCITING CAUSES OF FEVER. 143 which remains in the body whose animation is suspended. As in the management of the spark of culinary fire, we extinguish it by a strong blast, so by an excessive stimulus, dispropor- tionate to the excitement, we totally extinguish the small and feeble remains of the vital principle. This is no less applica- ble to the part than to the whole system. Absolute cold, as applied to the living body, is the real diminution of its tempe- rature below the healthy standard of 97^°. And except when the surrounding bodies are below 62°, it is remarkable that we retain that temperature, that is, the body being in a healthy state. But in debilitated habits, where, from want of nourishment, or debility otherwise induced, the heat-generating power of the system is certainly diminished in proportion to the weakened powers of the vital principle — in that case, the heat is dimin- ished and not supplied accordingly, and the patient suffers; as was the case with the people working at the Walkill, in drain- ing the drowned lands. Although the temperature was not as low as 62°, they could not counteract the abstraction of their caloric at that higher temperature. Fevers, then, are produced from moisture alone, and which, judging from the season of the year, could not have been as low as 62°. It is well ascertained, that air at 62° will not reduce our temperature, though denser bodies will, in proportion to their density. For in that proportion, as well as according to their own temperature, they abstract our heat : as mercury and water, which possess a conducting power in proportion to their density, and abstract it more readily than the atmosphere. Although, therefore, our bodies could resist an air at 62°, we could not resist the loss of our heat at that degree, immersed in water or mercury. On the contrary, we should soon be frozen. In like manner, in air beloio 62° our heat would be abstract- ed. Fordyce, Hunter, Crawford, and Sir Charles Blagden* by their celebrated experiments, (see Phil. Trans, vol. lxv.*) have also shown the wonderful power which the human body possesses of resisting heat, by preserving its temperature within a very few degrees of the natural temperature, although the * See also Hunter on the Animal Economy, and Crawford on Animal Heat, See also Gamett's Lectures on Zoonomia. 144 LECTURE XI. surrounding air was heated to a degree far exceeding - 97 J°, viz. at the high degree of 230° — a heat sufficient to roast eggs and to broil beefsteaks. Yet that heat was counteracted by the constant evaporation going on from the surface of their bodies ; the fluid issuing from their bodies combining with the caloric of the body from which it proceeded, leaving it relatively cool. How important then is the inference in favour of per- spiration counteracting a febrile state of the body by the ab- straction of heat. Hence, as before observed, fanning their bodies scorched them, by bringing a new stratum of heated air in contact with their surfaces, that had been thus relatively cooled. In like manner, the body has the power of resisting cold for a certain length of time, as well as heat. Delile has observed a degree of cold in Siberia, 70° below the zero of Fahrenheit, notwithstanding which, animals lived. Professor Gmelin has seen the inhabitants of Janiseisk, under the fifty-eighth degree of northern latitude, sustaining a degree of cold which, in January, became so severe that the spirit in the thermometer was 126° below the freezing point. Professor Pellas, in Siberia, those who visited Hudson's Bay, and the late navigators in search of a north-west passage, have experienced a degree of cold very nearly equal- to this. Hence, then, we see the wonderful power of the system in generating a greater degree of heat, when surrounded by so cold a medium. But in a cold climate and atmosphere, does the body generate more heat 1 Yes it does, and this must necessarily be the case, or death must ensue. Another question then arises, in what manner is this effected 1 To answer this question, it is necessary to remem- ber, that the heat of the body is chiefly generated by the de- composition of oxygen gas in the lungs during the process of respiration. The atmosphere, we must recollect, consists of two species of air — the one oxygen gas, or vital air, the other nitrogen gas — the one capable of combustion and of support- ing life — the other not ; and that these two gases exist in the proportion of nearly one of the former, to three of the latter. We also know, that air which has undergone the process of respiration, is found to contain a mixture of nitrogen and car- bonic acid gas, with a small quantity of oxygen gas, and a considerable quantity of water thrown off in the form of vapour. But from a variety of facts, it is ascertained that EXCITIXG CAUSES OF FEVER. 145 oxygen gas is decomposed in the lungs during respiration ; that a small and inconsiderable part of it unites with the iron in the blood, converting it into an oxide — that, 2dly, another and greater portion of it unites with the carbon brought by the venous blood from all parts of the body to the lungs, and thus forms carbonic acid gas. And that, 3dly, in addition to the watery fluid exhaled, another portion unites with the hydrogen brought in the same manner by the blood, and forms the hali- tus or vapour. Thus, then, we account for the appear- ance of those several products of respiration. Hence, we see that the explanation of the manner in w T hich animal heat is evolved, follows as a simple and beautiful corollary from the theory of combustion. That respiration is an operation in which oxygen gas is continually passing from the gaseous to the concrete state, and that the heat which it held in its gaseous form is given out at every inspiration ; and that this heat being conveyed by the circulation of the blood to all parts of the body, is a constant source of heat to the system. These facts lead to the solution of another interesting phenomenon. They enable us to explain the reason why the animal body preserves the same temperature in all the various changes which occur in the temperature of the atmosphere, whether in summer or winter, on the frozen plains of Siberia, or the burning sands of Africa; for it is a fact, that man breathes the atmo- sphere of this earth, whatever may be its elevation, its tempera- ture, its dryness or moisture, w r ith nearly the same results. The aeronaut who soars miles above the earth, or the miner below its surface, the peasant of the Alps, or the half frozen Lap- lander, the sirocco-breathing African, the inhabitant of the sandy deserts, or the Hollander in the midst of his dykes and canals, are by habit rendered equally exempt from the perni- cious effects of those opposite states of the atmosphere. In winter, we know the air is condensed by the cold, and conse- quently contains more oxygen in proportion to its quantity or its bulk. The lungs, therefore, receive at each inspiration a greater quantity of oxygen in the same bulk of air. The heat extricated will be consequently proportionally increased. In summer, on the contrary, the air being rarified by the heat, the same quantity of air will contain less oxygen in proportion 146 LECTURE XI. to its bulk ; consequently, a less quantity of oxygen gas will be received by the lungs in each inspiration ; and the heat which is extricated, will necessarily be less. For the same reason, in northern latitudes the heat extricated by respiration will be much greater in proportion to the bulk of air respired than in the southern. By this simple and beautiful contrivance, nature has modified the extremes of climate, and enabled the body to bear vicissitudes which would otherwise destroy it. Thus then, the body, as said before, possesses the power of re- sisting cold for a certain length of time ; but continued in con- tact with a body at 62°, especially a dense body, as water, the system loses its caloric faster than it can be restored, — a torpor of the system ensues, — gangrene follows, and at length life is exhausted. But though the human body has been so wisely constructed as to bear, without inconvenience, a considerable and even sudden variation of temperature; yet, I repeat it, there is a limit, below which the diminution of heat takes place faster than it can be regenerated ; and if this situation be con- tinued, the heat of the animal must be diminished — the func- tions lose their energy* — the sensibility of the body is destroyed — an insuperable inclination to sleep succeeds, which, if the unfortunate sufferer indulge, his sleep is death. This is con- firmed by the very interesting account given in Cook's Voyages, of the sufferings of Dr. Solander, Sir Joseph Banks, and other * I may mention here, although not immediately connected with our subject, the agency of cold in producing scurvy. Captain Morrik, a Dane, wintered in the year 1619 in Hudson's Bay, lat. 63° 20'. He was well supplied with pro- visions, and had with him sixty-four persons. All perished of scurvy, except himself and two of his men. In 1633, two experiments were made by the Dutch ; one at Spitzbergen, the other on the coast of Greenland, in lat. 77° or 78°. Seven sailors were left at each place ; and all died of scurvy at both. Captain James, an Englishman, with a crew of twenty-two persons, wintered on an island in Hudson's Bay. They were compelled to labour out of doors during the severest weather ; but only two died. Another singular fact is related. In one case, eight Englishmen, and in another, four Russians, were left by accident in the Arctic region, without provisions. In the ensuing spring, the Englishmen all returned home. The Russians all survived six years — then one of them died. The others were shortly after rescued. It is to be remarked, that those who died, in all the instances mentioned, fed on salted provisions, led an indolent life, and used spirituous liquors : those who survived, used fresh animal food, drank water, and used much exercise. EXCITING CAUSES OF FEVER. 147 fellow-voyagers, some of whom perished on the heights of Terra del Fuego. Dr. Solander, who had more than once crossed the mountains which divide Sweden from Norway, well knew that extreme cold produces this irresistible torpor, and propensity to sleep ; he therefore conjured the company to keep themselves always in motion, whatever exertion it might require. " Whoever sits down," said he, " will sleep ; and whoever sleeps, w r ill wake no more." Thus admonished and alarmed, they proceeded ; but while they were upon the naked rocks, the cold was so in- tense as to produce the effects which had been apprehended. Dr. Solander, himself, was the first who felt the inclination against which he had warned his companions, and insisted upon being allowed to lie down. Mr. Banks, (the late Sir Jo- seph Banks,) entreated and remonstrated in vain. Solander laid down upon the ground, though it was covered with snow — it was with the greatest difficulty he was prevented from sleep- ing. One of his black servants also began to linger, having suffered from the cold in the same manner as the Doctor. Partly by persuasion, partly by force, they were carried for- wards ; but they soon declared they would go no further. Sir Joseph again entreated and exhorted, but without effect. When the poor black was told that if he did not go on he w^ould shortly be frozen to death, he answered, that he desired nothing so much as to lie down and die. Dr. Solander said that he would go on if they would first allow him to take some sleep, though he had before told them, that to sleep was to perish. They both, in a few moments, fell into a profound sleep ; and after five minutes, Sir Joseph happily succeeded in awaking Dr. So- lander, who had almost lost the use of his limbs. The muscles were so much shrunk that his shoes fell from his feet; but every attempt to recall the unfortunate black to life proved un- successful. See Garnet's Zoonom. p. 32. So far, then, cold, when continually applied to the body, exerts a directly sedative effect upon the system, by its lower temperature, and its long continuance ; but cold, when it is suddenly applied, and for a short space of time, manifests a contrary operation — that of a stimulant to the part, or to the whole system — depending, for its effects, upon the previous temperature, and previous feelings of the body ; for the condi- 148 LECTURE XI. tion of the nervous system, the power of the vital principle, controls and influences the effect of this, as well as other appli- cations made to our bodies ; for we are not to reason of ani- mate as of inanimate bodies. Cold, then, is stimulant or seda- tive, depending on our previous temperature, and our previous sensations, as well as the time, manner, and other circumstances of its application. We are powerfully excited by a change of season : — after the relaxing effects of a hot summer, we are all animated by the cold of autumn or of winter ; — this is not only observable in man, but the horse, and almost every other ani- mal are in some manner excited by the first impressions of the cold of winter. Diseases, too, acknowledged by all to be diseases of excite- ment, as the phlegmasia?, are produced in great abundance by this cause. The dews and cold of the night, after a hot day, in like manner produce diseases. The system being previously excited, and the perspiration, which had been flowing freely, becoming suddenly arrested, dysentery is produced ; which is another disease of acknowledged excitement. It is well named by Dr. Sydenham febris introversa — a fever turned in upon the bowels. Cold, in the manner mentioned, is one of its most usual exciting causes. Yellow fever, another disease of excitement, is also frequently thus produced in the torrid zone, by exposure to the relatively cold air of the night, especially where predisposition exists ; and perhaps the materies morbi may already have been received into the system. Malignant fevers, where a predisposition exists, are frequently thus excited by the cold air and dews of the night, on ship-board and in camps. Even in jails, and the manufacturing towns, the night air is oftentimes one of the exciting causes of typhus fever. When the contagion may exist in the body, it is readily thus excited into operation by such change of temperature. Coming out of a heated atmo- sphere, after excessive exercise, as dancing or fencing, the body being previously heated by riding or running, and then suddenly cooled in a stream of cool air, by draughts of cold water, by throwing off our clothing, and by exposure of the body to a cooler atmosphere, or a cold bath — fever, in such case, is readily excited. While I had the direction of the botanical garden, I suffered EXCITING CAUSES OF FEVER. 149 several very severe attacks of sore throat, that were thus in- duced by exposure to the cold air, after remaining some time in the heated air of the hot-house ; for the circulation being excited by the causes mentioned, the excretion by the skin flow- ing and increased, a sudden change of temperature instantly produces a check of that discharge, by creating a preter- natural constriction of the small excreting vessels of the sur- face, and of the smaller circulating arteries. The conse- quence is, a sudden resistance to the propelling power of the heart and larger vessels. A sudden plethora of them is neces- sarily the result, which vents itself in a general fever, and per- haps the affection of some irritable part of the body. These I call the stimulant, not the sedative, effects of cold. These stimulant effects, too, are increased by the new impulse which is given to the circulation by the crowded state of the heart, and of the larger vessels — analogous to the mechanical effects of the tourniquet, when applied before or during the cold stage of fever, to prevent or shorten the paroxysm of an intermittent, as recommended and practised by Dr. Kellie. See Duncan's Commentaries, vol. xix. 14 150 LECTURE XIL CAUSES OF F E V E R, — C OLD. We also observe the stimulant effects of cold, when applied for the purpose of arresting hemorrhages, as in menorrhagia, or in. the hemorrhage after parturition, when the womb does not go on to contraction. A glass of cold w T ater given to the patient will bring on its action, and expel the placenta. And lately the practice of injecting the placenta through the vessels of the cord, with cold water, has been recommended for the same purpose, and used with success, Here let me say, that it is not necessary for this purpose, as recommended by Burns,. to stuff or plug the vagina, as he expresses it ; for you are to recollect you are not plugging an inanimate tube ; you are acting upon a very sensible part of the body. The application of cold to the pubes, or to the abdomen, is veiy generally sufficient, with other remedies addressed to the whole system. In epistaxis, cold is not applied to the bleeding vessel itself. Even prejudice at this day, the result of past experience, makes the application to a distant but sensible part of the body. In some countries, the great church key is sent for, and applied to the back of the neck, and is believed to possess some pecu- liar virtues ; though any other cold body would be equally efficacious. A cloth dipped in cold water, or a snowball, ap- plied to the scrotum, is also sometimes had recourse to, with success. These facts are familiarly known : the principle, too, upon which these remedies operate, is apparent. We see the stimulant effects of cold air, in arresting hemorrhage, after capital operations.* It is a good rule in operations to expose * See ray letter to Dr, Bard on this subject. CAUSES OF FEVER. 151 the wound to the air, until the circulation is restored. This, in my opinion, is not sufficiently appreciated. Cooper himself seems to think lightly of it. But surgeons would have less frequently to open newly dressed wounds, did they more gene- rally adopt it. I once extirpated the whole breast in a young lady, without using a single ligature. The hemorrhage was arrested by the exposure of the wounded surface to the air for some fifteen or twenty minutes. The stimulant and tonic effects of cold, are also observable in its counteracting the relaxation which frequently occurs in the system, both local and general. We see it in the removal of relaxations of the scrotum, of the cremaster muscles, and of the spermatic veins. Debility in all of these organs is a disease of frequent occurrence, especially in warm climates, and in the warm seasons of temperate climates ; it is, too, an important disease, for by its continuance, it is w^ell known that the power of the genitals is very much impaired. Indeed the vigour of those organs, we know, very much depends upon the tone and condition of these appendages. Although this disease has no place in our nosologies, it is very well known in the West Indies, and in southern climates. I allude to the disease vulgarly called the ivhiffles. In cold climates, and in cold seasons of our climate, this relaxation is not known, but which ought to be the case upon the principle that cold is a sedative, and debilitating to the body. This disease is cured by the application of cold water to the parts concerned, night and morning, or by a general cold bath, and other tonics, where the whole system is at the same time greatly debilitated. If the relaxation be very considerable, a suspensory bandage may also be employed with benefit, as an auxiliary in sustain- ing the debilitated organs. The veins of the testes, like the hemorrhoidal, become re- laxed, especially by age, when the venous system in general becomes enlarged from the diminished resistance in the coats of the veins. A similar varicose enlargement of the veins takes place in the lower extremities, both in males and females — more frequently, however, in the latter, the consequence of some previous pressure upon them, or impediment to the pass- age of blood in them, occasioned by pregnancy. I have seen a case of varicose enlargement of the veins of the lower extre- 152 LECTURE XII. mities, occasioned by a truss applied for a supposed hernia, which proved to be a varicocele. I also saw a case, in which the same disease was produced without any apparent cause. In both of these cases, a flannel roller and cold applications, either of spirits or water, and in summer the cold bath, are the remedies proper to be employed. The remedy now used in France, is to remove a portion of the vein thus affected, and afterwards pressure to facilitate the union of the parts from whence the excision may have been taken. In fluor albus, a disease frequently occasioned by debility, cold washing, and even cold injections into the vagina, are among the most valuable remedies that can be prescribed. Accordingly, the women of France, compared with American females, are seldom affected with fluor albus, owing to their daily use of the bidet. Here, however, let me caution you, on account of the stimulant operation of cold, against the use, or rather the abuse of it, during menstruation ; in obstruction of the menses; and in that species of fluor albus which proceeds from the fulness of the uterus, and of the whole system, the effect of the natural cessation of the menses — in other words, the effect of plethora, general and local, which is aggravated by cold, and is only to be relieved by venesection and other eva- cuants of the blood-vessels. In like manner, where the uterus, in consequence of such obstruction, is affected with pain, and other symptoms of inflammation, cold applications invariably aggravate the symptoms. The stimulant effects of cold suddenly applied to the system, are also apparent in the recovery of persons from deliquium, and in the asphyxia of new-born infants. And in asphyxia from the fumes of charcoal, it is one of the most efficacious reme- dies that can be employed. When dogs, at the Grotto del Cani, have been suffocated by its vapour, it is a common practice to plunge them in the ad- joining lake (Lake Avernus) to recover them. In like manner, in the torpor attendant upon convulsions, when weaker stimuli fail, the sudden affusion of cold water on the naked body will excite and increase sensation that has been dormant. In the convulsions attendant upon pregnancy or parturition, and which are frequently repeated in paroxysms, sprinkling the face and other sensible parts with cold water, frequently interrupts the CAUSES OF FEVER. 153 return of the convulsions, by the new impression that cold water thus applied produces upon the whole system. " The stimulant action of cold," says Dr. Currie, " though short in duration, is powerful in degree. 5 ' Nor is its effect short in duration, as Dr. Currie supposes ; for the cold bath is certainly one of the most powerful tonics of the materia me- dica, and one of the most permanent stimulants in its effects upon the system. We also see the tonic and stimulant operation of cold in the effects of a general cold bath, and the application of cold air. Such is the contractile operation of cold on the smaller ves- sels, that the very first effect is, in some cases, to produce a momentary paleness ; the excitement, however, instantly suc- ceeds, the whole surface glows with blood and heat, the circu- lation is manifestly excited, and preternaturally so. Respiration is proportionally quickened, and succeeded by a general diffu- sion of heat throughout the body. If, however, it be applied to the enfeebled body, and continued any length of time, it exhausts the excitement by abstracting the caloric, and with it the remains of heat and life. But to the body in health and previously heated, it is powerfully stimulant. By washing the body when thus heated, and the sweat is flowing from the surface, erysipelas, rheumatism, pains in the back and limbs, are freqently produced. Even washing the neck with cold water in cynanche tonsillaris, aggravates the disease, by in- creasing the excitement, as I have several times experienced in myself. Gargling the throat, I must tell you, though a very common practice, has the same effect of increasing the irrita- tion in that disease. I have also witnessed the same injurious effects from the application of cold, in increasing the inflam- mation attendant on dysentery. The same remark is no less applicable in enteritis, from whatever cause it may be produced. Though I perceive the application of cold water to the belly is sanctioned by Dr. Thomas, I must here most earnestly enter my protest against this practice in that disease, or indeed in any disease attended with active inflammation. I go still farther : the application of cold to an inflamed eye, to an inflamed testicle, to the re- cent injury of the joints from strains, I consider equally objec- tionable. On the contrary, the relaxing, soothing, -and emol- 14* 154 LECTURE XII. Kent effects of tepid applications, are indicated in the first stage of those diseases of excitement. I tell you this as the result of nearly forty years' experience in practice. But the beneficial operation of cold bathing, general and local, in the last stage of those diseases, is well established, except when the debility is excessive, and the heat-generating power of the system has been greatly impaired. Habit, however, may counteract the effects of cold upon the system. Accordingly, in Russia, it is not unusual to go from apartments highly heated, or from a bath heated from 106° to 116° of Fahrenheit, and plunge into snow or cold water, at the freezing point, without producing fever. The Roman youth, when heated by their exercises in the Campus Martius, in like manner plunged into the Tiber with impunity. The previous excitement, especially in athletic habits, is such as instantly by its reaction to counteract any check given to the action of the smaller vessels of the surface. Habit cer- tainly may diminish our susceptibility to the effects of cold, as of other agents upon the constitution. We do not all take the small-pox when exposed to it. We do not all take contagious fevers, as yellow fever or dysentery, though we may be ex- posed to them. Physicians and nurses, habituated to the action of the poison producing diseases, frequently escape on this account. Nor do we all take cold even from wet feet ; but where persons are much in the practice of bathing the feet in warm water, this is not an unusual effect of the great sensi- bility that is thus endured. I was formerly subject to frequent attacks of sore throat, and at that time was in the habit of bathing my feet in warm water two or three times a week. But since I have adopted the practice of washing exclusively with cold water, I have rarely been affected with the disease. Many persons subject to cold feet and legs, are thus cured by the application of cold water. Frosted heels are in like manner prevented, by the practice of cold washing, as well as by the local use of spirits of turpen- tine, alcohol, or other stimulants. Sudden vicissitudes produce fever, as going from a warmer to a colder atmosphere. In the interior of Africa, it is not uncommon for the temperature of the atmosphere to be, for CAUSES OF FEVER. 155 weeks together, as high as 130° of Fahrenheit. In such case, the sudden change down to 100°, as Dr. Fordyce believes, would doubtless, as a stimulant, constrict the extreme vessels, both exhalent and circulating, and fever be the consequence. But he states, that he has known going from 100° to 80°, and even the transition from 60° to 40°, to produce fever, (p. 134,) and which, by the by, is another example of the effects of cold in producing diseases of excitement. In other words, that cold under peculiar circumstances, and those chiefly depending on the state of the nervous system, operates as a powerful stimu- lant or excitant to the system.* They show the direct stimulant effects of cold water and ice applied to the limbs. Another important result arrived at from those experiments is, that the arteries derive their power of ac- tion from the nerves with which they are supplied, and not from a separate vis insita, or inherent irritability. * Experiments of Dr. Home — see Eng. Journal, No. 4. vol, iv. 156 LECTURE XIII. CAUSES OF FEVER We have noticed the stimulant, as well as the sedative ope- ration of cold, and endeavoured to show that these different and even opposite effects are produced by it, depending on the manner in which cold is applied to the body, the medium through which it is applied, whether by air or by denser bodies, as water or mercury, the temperature of that medium, the dura- tion of its application, the suddenness with which it is applied, the state of the nervous system, and the vigour of the circula- tion, or of the power generating and diffusing the heat of the body. In the conclusion of the last discourse, I also stated, that sudden changes from a higher to a lower temperature, as ob- served by Dr. Fordyce, expose the body to diseases of excite- ment ; that they not only render the body liable to fever, but to many other diseases of a febrile character. Dr. Fordyce admits the fact that fevers — that is, fevers strictly so called, are of more frequent occurrence in warm than in cold climates ; but he ascribes it to the sudden diminu- tion of temperature as the cause, at the time when the body is exposed to a high temperature ; that is, that in a very hot climate, exposure to cold or night air produces fever; whereas in a temperate climate, such exposure to cold would not pro- duce fevers, but perhaps one of the phlegmasia ; and, there- fore, that the cause of these different effects, is to be looked for in the high thermometrical range which occurs in hot lati- tudes. But great heat or excitement of itself, acting upon the stranger, doubtless, as before remarked, will directly produce fever, without such vicissitude. Yet from cold, as dews and the night air, this effect is certainly more likely to happen. CAUSES OF FEVER. 157 But this more frequent occurrence of fevers in hot climates, is probably in part owing, not merely to the vicissitudes in a high thermometrical range, as Fordyce expresses it, but to the long-continued previous effects of heat upon the constitution, changing the condition of the body, of the fluids as well as the solids, at the same time that the sensibility to impression in the nervous system is increased by the debilitating effects of heat. In cold climates, again, we see catarrh, pneumonia, and the phlegmasia?, in general produced; and in cold climates there is certainly no such predisposition to fevers, properly so called, compared with the predisposition we find in hot climates ; — no such septic tendency of the fluids of the body, nor such debility and consequent irritability of the nervous fibre, both of which have effect in a hot climate, as predisposing causes of fever. This, I believe, is the true reason of that difference of pre- disposition, and not that assigned by Dr. Fordyce, who (p. 135, vol. i.) considers merely the higher temperature of the climate in which those transitions take place, as having the effect, without explaining the manner in which that temperature ope- rates. " As to the manner," he says, " it is not attempted to be explained." But, in my opinion, the manner of its opera- tion is very apparent, and in the way already stated, viz., by producing a debilitated habit of body. And it is to be ob- served, that intemperance and excesses of different sorts, very generally concur with the heat of the climate, in producing such debility — an irritable, susceptible state of the whole sys- tem, is the inevitable consequence, followed by a deranged state of the digestive organs, and of the whole alimentary canal, and consequently an altered or deranged condition of the whole mass of the circulating fluids — for an imperfect or bad chyle cannot produce perfect or healthy blood. And to these is added, a disturbed state of most of the secreting and excreting organs of the whole system. All fevers and febrile diseases must hence, necessarily, have a greater tendency to the typhoid character, in a hot and relaxing, than in a cold and invigorating climate, unless we totally exclude the fluids from all concern in the human body, and from all participation in its diseases — and, indeed, the solids too ; for if the secretory organs of the body are deranged, such derangement of the fluids, the product of the secretions, must necessarily be de- 158 LECTURE XIII. ranged also. And vice versa, if the fluids are affected, the solids secreting and influencing the character and properties of such fluids, must also themselves have been in some degree deranged or impaired, to produce such condition of the hu- mours they convey or secrete. We also witness a similar predisposition to fevers, in the hot seasons of our own climate, and indeed in the hot seasons of most temperate latitudes. Besides, where cold, in a hot cli • mate, or in the hot season of temperate climates, is the exciting cause of fever, the heat of such climate and of such season, operating upon the constitution, before the application of cold, the nerves and blood-vessels, I say, all being previously ex- cited, and the secretion flowing, the result of that impetus given to the vascular system, cold in that case, has assuredly more effect than it could otherwise produce, without such predisposition. Cold, then, arrests all these excretions and ex- halations, diminishes very suddenly the flow to the surface, and in this way excites the whole system into febrile action. This leads me to notice what I consider to be another error of that great practical physician, Dr. Fordyce, see p. 136, vol. i. He observes, that cold suddenly applied, and cold slowly or gradually applied, have the same effect ! He grants that, in both cases, cold acts by restraining the evaporation from the surface, and by contracting the exterior vessels. Yet, in the one case, he asserts that when cold is suddenly applied, fever is produced ; in the other, not fever, but some other disease. He further observes, that the gradual diminution of temperature has never been observed to produce fever, and therefore con- cludes, that such fever cannot be the operation of cold. I grant this fact, that the gradual changes from heat to cold will not produce fever ; and I will grant another fact connected with it, that by going from a cold climate to a warm one, in the winter season — or, in other words, gradually changing our tem- perature, we do not readily take the fevers of a hot climate ; i. e. not as arising from the climate itself. But I deny his pre- mises, that the sudden change and the gradual are alike in their effects ; and, of course, I deny the conclusion he has de- duced from those premises. His conclusion is as follows : — " That, therefore, fever does not arise from mere contraction of the extreme vessels, the diminution of vapour rising from CAUSES OF FEVER. 159 the body, or the diminution of the exudation from the skin; as these are," he says, " alike produced from the sudden and gra- dual exposure to cold !" On the contrary, the effects are very different, for in the one case a sudden check is given both to the small circulating and the exhalent vessels, and thereby an instantaneous and powerful impulse is given to the heart and larger vessels, which, in their reaction, manifest great and increased excitement throughout the whole system. As in the febrile excitement produced in those cases which so frequently occur from the use of cold water, when the body has been previously excited by heat and spirituous liquors. At first, there is a shock of the nervous system, then excitement of the vascular, producing an engorgement of the brain, &c. In other words, fever is the consequence ; but this is not the case where cold is gradually applied. Nothing is more commonly known, even in this climate, than the fact that plunging into the river, when the body is heated, is an exciting cause of fever; exposure under similar circumstances to a shower of rain, operates in the same way. In every hot season, facts of this nature present themselves to the practi- tioner in this city, showing the effects of a sudden check to the discharges which so usually occur in such season, espe- cially when an additional impulse is given to the circulation by exercise. Yet he considers his reply as furnishing an ample re- futation of the doctrine he opposes, when he says, " that cold operates by its contraction and obstruction of the extreme vessels, whether suddenly or gradually applied ; and that, as fever in the latter case is not produced, so it is not in the for- mer !" To my mind, the explanation here given, appears more sa- tisfactory, viz. that the body being previously excited, the sudden exposure and change of temperature, account for the phenomena produced. Dr. Fordyce also observes, that the effect of sudden expo- sure to cold, is to produce other diseases, but not fever; and that one hundred other diseases, as the phlegmasia?, are pro- duced for one of fever by that cause ! This may be, and pro- bably is true, in a cold climate, but it certainly is not true in a hot one. 160 LECTURE XIII. Again, he remarks : " If a man when fatigued is suddenly exposed to cold, the exposure is much more frequently follow- ed by disease, and particularly by fever," p. 138 ; and adds, by way of illustration, "if a man has been in a crowded assem- bly, where his attention has been strongly excited, and comes suddenly out into the cold air ; or if he has been fatigued by exercise, if he should throw himself into cold water, there are many instances of fever having immediately ensued." Here, then, he admits the effects of cold suddenly applied, producing fever ; but qualifies it by premising fatigue, dancing, or other exercise, to put the body in a state to be acted upon by cold, to produce fever. I ask, where is the difference between the excitement given to the system by fatigue, or by exercise, and that communicated by the climate ? You will all answer — certainly none. This question answered, I again ask, is it not more conso- nant with facts and correct reasoning, to say, 1st, that in a cold climate, when the body is heated by exercise, by intem- perance, or any other cause, and then suddenly exposed to cold, fever, and especially the phlegmasia?, are produced. That in a hot climate, such sudden exposure, in the habit of body debilitated by the heat of climate, and other causes, will generally produce fever ; and again, that where the habit is vitiated, in other words, a putrescent tendency of the fluids exists, as from bad diet, impure air, and other causes, it will produce fever that readily assumes the typhoid character. In the one case, the effect produced may be considered in some degree as merely a mechanical check or interruption to the discharges of the body; I mean the effect of cold in pro- ducing the phlegmasia?. But in the other case, where the fluids of the body have a septic tendency from climate, diet, or any other cause, a chemical action is united with, or added to, the constriction of the vessels, to produce the more com- pound effects upon the system, viz. typhus fever. Such, at least, is the conclusion I have been led to upon this subject, after a very careful examination of the facts, and the most correct reasoning I can bestow upon them. I also observe, that upon the sudden application of cold to the body in producing fever or febrile diseases, such is the connexion of nerves throughout our machine, that it is not ne- CAUSES OF FEVER. 161 cessary that the whole surface of the body be exposed to the action of cold. A snowball, or a cake of ice, applied to the scrotum, we know by the constriction it produces, will check a bleeding vessel of the nose. Cold, in like manner, applied to the feet, will excite the action of the bowels, by checking the flow of fluids to the surface of the body ; and in this way, we know that obstinate constipation of the bowels has been, in some cases, cured. See Med. Essays of Edinburgh. So, in like manner, will a partial stream of air, received upon the neck, or poured into the lungs, produce either one of the phleg- masise, or a fever, according to the circumstances of climate, or the condition of body. 4th. Moisture is an exciting cause of fever. A moist atmo- sphere, we know, predisposes to inflammatory diseases, as croup, pneumonia, and phthisis, by its action more especially upon those organs which are the seat of those diseases. But how does moisture operate, as an exciting cause, in producing fever ? Both by relaxing the whole system, and by abstracting our caloric. And as our heat is constantly carried out by our secretions, as a vehicle, and still more abundantly by the con- version of that fluid into vapour, by which the temperature is diminished ; so moisture, when constantly applied to our bodies, in a similar manner abstracts our caloric and reduces our temperature, and with it impairs the functions of the system. As it regards its operation upon the body, moisture may be re- solved into cold, for it produces the same effects : for, by the application of moisture to our bodies, we lose our heat in the same manner as it is carried off by the fluid of perspiration or sweat. Fordyce does not appear to understand this subject. In page 148 he observes, that the operation of moisture on our system is not very clear : — to him it certainly is not, for chemistry never received from him that attention which should be given to that highly interesting branch of science by every physician. As I have already remarked, the fact is familiarly known, that evaporation produces cold, agreeably to the first law go- verning the communication of heat, viz. that all bodies pass- ing from a denser to a rarer state, absorb caloric, as illustrated by Dr. Cullen, in his excellent paper on cold. As before re- marked, we observe its effects in the process of cooling liquors 15 162 LECTURE XIII. in a hot climate, by means of evaporation. We experience it in cooling the air of a house, by wetting the floors ; and the same effects are observed in the change produced in the tem- perature of the air after a shower of rain. In like manner, our heat is carried off by moisture, both as applied to our bodies, and flowing from the surface by perspi- ration. Indeed, this discharge being excessive, even cold sweats, as they are denominated, are produced ; for we fre- quently find the perspiration out of all proportion to the previ- ous excitement of the arterial system, and entirely the conse- quence of a relaxed, exhausted state of body, and of course a relaxed condition of the excreting vessels. Under these cir- cumstances, the stimulus so necessary to health being with- drawn, (even though gradually withdrawn,) great exhaustion and debility follow — sometimes death itself. But the effect of the sudden and temporary application of cold to the body is exciting to the system, especially if in the vigour of health. Not so the continued application of cold or moisture. Standing immersed in water — remaining in wet clothes, or clothes put on wet or damp — sleeping in damp sheets — a wet greatcoat, even though the body be covered with dry clothes underneath, — all these chill us, by abstracting our heat, and thereby arresting the circulation in the smaller vessels. We hence see the propriety, when not in exercise, of throwing off our greatcoats when wet, even though we may have dry clothes beneath. Although w 7 e may, by the non-conducting media of cotton or flannel, guard ourselves, under ordinary circum- stances, yet these are not always sufficient to prevent the ab- straction of our heat ; such is its ready union with moisture, its natural conductor. Cold and moisture in this manner, and in a septic state of body, become an exciting cause of scurvy. Otherwise, even though the system be affected by the diet, ex- ercise, and warmth, it will frequently escape that disease; — not so when idle, and lodged in a damp and cold atmosphere. See Capt., Parry's Voyage. According, then, to our condition of body as to strength, and the power of restoring the circula- tion, and with it the heat, and thence the power of resisting disease ; and according to our predisposition at the time — in- flammatory complaints, such as rheumatism, and the various forms of cynanche and pneumonia, are, or are not produced. CAUSES OF FEVER. 163 In like manner, depending upon the state of our fluids in con- nexion with the debility of body, from fatigue and intemperance, fevers of a mild or a malignant character are produced. The Walcheren fever, (see the account of it given by Davis,) which cut off so many of the British troops in the summer and autumn of 1809, and which occasioned the failure of the ex- pedition to Zealand, was thus engendered by these combined causes — the moisture, miasma, influence of season, intemper- ance, bad diet, and other circumstances usually met with in large armies. The malignant fevers of Flanders, the Netherlands, (Hol- land,) and the malignant fevers of Batavia, are also in the same manner to be accounted for. Batavia, in a remarkable degree, unites both moisture and miasma ; for the Dutch, by cutting canals through it, have made another Holland of it. Indeed, in consequence of this union of moisture and miasma, Batavia is more unhealthy than Holland. The greater heat of Batavia, too, is another predisposing cause of the more violent and fatal fevers of that country. So, in like manner, the fens of Lincoln- shire, and indeed the marshes of all countries, are unwhole- some, in consequence of this noxious union of miasma with moisture; while the banks of the Thames, or the Seine, are comparatively healthy. Hence, too, the fact that running wa- ter, sea water, and river water, (which emit no miasmata,) are less injurious than the water of stagnant pools or marshes. A fact illustrative of this distinction was communicated to me some time since, as occurring during the last war. Three hundred sea-fencibles were stationed at Fort Diamond, at the Narrows, two or three hundred yards from the shore. Al- though not exposed to moisture from the soil itself, yet the bar- racks were so bad that they were drenched by every shower of rain. They enjoyed good health, and were free from fever ; not a man died in five months. Here they were exposed to mois- ture alone. In October and November, 1814, a brigade of troops were stationed at New Utrecht, some in barracks, others in tents ; but both in the excavation of a hill, that afforded a large receptacle for the rain that fell. These troops, in consequence of this lodgment of rain, became the subjects of typhus fever, and a considerable number were destroyed. Again : a company 164 LECTURE XIII. of riflemen was also stationed in the sandy beech below, in bar- racks, situated at the bottom of a high bank. Among these, only two or three cases occurred, but none of which proved fatal. No lodgment here took place either of rain or moisture from below, for the sandy bottom readily conveyed it off as fast as it fell. Similar facts are stated by Sir James Fellowes, in his work on the Walcheren fever. He remarks, that many cases of fever were induced by the men remaining out in the evening air, smoking their pipes under the trees, with their bodies frequently exposed by taking off a part of their dress ; while others - more prudent were sheltered, and remained in health, p. 343. He also states, that the practice of taking out the- troops to exer- cise before sunrise, was attended with fatal consequences, from exposure to the damp and noxious exhalations. But, as I have before observed, fevers are, in some instances, produced by moisture alone. During the war which took place in Flanders, between 1710 and 1711, an army was encamped upon sandy ground, in which water was found in digging less than a foot deep. Upon digging the wells the air immediately became loaded with moisture, and in a few days fevers were produced in great numbers, although the army was healthy be- fore; and upon changing their grounds (see Fordyce, p. 147,) no more fevers were produced. The predisposition to fevers, in such case, was to be presumed as existing among the soldiers. Moisture, abstracting their heat, would not only debilitate them, but would necessarily produce a similar constriction upon the exhalent and small circulating arteries, which we have noticed from cold when directly applied to the body. I have seen the same effects occasioned by moisture in the state prison, after wetting the floors, which was done once a week, and without removing the prisoners from the apartment while this process was performed. The consequences were, remitting fevers, the phlegmasia?, and, in some instances, diar- rhoea — analogous to the effect of throwing cold water upon the extremities in cases of constipation of the bowels. In the same manner, rock-blowers and well-diggers, being constantly immersed in water, are affected with rheumatism ; and a com- pound of palsy and rheumatism of the lower extremities, called CAUSES OF FEVER. 165 berbiers; so called on account of their hobbling gait, resem- bling the motion of a sheep. 5th. Another exciting cause of fever is our food. It may prove so in various ways. — 1. Food may be an exciting cause of fever, as it is of nervous affections, from being indigestible. In this case it may create, by its operation upon the stomach and intestines, considerable excitement throughout the system, that is otherwise predisposed to fever. 2. The excessive use of animal food, in a hot climate, or in hot seasons of the year, produces a putrid state of the bowels. In this way not only dysentery is produced, but by the operation of that food the whole mass of fluids becoming tainted, other fevers of a ma- lignant character are the consequences. Fish, oysters, eggs, as well as other animal food, may thus become the exciting causes of fever, as they readily run into the putrefactive fermen- tation. Animal food, too, in like manner, becomes an exciting cause of a relapse, when too early employed during convales- cence from fever, especially the typhus form. Of the malig- nancy of the fluids, occasioned by the excessive use of salted animal food, we have already spoken; particularly as pro- ducing a scorbutic state of body, and thereby especially predis- posing the body to malignant fevers. 6th. Another exciting cause of fever is, concentrated human effluvia. Even in the individual, neglect of the bowels, in the summer season, creates a febricula, manifesting itself by the furred tongue, hot hands, burning feet, thirst, headache, and a frequency of circulation. These neglected and long continued, are soon followed by a more formidable attack of fever. In this way dysentery and typhus fever are frequently engendered in the individual, as well as in the congregation of a great number of individuals, as in a jail, a ship, or a hospital. In the latter cases, the excretions of the surface, and some others still more offensive, are not unfrequently additional sources of filth, and thereby become the exciting causes of fevers. In the individual, too, in whom an obstructed liver exists, typhus fe- ver is frequently engendered by the obstruction of the bowels, from the want of the natural cathartic. 7th. The passions of the mind are among the exciting causes of fever. Case of Mr. B — — G. ; — he had an intermittent — 15* 166 LECTURE XIII. was free from it — he lost a great quantity of blood from the nose ; the fever was not renewed by this hemorrhage, nor did a diarrhoea afterwards renew it ; but his mind becoming agitated by the sufferings and pain, and the screams, of his bro- ther during an operation, immediately renewed his fever, by the irritation it communicated to his nervous system. This shows that irritation, and not debility, is the source of fever : other- wise, his exhaustion from hemorrhage and diarrhoea would certainly have renewed it. 167 LECTURE XIV. CAUSES OF FEVER.— MIASMA AND CONTAGION, The eighth exciting cause of fever, is the miasma of marshes. Marsh miasma produces both intermitting and remitting fevers, depending upon the condition of body, the nature of the climate, season of the year, and the quantity or degree of concentration in the miasma. In the most healthy seasons in the island of Jamaica, and the other West India islands, inter- mittents are produced. Again, as the season is hot, there is a tendency to the continued form of fever, or to a less perfect intermission. In winter, again, the intermittent character re- turns. It is certainly very extraordinary, that although the insalu- brity of swamps and stagnant waters was well known, and was noticed even by Hippocrates, Galen, Varro, Columella, Palla- dius, Vitruvius, Diodorus Siculus, Dionysius Hallicarnassensis, Strabo, and others, Sydenham should not have known or suspected that intermittents or remittents arose from marsh miasmata. He acknowledges he tried in vain to find out why seasons, apparently similar, should have such dissimilar effects on the human frame. Yet so it is, he says : " Ita enim se res habet ;" and adds, " variae sunt nempe annorum consti- tutiones, quae neque calori, neque frigori, non sicco humidoque ortum suum debent, sed ab occulta potius et inexplicabili quadem alteratione in ipsis terras visceribus pendent, unde aer ejusmodi affluviis contaminatur, humana corpora huic aut illi morbo addicunt determinantque." De Morb. Epidem. c. ii. p. 41. 168 LECTURE XIV. In these various effects, you perceive an operation analogous to the effects of cold air in cold climates and cold seasons, producing the phlegmasia? ; — and of the dews and cold night air in hot climates and hot seasons, producing fevers ; while the same, causes in a vitiated habit of body produce typhoid or malignant fevers. Lancisi, who lived from about the middle of the seven- teenth century to the beginning of the eighteenth, (he died in 1720,) was one of the first accurate observers on the subject of marsh miasma.* In the Med. and Phil. Register, vol. i., you will find a faithful translation of his valuable work, by the late Lieutenant Governor Colden, who was a learned physician. In Bruce's Travels, you will also see an account of the disease produced by the same effluvia, when exhaled from the mud and marsh left by the waters of the Nile after the inundation. The remittent fevers of Bussorah are in like manner induced after the inundation occasioned by the Euphrates. Indeed, in some cases its banks have been intentionally destroyed by the Arabs, in their hostility to the Turks of Bussorah. The deserts in the neighbourhood being overflowed, stagnant water is the result, filled with putrid fish, and decomposed animal and vegetable matters of various kinds ; the effluvia from these produce remit- ting fevers of the most malignant type. Twelve or fourteen thousand inhabitants have been thus swept off by the fevers occasioned by a single inundation in that hot country. For an account of the Bussorah fevers, see Transactions of the Medical and Chirurgical Society for 1793. See also Wilson, vol. i. p. 84. In the 2d vol. p. 192, lately published of the same Transac- tions, you will also find an interesting description of a similar malignant remittent occurring in Portugal ; and of the fever of the East Indies, or jungle fever, as it is called. Miasma in our own climate, and in all temperate latitudes, exists most abundantly in the autumn. The system is then more disposed to be acted upon, the habit of body being at that * Lancisi (de nox. paludum effluv.) He gives a remarkable instance of the hurtful quality of the air of putrid marshes. Thirty gentlemen and ladies, of the first rank in Rome, had been sailing upon a party of pleasure, towards the mouth of the Tiber. Upon the wind suddenly shifting and blowing south, over the putrid marshes, twenty-nine of the thirty were immediately seized with a tertian fever — one only escaping. CAUSES OF FEVER. 169 time relaxed and debilitated, in consequence of the heat of the preceding summer : — and we may add that the body is also, by the action of the same causes, in a more vitiated state. Observe, that the vitiated habit gives malignancy to fevers, but not sus- ceptibility, or at least this is less certainly the case. And in- deed, upon some occasions, it would appear that the deleterious action of such vitiation upon the nervous system has a con- trary operation, that of rendering the system less liable to be acted upon by some of the exciting causes of fever, particularly contagion ; for the stranger is certainly more susceptible of yel- low fever than the native. We are at that time, therefore, as a consequence of the debility and relaxation occasioned by the summer's heat, more susceptible of the operation of the miasma of autumn. This predisposition, however, may be counteracted by generous living, but not by water-drinking or a vegetable diet, but by the moderate use of wine, and a due proportion of animal food. An illustration of this is afforded by the case of some friends of mine, living in Duchess county. Two of them are water- drinkers, and they frequently have the fever of that region. Two others, living in the same neighbourhood, who drink good old Madeira, have always escaped. In autumn, too, from the causes which have been mentioned, such is the predisposition, that the intermittent readily becomes a remittent, and the remittent not unfrequently assumes the typhoid character. Such was the case with one of the water- drinkers just referred to, in 1812. His disease began as an intermittent ; it soon became continued ; and finally ended in typhus. His nervous system became very much impaired, showing itself in his mind and body, for many months after an attack of fever thus induced. Miasma no doubt operates as a ferment upon our whole system, having its peculiar laws, like every other poison in- troduced. As marsh miasma is the result of the putrefaction of vegetable matter, Dr. Hugh Williamson, in his very interest- ing account of the fevers of North Carolina, contained in his history of that state, considers even the most simple species of intermittent as in some measure the effect of a putrefactive taint introduced into the system ; especially, as he observes, the most putrid fevers arise from the same cause ; that is, that in this 170 LECTURE XIV. country the heat of the climate contributes to this effect by its predisposing action on our system. Hence, too, it happens that intermittents in this climate, in common with all hot lati- tudes, have a great tendency to assume the continued type, and thence to end in a typhoid state of the system. To the same cause it is owing, that even the inflammatory diseases of winter in that climate have the typhous tendency, and will scarcely admit of the lancet. Hence, too, the typhous termi- nation even of the intermittents of that country, as observed by Dr. Williamson. This leads us to inquire, what are the circumstances favour- able to the operation of marsh miasma? They are, 1st, mois- ture. — Troops occupying the lowest situations, have been always observed by army physicians to be most liable to the influence of miasma. In the island of St. Lucia, it has commonly been remarked, that when the garrison, in a lofty position, is healthy during the time of dry weather, the inhabitants of the town at the base of the same hill, immediately below, and within half cannon shot, are visited by the worst fevers. Medical and Chi- rurgical Transactions vol. viii. p. 132. Even the smallest emi- nences, by their relative dryness, though equally exposed to the miasma, are observed to afford some security against its effects. The ground floor of the same building or barrack, is more unhealthy than the upper apartments. Hence, too, as observed by Sir J= Pringle, the cottage is less healthy than the town. The same author, in illustration of this fact, states the situations of two battalions : one was in a town remarkably healthy ; while the other, in a cottage, was, in consequence of their comparatively damp situation, rendered very sickly. The same observations have been made by Dr. Brocklesby, by Dr. Donald Monro, and by most army physicians. " The lower and moister the camp or garrison, and the more moist the season, the more subject an army is to agues," says Monro. See Wilson, p. 85. We may add, that this usually arises in consequence of the debilitating effects of cold in this instance. The effluvia of marshes, it may also be observed, are worse, and more virulent in their effects, when the water is drained off. As at the Nile, fevers are not prevalent during the inundation, but afterwards become so ; at the same time that they are more malignant. The same thing was observed, after the CAUSES OF FEVER. 171 overflowing of the Tiber. Baglivi, Op. Omn. p. 51, the great Roman physician, observes : " Certa Romanorum observatione constat, post ingentes Tyberis inundationes oriri febres epide- micas in urbe valde graves ac perniciosas." I have observed the same thing to occur at Newtown, Long Island ; that after the waters of the creek that puts up from the arm of the sea which passes between us and Long Island, improperly called the East River, has retired after an uncom- monly high tide, a great quantity of matter was left bare, from which an exhalation arose, loaded with the poison of a very formidable remittent and typhus fever. A similar observation has been made by Dr. Rollo, at St. Lucia. Intermittents oc- curred during the rains, but remittents after the waters were drained off. It is well observed by Melville, in his Experimental paper in the Edinburgh Literary Essays, " that light only communicates heat when its rays are obstructed, reflected, or refracted." This obstruction or reflection does not take place so readily when the ground is overflowed with water. The water being clear, will not become readily heated in such case, as the rays of the sun are not so readily reflected. Of course, the putre- factive process is less perfect and extensive, as the sun has not the same effects on the earth, the reflection of its rays being less powerful. But moisture alone will produce agues. They are fre- quent, says Dr. Moseley, in rainy seasons, when there is no miasma to produce them. " Agues," says Dr. Lind, " occur in the most healthy parts of Great Britain," i. e. from the moisture of the climate, without miasma. But it is by all ad- mitted, that they are certainly most frequent in the fenny coun- ties of England. Yet, though moisture favours the action of miasma and the putrefactive process that begets it, it is not essential to the production of fevers. For at Newtown, Long Island, and in most parts of this island, those diseases have existed — in seasons, too, of the greatest drought. I have known families residing on this island compelled to come to the city, in seasons remarkable for drought, on account of intermit- tents. In such cases, there appears to be still a peculiar effluvium exhaled from the soil, i. e. from ground that had been before 172 LECTURE XIV. marshy — though dry, it will still exhale such effluvia, especially when acted upon by an inordinate degree of heat. A similar observation is made by Livy, lib. v., and by Baglivi, Op. Omnia, p. 157. Speaking of marsh miasma, (the malaria of the Italians,) he observes: " Pestilentia orta sit in agro Romano, ob siccitates et nimios solis calores." And we may observe, that in cases of great drought, there is also an early fall of the leaf. May not the decomposition, therefore, of those leaves, aid in the production of such effluvia ? According to Lind, ships at a considerable distance from a swampy shore escape, while those that are near, within a mile, suffer. The first have the moist fog, but the last have the peculiar miasma, combined with that moisture. Dr. Fran- cis informs me, that the crew and passengers of the ship he returned in during the month of August, (1816) all enjoyed good health, until they were exposed to the fogs on the banks of Newfoundland, where they had not only moisture, but the peculiar effluvia blended with it, that proceed from the soil, which in some of the banks is very near the surface. In like manner, Pringle states, that the men-of-war which lay at anchor in the channel, between South Beveland and Walche- ren, during the worst period of the distemper that prevailed among the British troops in 1747, were not affected with either flux or fever, but enjoyed the most perfect health. See also Davis on the Walcheren Fever, p. 15. But although miasma most generally produces intermittent and remittent fevers, and moisture may favour its operation, it is also very certain that the cause of those diseases is, in some instances, generated within the system, but perhaps called into action by fatigue, heat, cold, or moisture. Accordingly, in the city of New York, we have intermittents and remittents at all seasons, winter and summer, as well as in the spring and autumn. Dr. Willan also met with intermittents in persons residing in the most healthy parts of London. See his works, p. 167-8. Dr. Gregory makes a similar observation of their occurrence in elevated parts of Edinburgh, independently of any previous exposure to marsh miasmata. Dr. Bateman makes the same remark. See also Medical Facts and Observations, vol. vii. Three cases are noticed by Dr. Beddoes, as occurring at Bristol during a hard frost. CAUSES OF FEVER. 173 Before I conclude these observations on the effects of moist and marshy situations, let me refer you to a very instructive document on this subject, as it regards their influence on health and life in general, independent of their agency in the more immediate production of fevers. This document you will find in the second volume of Dr. Price's celebrated work on Annui- ties and Lives, exhibiting the proofs of the insalubrity of marshy situations. He observes, (see vol. ii. p. 29,) that the probabilities of living are highest in the most hilly parts of the province, and lowest in the marshy parish, (the parish referred to is a part of the district of Vaud, in the Canton of Berne, in Switzerland, containing one hundred and sixty-nine families, and six hundred and ninety-six inhabitants.) One half of all born in the mountains, live to the age of forty-seven. One half of all born in the marshy parish, live to the age of twenty-five. One in twenty of all born on the hills, live to eighty. One in fifty-two only, in the marshy parish, reach eighty. In the hills, a person aged forty has a chance of eighty to one for living a year. In the marshy parish, his chance is not thirty to one, for living a year. In the hills, persons aged twenty, thirty, and forty, have an even chance for living forty-one, thirty-three, and twenty-five years respectively. In the fenny parish, per- sons at those ages have an even chance of living only thirty, twenty-three, and fifteen years. See also Priestley's Observa- tions on Stagnant Waters, in the Royal Society's Transactions for 1774. Also, Murat's Observations, published in the Me- moirs for 1766 of the Economical Society at Berne. See also Simond's Travels, vol. i. 2d. Besides moisture, woods are also observed to be favour- able to the action of miasma. Pringle, Cleghorn, and Jackson, have all made this observation. They may, and probably do. operate in part by confining the effluvia, and by concentrating their force ; whereas light and air otherwise would dissipate and dilute them. On this account, the practice of planting trees very close to a dwelling-house is injurious. But trees or woods may also have an injurious effect by the very moisture which they create, by preventing the access of the sun's rays to dis- sipate the vapour produced ; and its effects are manifest in the early decay of such buildings as are so closely surrounded by trees. Even brick and stone buildings show the effect of such 16 174 LECTURE XIV. moisture constantly involving them ; the inhabitants, there- fore, must experience their ill effects. Yet it is remarked, that woods are, in some cases, useful too, to prevent the bad effects of miasma. The first cutting down and clearing the woods of North Carolina, begot diseases. The historian of that state observes, that the first colony were those who were sent out by Queen Anne, consisting chiefly of the persecuted protestant Palatinates — they did not remain in that part of the country, not getting the lands that had been promised them. The second colony of adventurers lived twelve months in that country before it was cleared, and lost only five men out of one hundred and seven — though badly sheltered and badly fed ; but the trees being cut down, and the surface of the earth exposed to the sun, the exhalations, says Dr. Williamson, soon gave rise to fevers. Woods are also useful, when they are situated between an encampment or a dwelling and marshy ground. Whole fami- lies, says Mr. Bartlet, have resided near the Pontine marshes in the vicinity of Rome, and by the intervention of shrubs and trees, have escaped for years the noxious effects of the mephitic vapours which those putrid waters engender. See Thompson's Annals. Observations by J. M. Bartlet. See Edinburgh Journal for July, 1820, p. 621. Dr. Williamson, in his late History of North Carolina, states a very striking instance of this effect, produced by a piece of wood. A gentleman in Craven county, with a family consist- ing of fifty or sixty persons, lived forty years without inter- mittents. But in 1785, he cut down a thick wood for pasture and fresh air — thirteen of his family the next year were at- tacked with intermittents. Col. Howell's family, too, in New Jersey, was attacked with fever, in consequence of cutting down a wood that separated them from a morass in the neigh- bourhood. Before that operation, they had been healthy ; but the consequence of this change was, that most of the family were attacked with fevers — three died — eight or ten recovered by means of blisters, and the free use of bark, wine, and snakeroot. Similar facts have frequently occurred in the West Indies. 3d. The cold of the night air is favourable to the action of miasmata. All sudden changes of temperature or season give CAUSES OF FEVER. 175 effect to it, as a cold night after a warm day. " A cold and wet autumn," says Raymond, " after a hot and dry summer, spreads and renders fevers more malignant." Raymond, In- termittents of Mettleburgh. See also Wilson, p. 85. Bade- nock, vol. iv. Obs. and Enq., ascribes the bilious remittents of warm latitudes to the cold night air, as one of the principal exciting causes. Bontius observes, that the w T orst fevers of Batavia are produced by night air. Lind also states, that the boat of the Med way man-of-war, while at Batavia, attend- ing the shore at night for the purpose of procuring provisions, was no less than three times successively manned, having lost her hands in that service. 4th. Temperate seasons are also most favourable to the ac- tion of miasma, viz. spring and autumn. So also are temper- ate climates, neither very hot nor very cold. Intermittent s are accordingly seldom met with very near the Equator. Bon- tius, Lysons, and Clarke, concur in this remark. In very hot latitudes, if they do exist, they assume a more malignant cha- racter, blended with typhous symptoms ; and in this w r ay they become contagious, as stated by Cleghorn. See also Wilson, p. 91. 5th. The mixture of sea water with the water of marshes, is said by Pringle to produce a more noxious exhalation than miasma alone. Pringle drew this conclusion from his experi- ments, showing that a small quantity of salt promotes putre- faction. This is sanctioned, too, by his experiments, for the purpose of showing that salt favours putrefaction ; but the di- lution more than counteracts this tendency. Accordingly, this is not confirmed by other writers. It is observed by Jackson in Jamaica, and on the coast of the Carolinas, where the sea and river waters are mixed, that those places are not more unhealthy than those where they are separated. It is also a fact, observed at Hoboken, in the vicinity of this city, that it has become very sickly since the sea water has been kept out by embankments. Before these embankments, no intermittents or remittents existed — now they are so frequent and formidable, that many persons have removed to town, to avoid the fevers of that place and its vicinity. Mr. Stevens informs me, that during the summer of 1812, the salt water was again admit- ted — the marshes as formerly were overflowed, and they en- 176 LECTURE XIV. joyed an exemption from their usual visitants — intermitting and remitting fevers. 9th. Contagion is another of the exciting causes of fever. It is sometimes, like miasma, a predisposing cause of fever, for a person may have contagion in his system, and yet escape disease, unless it be called into action by heat, cold, fatigue, or intemperance. For the most part, however, it is sufficient of itself, as an exciting cause, to produce disease. It is, in- deed, the source of a great number and variety of fevers and febrile diseases. The term contagion is derived from the verb contango, signifying to touch, or to come in contact. And accordingly it signifies, in its strict etymological sense, the communication of disease by contact. Its meaning, how- ever, has been extended beyond these bounds, which the ety- mology of the term appears to prescribe. A contagious disease in the modern use of the term, denotes a disease in which a specific material is generated in the system, and which excret- ed, will communicate such disease from one person to another. But notwithstanding the apparent precision of this language, there is, perhaps, no subject which has ever occupied the human mind, that has created more controversy, and more confusion, than that of contagion ; especially that of defining the limits and circumstance which characterize a contagious disease. Truly it may be said, that clouds and darkness rest upon it. Some have proposed to confine the term contagious to diseases which are communicated by a specific matter, which can be taken but once in the course of life, and which can be communicated by inoculation as well as by contact. And the example they usually give of such specific contagion is small-pox. This they consider the most perfect example of the diseases they denominate specifically contagious. While to fevers that are communicable from one to another, some of which may be communicated by inoculation, as the plague, and may be taken frequently by the same person, they refuse the term specific contagion.* * " A considerable diversity of opinion has prevailed respecting the cause of fever. Physicians seem now to be agreed in referring it to a general or specific contagion, the former giving rise to typhus in the various forms under which it appears, while the exanthemata or eruptive fevers proceed from the latter." Hamilton on Purgatives, p. 14, 16. CAUSES OF FEVER. 177 But this distinction, I contend, is a bad one in many re- spects, even upon their own principles. For instance, syphilis is surely communicated by a specific poison or material — it may be conveyed by the lancet or the knife, as well as by sexual intercourse, and accordingly we see it thus occasion- ally communicated by dissection. Yet syphilis, although it is thus restrained in the manner of its communication, viz. by contact, you all well know that it is frequently contracted by the same person. Here, then, is at once an exception to the character of a specifically contagious disease, as above defined, inasmuch as the pox may be taken frequently, and the small- pox but once. Dysentery, too, has its specific material as well as small-pox, though it may not be communicated by inocula- tion. Yet dysentery as uniformly and regularly produces dys- entery, as small-pox produces small-pox, though the one can be taken but once, while the other is frequently contracted by the same individual. The plague, too, has its specific material ; it can be taken frequently, and it can even be communicated by inoculation,* as I shall show you to-morrow. Yet it is not, in the sense they consider small-pox, one of the specifically contagious diseases. Other physicians, again, have confounded all contagious dis- eases, making no distinctions whatever as to the several modes of communication. Lind even, in his valuable papers on con- tagion and infection, is guilty of this error. The late Dr. Richard Bayley of this city, in his account of the yellow fever which prevailed in New York in 1795, pro- posed what at first view appears to be a plausible distinction between contagious and infectious diseases. He made use of the term contagious diseases, to distinguish those which are communicated under any circumstances of atmosphere, whe- ther foul or pure, as small-pox, measles, &c. Infectious diseases he denominated such as are communicated by the * It is said that Desgenettes inoculated for the plague some of the French soldiers in Egypt, but could not communicate the disease. But read his own account. He tells you that he did it for the purpose of giving confidence to the soldiers ; that he did it under circumstances unfavourable to its communication ; made use of the matter at too early a period of the disease ; and adds, " that the contagious nature of the plague was demonstrated by a thousand examples — demonstree par milles exemples." 16* 178 LECTURE XIV. impurities of the atmosphere, or by the foul air surrounding the patient. That is, that the impurities of the air communicate the disease — not that the air contains any specific material derived from the diseased body, except such as arises from mere want of cleanliness, and from the foul air surrounding the patient. But an obvious objection to this arrangement is, that the same disease under which the patient is suffering is com- municated to the visiter. He takes yellow fever, or dysentery, or typhus fever, when the sick man has any of these diseases ; and he receives no other. For this reason, then, I make use of the terms infectious and contagious, as synonymous : — yet each of the disorders so denominated, whether contagious or infectious, has its own peculiar laws. Others, again, are frequently contracted, as the clap and syphilis; indeed, without these peculiarities, they would be the same disease — they would truly be unit, as they have been considered by Dr. Rush and some of his followers, who are without his talents or genius to give the same plausi- bility to error that it received from that able and eloquent teacher and writer. No one, therefore, can be a standard of comparison for the others, as each disease has something pe- culiar to itself. Hence, then, we see the error of those who make small-pox a standard — and who pronounce upon the con- tagiousness or non-contagiousness of fevers and other diseases, according as they do or do not resemble small-pox. In this way they have reasoned upon the contagiousness of yellow fever, denying it altogether because it did not square with the disease they made choice of as the standard — because, for- sooth, the yellow fever was not small-pox. They might as well say that scarlet fever is not a contagious disease, because it has not the pustules of small-pox ; or, they might say, that even small-pox is not contagious, because it has not the buboes of plague or syphilis. As an old lady, after listening to a learned disquisition on these distinctions, said, " At any rate they are catching diseases." In like manner, I call them all communicable diseases — communicable from one person to an- other. But, as some of these diseases are conveyed in one form, and others in a different, we should be careful to mark those circumstances in which they differ, as well as those they possess in common. Can this be accomplished ? CAUSES OF FEVER. 179 Such an arrangement appears to me not only to be practi- cable, but at the same time calculated, in some degree, to bring the contagionists and non-contagionists together. Und^r these impressions, in the year 1808, in a letter addressed to Dr. Chisholm, I first suggested my reflections on this subject, and proposed to arrange all those diseases which are communica- ble from one to another into three great classes, according to the several laws which appear to govern their communica- tion. See American Medical and Philosophical Register, vol. ii. p. 17-22. Dr. Chisholm expressed his approbation of the first two classes, but objected to the third that the foul air which I made the medium of communicating the contagion, and of spreading the disease, only operated by predisposing the body to receive the contagion from the individual to whom he might be exposed, but that it could have no other operation — but this certainly is not all. Dr. Chisholm requested me to reconsider the subject. I have done so : the result of that consideration will be laid before you at our meeting to-morrow. 180 LECTURE XV. CONTAGION, AND ITS LAWS. As I stated to you in the last lecture — in July, 1808, I ad- dressed to Dr. Chisholm some observations on contagion, or infection.* The object of that communication was, if possible, to narrow the ground of controversy upon that important and much contested subject. This I endeavoured to do, first, by showing that the distinction which had been proposed by some late writers, between contagion and infection, was unnecessary and fallacious ; secondly, by dividing all diseases which are contagious, infectious, or communicable from one person to another, into different classes, according to the several laws which appear to govern their communication. These classes are three in number. The first embracing those diseases which are communicated exclusively by contact ; as the itch, syphilis, hydrophobia, &c. which are never conveyed through the medium of the atmo- sphere. The second including those diseases which are communica- ble both by contact, or the near approach to the sick, and by the atmosphere, as measles, small-pox, scarlet fever, &c. which are communicable in every season of the year, and in every climate ; in a pure as well as in an impure air, though more readily by means of the latter than the former, and with which persons are rarely infected more than once in their lives. Under the third class are enumerated those diseases which are only, in general, communicable or contagious through the * See Edinburgh Med. and Surg. Journal, vol. v. p. 247. American Medical and Philosophical Register, vol. ii. p. 14. CONTAGION, AND ITS LAWS. 181 medium of an impure atmosphere ; the air being rendered thus impure by the decomposition of animal and vegetable sub- stances, as in low, marshy countries ; or by concentrated hu- man effluvia, as in camps, jails, hospitals, or on shipboard ; but the same diseases I alleged, in a pure air, in large and well ventilated apartments, when the dress of the patient is frequent- ly changed, all excrementitious discharges constantly removed, and attention paid to cleanliness in general, are not usually contagious, or, under such circumstances, are very rarely com- municated from one person to another. In this class I included the plague, dysentery, typhus fever, in its various forms of jail, ship, hospital, or lake fever, and the yellow fever. I also remarked, that these diseases, like many of the first class, may be repeatedly contracted ; but that they are com- municable, or otherwise, according to the condition of the air in which they occur, or into which they may be introduced : it was further observed, that the atmosphere thus impregnated by the peculiar virus emanating from the diseased body, becomes assimilated to the poison or ferment introduced, and thereby is rendered capable of reproducing in others the same specific disease, whether it be the plague, dysentery, typhus, or yellow fever. Such are the outlines of my first communication to Dr. Chisholm. In 1809, Dr. Chisholm did me the honour to reply* to the foregoing observations, expressing his entire approbation of the first two classes, but objecting to the third. After enumerating his several objections, he requests me to reconsider my third division, which appears to him to be the only objectionable one. This I have done, and now submit the result of a further examination of this subject, and a detail of the facts by which I have been led to my conclusion relating to the laws of com- munication which I have more particularly assigned to the febrile diseases enumerated in the third class. In my first communication, I acknowledge I stated my ob- servations without so full a detail of the facts themselves whence my conclusions were deduced, as perhaps ought to have been exhibited. Yet they have been approved and adopted by the * See American Medical and Philosophical Register, vol. ii. p. 121. 182 LECTURE XV. physicians of Edinburgh and London, as you may see in the Edinburgh Journal, and the London Register and Review. To the European reader, unacquainted with the peculiarities of yel- low fever, more especially as it has appeared in the cities of the United States, my first statement may perhaps appear defective in that evidence which is so justly exacted upon subjects of this nature. This evidence I shall now endeavour to supply, and thereby to confirm the correctness of the classification which has been proposed. Waiving for the present all inquiry relative to the nature or properties of the contagious principles secreted by the diseased body, or the chemical qualities of the atmosphere deemed ne- cessary for its propagation, or the manner in which the con- tagion diffuses itself, I proceed to observe, that the history of each disease enumerated in the third class, viz. plague, dysen- tery, typhus, in all its forms, and yellow fever, furnishes evi- dence of the correctness of the remark, that they are governed by a law peculiar to themselves, that they are contagious or communicable in a foul atmosphere, but that they are never or very rarely so in a pure air, where the sick enjoy the benefits of cleanliness and ventilation. The same evidence, I trust, will demonstrate another truth, that these diseases are in no instances epidemic, as they have been improperly denominated by most practical writers, but that their sphere of operation is, with very few exceptions, confined within the limits to which the vitiated atmosphere ex- tends, in which they may be engendered, or into which they may be introduced : and that, in this respect, they differ from ordinary epidemics, " which appear in different and distant parts of the same place, and at the same time." That the plague when once generated, whatever may be the sources whence it derives its origin, is communicated by a pe- culiar virus secreted by the diseased body, will not, I trust, be questioned at this day. Independently of the facts contained in the writings of Thucydides, Lucretius, Mead, Dr. Patrick Russell, and others, showing the contagious nature of the plague, the communication of this disease by inoculation, as performed by Mathias Deggio,* Dr. Whyte,f and the Russian * See Med. Com. vol. viii. p. 349. t See Wilson's Expedition to Egypt, and M'Gregor's Sketches. CONTAGION, AND ITS LAWS. 183 surgeon noticed by Sonnini,* have recently established the fact of its propagation by a specific secretion, beyond all possible controversy. It has been observed by Assalini, that Dr. Desgenettes, while in Syria, had in vain endeavoured to inoculate himself with the virus of the plague : and by the same writer it is incorrectly added, that Dr. Desgenettes made the experiment under the persuasion that the disease was not contagious : but from the account of the facts as stated by Dr. Desgenettes himself, it appears that the experiment was not made under that persua- sion. On the contrary, he expressly declares, that its conta- giousness was demonstrated by " a thousand examples," and observes, contrary to the opinion of many, that the same per- son was liable to a second attack of it, as was the case with the convalescents w r hom he employed to attend upon the sick. Furthermore it appears, from his own account, that he inocu- lated himself with the matter taken from a person who had the disease in its mildest form, what he denominates the first degree ; in which the fever was slight, and the patient easily and promptly cured. Dr. Desgenettes adds, that it was an im- perfect experiment, and that it does not disprove the commu- nication of the disease by contagion ; and that he made the experiment for the purpose of quieting the fears of the French troops, and of inspiring them with confidence. But that the plague, in common with the other diseases I have associated with it, is only communicable through the me- dium of an impure or vitiated atmosphere, is an opinion which, although it has never been attended to by physicians, will be found to be verified by almost every writer on this disease. 1st. The plague of Athens, the first of which we have any authentic or satisfactory account, furnishes evidence of the truth. Whether that disease originated in the city of Athens, or was introduced into it from Ethiopia, the fact is established, that the circumstances under which it appeared in that city were peculiarly favourable to its diffusion. It appeared, ac- cording to Thucydides, in the beginning of the summer sea- son, and first of all at the Piraeus, the port and harbour of Athens, from whence it spread with increasing mortality into * See Travels into Greece and Turkey, p. 497. 184 LECTURE XV. the upper part of the city. It appeared, too, at a time when Athens was so crowded with those who had fled thither from the adjacent country of Attica for safety from the invading ar- mies of the Peloponnesians and their allies, that many of them were forced to lodge themselves within the turrets of the walls, or wherever they could find a vacant corner. " The city," says the historian, " was not able to receive so large a conflux of people :" " afterwards the long walls, and a great part of the Piraeus, were portioned out to them for little dwellings ; at the same time, too, the Athenians were fitting out, at the Piraeus, a fleet of one hundred ships to infest Peloponnesus." Even the Pelasgic, a hitherto vacant spot of ground below the citadel, w r hich it was thought profaneness to occupy, and the settlement of which the Pythian oracle had specially prohibited, they were constrained, by urgent necessity, to turn into a dwelling-place. By this influx from the neighbourhood of Athens, its number of inhabitants, as stated by a late writer, was suddenly increased from fifty thousand to more than four hundred thousand per- sons.* In another place, Thucydides observes, " Those who had come in from the country had no houses, but dwelled all the summer season in booths, where there was scarcely room to breathe." He adds, " The pestilence destroyed with the ut- most disorder, so that they lay together in heaps, the dying upon the dead, and the dead upon the dying." Even in the public streets, some were tumbling one over another, or lay expiring round about every fountain, whither they had crept to assuage their immoderate thirst. The temples, too, in which they had erected tents for their reception, were full of the bodies of those who had expired there. Thucydides proceeds : " In a calamity so outrageously violent, things sacred and holy had quite lost their distinction ; all regulations observed before in matters of sepulture were quite confounded, since every one buried wherever he could find a place." He also observes : " It raged the most, and for the longest time, in Athens, but afterwards spread into the other towns, especially in the most populous, but never extended itself to Peloponnesus." We are told by the same historian, that " at the siege of Potidaea, which took place during the same season, the plague followed * Medical Repository, vol. i. p. 16. CON'TAGION, AiVD ITS LAWS. 185 them even thither, and, making grievous havoc among the Athenians, destroyed the army ; and that even those soldiers that had been there before, and had from the beginning of the siege been in perfect health, caught the infection from the troops brought thither by Agnon. After a stay of forty days, having, in that time, lost one thousand and fifty out of four thousand men, he returned with his ships to Athens."* With these facts before us, the season of the year in w T hich the plague made its first appearance, the part of the city in which it commenced, the multitudes which crowded into it, and those too unaccustomed to the air of the town, having been habituated to active employment in the pure air of the country, the impure state of the atmosphere necessarily result- ing from this condition of things, combining the evils both of pestilence and war ; the disease itself being confined w r ithin the walls of the city, while, at the same time, it never extended itself to the neighbouring country, not even to the contiguous towns of Peloponnesus and Boeotia, we are led to the conclu- sion, at least to the strongest presumptive evidence, that an impure atmosphere is the vehicle or medium by which this disease is propagated. 2d. The circumstances attendant upon the plague, as it has appeared at different periods in the city of Rome, are no less demonstrative of this truth. I will only notice the more re- markable visitation of this disease which took place in the year of Rome 290, and four hundred and sixty-one years before Christ. " This," says Livy, " was a season of great distress ; for during this year a pestilential disorder spread itself not only through the city, but over the country, affecting both men and cattle with equal malignity ; the violence of the disorder was increased by admitting into the city the cattle and the inhabi- tants of the country, who fled thither for shelter from the ene- my's ravages : such a confused collection of animals of every kind suffocated the citizens by the unusual stench, while the country people, crowded together in narrow apartments, suf- fered no less from the heat, the want of rest, and their attend- * Smith's Translation of Thucydides, vol. i. p. 153, 17 186 LECTURE XV. ance on each other ; besides even contact served to propagate the infection."* Baker's Livy. Dionysius of Halicarnassus mentionsf that the disease seized studs of mares, herds of oxen, and flocks of goats and sheep, doubtless denoting that this disease was remarkably fatal to those animals when collected in numerous bodies. Orosius, in his account of the same pestilence, observes, " Many of the patricians were victims, but it was most fatal to the poor." J Livy also has a similar observation, that many illustrious per- sons died, but that among those of inferior note the virulence of the disorder spread its ravages wide. 3d. The history of the pestilence of modern times, the ac- counts of which are more minutely and satisfactorily detailed, no less proves that this disease, when once introduced, spreads its devastation by means of a vitiated atmosphere, more espe- cially where such vitiation proceeds from confined human effluvia. Erasmus, in 1515, in a letter to Franciscus (Wolsey's physician) ascribes plague, and the sweating sickness, partly to the incommodious form and bad exposure of the houses, to the filthiness of the street, and the sluttishness within doors. " The floors," he writes, "are commonly of clay, strewed with rushes, under which lies unmolested an ancient collection of beer, grease, fragments, bones, spittle, excrements of dogs and cats, and every thing that is nasty," &c.§ Diemerbroek also remarks, in his excellent treatise on the plague, that whenever that disease has been introduced out of its proper season it has not spread. It has also been observed by Dr. Russel, that in winter time, when infected persons have come to places about Aleppo, some of whom have died of the disease in families where they lodged, the distemper was not propagated. Dr. Hodges also stated that those who fled from London, in the * Grave tempus et forte annus pestilens erat urbi, agrisque, nee Iiominibus magis, quam pecori ; et auxere vim morbi tenore populationis, pecoribus agresti- busque, in urbem acceptis. Ea colluvio mixtorum omnis generis animantium, et odore insolito urbanos et agrestem confertum in areta tecta, sestu ac vigillis an- gebat, ministeriaque in vicem ac contagio ipsa vulgabant niorbos. Tit. Liv. lib. 3. c. 6. t Lib. 10. t Lib. 2. ^ Life of Erasmus by Laycey. Lond, 1805, CONTAGION, AND ITS LAWS. 187 autumn of 1665, during the ravages of the plague, and returned in winter time to the houses and beds in which their friends died of the malady, escaped the infection. It therefore depends both upon temperature and the condition of atmosphere for its propagation. It is likewise an unquestionable fact, says Dr. Bateman, writer of the article Plague, (see Rees,) that this disease has always first appeared and established its head quarters in the filthiest parts of crowded, ill-constructed, and large cities, and has committed its most fatal ravages among the lowest of the people. Thus at Grand Cairo and Constantinople it appears almost annually. In London, Dr. Heberden observes that the plague of 1626 and 1636, broke out at White-Chapel, a part of the town which abounds with the poor and with slaughter-houses. In the plague of London, in 1665, at which time nearly one hundred thousand persons perished, it is stated to have broken out first at St. Giles's. We are also told by Hodges, that while the bet- ter sort of people had various resources to avoid the dreadful consequences of this fatal distemper, it was entirely confined to the poor, insomuch that some gave it the name of the poor's plague. The rich, says Mr. Howard, are less liable to the plague than the poor, both because they are more careful to avoid in- fection and have larger and more airy apartments, and because they are more cleanly, and live on better food, with plenty of vegetables ; and this I suppose is the reason why protestants are less liable to this distemper than catholics during their time of fasting ; and likewise, why the generality of Europeans are less liable to it than Greeks, and particularly Jews. He adds, I have heard of instances of servants in European families, who, through imprudence and carelessness, have been attacked with the plague, while the rest of the family escaped it.* We are told by Diemerbroek, that it was a common prac- tice in Italy and France, when the plague appeared in any large town, to drive out the poor immediately : so fully were the ma- gistrates convinced that the disease was preserved and propa- gated by them. Upon the same principle, at the commence- * Account of Lazarettos, p. 52. 188 LECTURE XV. ment of the plague at Marseilles, all beggars were ordered to quit the town.* " Indeed," says Dr. Blane, " it is a general re- mark in the history of all plagues, both in Asia and Europe, that they break out and prevail only among the lowest and poorest ranks of people, never becoming epidemic among the better sort."f When the plague was last in England, upon its first entrance into Poole, in Dorsetshire, the magistrates imme- diately suppressed it by removing the sick into pest houses without the town.J Lord Clarendon, in the history of his own life, relates that when he and other people of condition, who had fled from the plague, returned to London, they hardly missed one of their friends or acquaintances, the mortality having been confined almost entirely to the lowest orders of the people. " At that time, too, the streets of London," says Thornton, " were nar- row, crooked, and incommodious, the buildings chiefly of wood, dark, close, and ill contrived, and by the several stories pro- jecting beyond each other as they rose over the narrow streets, the circulation of the air was almost entirely obstructed. To these inconveniences," he adds, " may in some measure be at- tributed the destruction which had been repeatedly made in the city by the visitation of the plague ; for as the air was confined, so the noisome vapours and pestilential atoms were harboured and nourished. Though the destruction of London by the great fire in the succeeding year (1666) occasioned great tem- porary distress, yet, in the end, it proved of the utmost utility ; for, by the rebuilding of the city, and the enlargement of the streets, the free circulation of air was admitted, the offensive vapours expelled, and the city freed from all pestilential disor- ders."§ It is also stated by Dr. Hodges,|| that at the breaking out of this plague, the city was unusually full of people : he supposes that there must have been upwards of one hundred thousand persons more than usual in the city ; and according to Dr. Baynard, during the progress of this merciless pestilence, there was such a general calm and serenity of weather as if * Ferriar's Med. Hist, and Reflect, vol. i. p. 287. t Diseases of Seamen, 3d ed. p. 622. X Roberton's Med. Police, vol. ii. p. 149. § Thornton's History of London, I! De Peste, CONTAGION, AND ITS LAWS. 189 both wind and rain had been expelled the kingdom, and that for many weeks together not the least breath of wind could be discovered. It is also worthy of remark, that the city of Oxford, to which the parliament was removed during the prevalence of this dis- ease, remained uninfected; which exemption is ascribed, by Dr. Plott, to the draining and greater cleanliness of that city.* 4th. The great plague with which Marseilles w 7 as visited in 1720, and which destroyed upwards of sixty thousand of its inhabitants, presents us w T ith a detail of facts which leads to the same conclusion. Blackmore takes notice, that the impurity and filth connected with the galleys and slaves at Marseilles, filled the air with offensive smells, and in 1720 the plague broke out there in a part of the town thronged by the poorest people. This disease, it is well ascertained, was introduced from the Levant by a ship which arrived at Marseilles from the coast of Syria. It appeared first among the sailors of the suspected ship ; it was next taken by the porters engaged in opening and airing the merchandise in the Lazaretto ; it was then introduced into the city, and spread among the poor, and first of all in a street which was only occupied by the low r er class of people.-)- In the commencement of the disease, Bertrand remarks, none but children and poor persons were attacked by it.J In a short time it extended to the neighbouring streets ; it was also conveyed into the Hotel Dieu, by a person received as a patient from the street where the distemper first broke out ; two of the nurses and the matron of that institution first died of the disease, when the infection spread with great mortality, de- stroying the physicians,^ surgeons, apothecaries, confessors, and all the other officers and servants of the house, with the whole of the poor in the hospital, including above three hundred foundlings. || Soon after, all intercourse was prohibited between the town and neighbouring country ; the scarcity of provisions which ensued, independently of the crowded state of the city, greatly * History of Oxfordshire. t Bertrand's Relation Historique, p. 414. t Bertrand, p. 50, § Speaking of the plague of Egypt in 1800 and 1801, Sir James M'G-regor tells us, that of thirteen physicians seven were attacked with the disease, and that of this number four died. H Bertrand, p. 92. 17* 190 LECTURE XV. added to the mortality of the disease : the number of the sick increasing, an hospital was opened for the reception of the in- fected, where the disease proved fatal to all the attendants. But the disease was not only propagated in those public institutions, where great numbers were crowded together, and in the con- fined dwellings of the poor ; other circumstances occurred which served greatly to diffuse the poison still more generally throughout the city. According to Bertrand, the streets were crowded with " the sick, the dying, and the dead," and the va- pours which arose from the putrid dead bodies, in every part of the city, served to infect the air and spread the contagion ; indeed, it soon extended to places that before this had been in- accessible to it ; monasteries, and houses shut up in the most exact manner, were no longer places of security; the whole city became more or less one infirmary.* The infection, too, was very much increased from another source not less dangerous. An opinion prevailed that the dogs received the contagion from contact with infected clothes, and thereby became the means of spreading it still more extensively; . the consequence was, an order to destroy them : in a few days the streets were strewed with their carcasses ; a prodigious quantity were thrown into the water ; these also were soon cast upon the shore, where, by the action of a hot sun, the air was filled with the most noxious vapours. Infected clothing and furniture were also continually thrown into the streets from the windows of the houses in which the disease prevailed ; and, if possible, still further to give wings to the poison, fires were in- judiciously had recourse to, for the purpose of destroying the infection. " At hours appointed," says Bertrand, " the whole city appeared on fire, and the air became loaded with a thick black smoke, better calculated to retain than to dissipate the contagious vapour. "f In fact, these fires, he adds, appeared to relume that of the contagion ; " they heated the air, already rendered suffocating by the heat of the season and climate ; the pestilential poison became more active, and the disease acquired new force."J 5th. The plague of Aleppo, in 1760, 1761, and 1762, might also be cited upon this occasion, as well as many others, both * Bertrand, p. 145. f Ibid. p. 74. I Ibid. p. 75. CONTAGION, AND ITS LAWS. 191 anterior and subsequent to that period, to show that the epi- demic influence of this disease is chiefly dependent upon the atmosphere into which it may be introduced. 6th. I cannot however pass over without comment, the plague which the British and French troops suffered during the celebrated expedition to Egypt in 1800 and 1801, inasmuch as it will show that this disease, even in its native climate, is go- verned by the same laws of communication which have been observed when it has been introduced into other countries. We are accordingly told, by the learned Dr. Wittman,* " that the disease is more prevalent at Rosetta than in any other town, or part of Egypt ;" he adds, " the streets of Ro- setta are extremely narrow and very dirty. The crowded manner in which the inhabitants live together would appear sufficient, in a stagnant state of the atmosphere, in most of their towns, to generate pestilential or malignant diseases. The . very few comforts and conveniences w T hich fall to the lot of the poorer class of the natives of Egypt, by far the most numerous, would lead one naturally to expect great mortality when the plague prevails among them. Dreadful examples are seen an- nually to happen." In another part of the same work, he is still more explicit on this point, showing that the plague " does not always possess the same activity and force ;" and the ne- cessity, as he expresses it, of some " powerful agent to put the contagion into action, and give it its full force." He then asks, " May this agent reside in the atmosphere ? Does this peculiar constitution of the air consist in a superabundance, or diminu- tion, of the ordinary proportion of oxygen in the atmosphere ? or in the combination of some peculiar gas or gases diffused in it?" He suggests that a series of eudiometrical and other observations, continued for several years, might throw some light on this subject. " Time alone," he adds, " may unfold this mystery."! But when we take into view the facts he has already stated relative to Rosetta, and are told by the same author that in Egypt the plague prevails when the Nile is low, and of course the air loaded with impurities thence arising ; that at Constantinople, the cold weather, in winter, puts a period to its progress ; and the still more general observation, that the ex- * Travels in Egypt, p. 525. t Ibid, p. 533. 192 LECTURE XV. tremes both of heat and cold are unfavourable to the propaga- tion of plague ; — these facts, in connexion with those already stated of this disease, as it has appeared at different times and in different parts of the world, are certainly calculated to dis- sipate much of the mystery in which this subject has been en- veloped. The remarks of Dr. M'Gregor, (now Sir James M'Gregor, principal of the medical staff,) that the plague varies its type according to the state of the air, and other circum- stances, and that by ventilation, fumigation, and attention to cleanliness, the progress of the disease was arrested,* also serve to confirm the correctness of the view which has been taken of this subject. Even the writings of Assalini, who dis- believes the communication of this disease by contagion, fur- nish additional support to the principle here contended for ; for he admits that when persons are shut up and crowded together in infected places, the disease is readily contracted-! In an- other place he observes, " that if a person be exposed to breathe the infected air in the chamber of a patient, or should he stay too long in the same atmosphere, he will run a great risk of contracting the prevailing malady."J He moreover proceeds ; in order to prevent all suspicion, and avoid all danger of car- rying the disease where it has not been before, that they should take nothing with them but the necessaries of life ; they should avoid, as much as possible, halting in villages ; and each time when they happen to encamp, they should expose their baggage and clothes to the air, which would not fail of dispersing every particle of contagion. As a further evidence, too, of the con- nexion between the prevalence of the disease and the state of the air, he remarks, that during the epidemic, " the inhabitants residing near the sea were more exposed than those who were at some distance, and that there were several villages situated on the heights which had not even a single sick person." In many other parts of his work, he shows that his mind was not totally divested of belief in the communication of the plague by contagion ; and when danger approaches, like some modern professors of religion, he proves himself to be the practical infidel, by distrusting even his own doctrines ; for he takes great * Med. Sketches, p. 111. t Observations sur la Peste. 1 Observations, &c. CONTAGION, AND ITS LAWS. 193 pains to inform us of the various means he made use of to pro- tect himself against the disease, and which are both as efficient and judicious as the most sturdy contagionist could possibly have employed. Imlac, in Rasselas, speaking of the appear- ance of departed spirits, says, " Some who deny it with their tongues, confess it by their fears." So with Assalini, and, in- deed, the same may be said of many others who affect to dis- believe the doctrine of contagion, but who are among the first to fly from the disease whenever it made its appearance in our cities. And they w^ere the first to write on this subject ; and wrote the most. Indeed, some of the very books that were published by them w r ere written, not on the battle ground, but actually on the Catskill mountains. Is it possible, then, that you can attach value to such flying observations as these must necessarily be ? 7th. In addition to the details cited from Thucydides, Livy, and from the writers of modern times, I might here introduce similar facts recorded of the plague of Florence, which ap- peared in that city in 1348.* But to conclude upon this part of the subject, and in the lan- guage of Dr. Chisholm himself, " Every physician who has delivered his opinion of the origin of the plague maintains, that a peculiar state of the air is absolutely necessary to establish the powers of contagion, and give circulation to the imported infection."! Another disease which I have placed in the same class with the plague, and have considered as governed by the same law 7 s of communication, is dysentery. By this disease I mean not that local affection of the bowels which is frequently symptom- atic of diarrhoea, and unaccompanied wqth fever, but that form of it which has been described by Sir John Pringle, Sir Gil- bert Blane, and other practical writers, under the title of epi- demic dysentery, or the dysentery of camps. This disease, like the plague, appears also to derive much of its infectious character from the condition of the atmosphere in which it takes place. In pure air, where cleanliness and ventilation are attended to, it rarely extends beyond the indi- * See Introduction to Boccacio's Decameron. t Essay on the Malignant Pestilential Fever, vol. i. p. 286. 194 LECTURE XV. vidual in whom it first originates ; but in a vitiated atmosphere, loaded with moisture, marsh effluvia, or the perspirable matter, and other excretions of the human body, especially where many persons are crowded together and in small apartments, dysen- tery communicates itself to the greater part of those who may be exposed to its influence. Zimmerman remarks, that " in general it appears to him that dysentery became contagious purely through nastiness and the crowding many people to- gether in a small space, but was by no means so of itself."* And as a further evidence that the disease was derived not from the noxious qualities of the atmosphere alone, but from contagion communicated through that vitiated medium, he also observes of the dysentery which occurred at Dettingen, in 1743, that such of the officers, among whom it was not so general as among the soldiers, as had lain wet at Dettingen, were first attacked by it ; the rest received it by contagion : but a regi- ment that had not lain in the damp, nor been exposed to the rain, remained perfectly free from it, at a small distance from the camp ; though, excepting that they were not subject to the contagious effluvia of the rest, " they breathed the same air, ate the same provisions, and drank the same water."f And in the hospital in the village of Feckenheim, about a league from the camp, the dysentery being introduced, " the air became in- fected to such a degree that not only the rest of the patients, but even the apothecary, nurses, and the other servants, with most of the inhabitants of the village, were infected."J Dr. Donald Munro, who, as an army physician, had frequent opportunities of observing the character and progress of dysen- tery, ascribes the greater violence of this disease to obstructed perspiration, moist and putrid vapours, the putrid steams of dead horses, of the privies, excrements not covered with earth, or to the unwholesome, moist, putrescent vapours of marshy or wet grounds, or pools of stagnated water acted upon by the heat of summer, and of other corrupted animal or vegetable substances, all which served to increase the infection. Hence he observes, that in camps the more hot and rainy the season, the more wet and marshy the ground, and the more the air is * Zimmerman on Dysentery, p. 20. t Ibid. p. 26. i Ibid. 139. CONTAGION, AND ITS LAWS. 195 replete with putrid vapours, the more frequent and the more fatal is the dysentery.* The remarks of Sir John Pringle are also in point on this subject. " Some dysenteries," he observes, " appear upon first taking the field, but the cases are never so bad nor nearly so frequent, as towards the end of summer ; they then become epidemic and contagious. They have always been numerous and w r orst after hot and close summers, especially in fixed camps, or when the men lay w r et after a march in warm wea- ther."! " In general the contagion does not suddenly spread ; for whole towns and camps are never seized at once from the impurities of the atmosphere ; but the infection is carried from one to another by the effluvia, or clothes and bedding, &c. as in the plague." " In camps the contagion passes from one who is ill to his companions in the same tent, and from thence, per- haps, to the next." " The foul straw," he adds, " becomes in- fectious ; but the greatest sources of infection are the privies, after they have received the dysenteric excrements of those who first sicken. The hospitals likewise spread it, since those who w r ere admitted with the flux not only gave it to the rest of the patients, but to the nurses and other attendants of the sick."J And to show that this disease is not dependent on a general constitution of the atmosphere, but upon that which is impure, and to which the dysenteric taint has been communicated, he observes of the epidemic which raged at Nimeguen, in 1736, " that none of the neighbouring towns suffered, unless by their communication with the place infected."§ Similar facts, illus- trative of the rapid extension of this disease, when introduced into ships of war, are recorded by Dr. Blane, in his valuable work on the Diseases of Seamen. That the contagiousness of typhus fever is also, in a great degree, ascribable to a similar condition of atmosphere as its pabulum, is demonstrated by facts recorded in almost every book of practice, more especially in those relating to the dis- eases of the army and navy, which have ever been found to be nurseries of this disease. The observations made upon this subject by the Linds, Pringle, Blane, Percival, Smyth, Trotter, * Diseases of the Army, vol. i. p. 314—316. t Ibid. p. 218, 7th ed. X Ibid. p. 254. § Ibid. p. 252. 196 LECTURE XV. Haygarth, Ferriar, Currie, and others, relating to the spread of this disease, when introduced into hospitals and ships of war ; its prevalence and diffusion among the poor of London, Edin- burgh, Liverpool, and the manufacturing towns of Great Bri- tain; the beneficial effects which have been derived from the establishment of fever wards, and houses of recovery ; the ad- vantages which have been experienced from the fumigating or oxygenating processes introduced by Dr. Johnstone of Wor- cester, Guyton De Morveau, and Carmichael Smyth, in arrest- ing the progress of the typhus fever — all irresistibly lead to the conclusion, that the impurities of the air constitute the fuel of this disease ; and, to use the expressive language of Dr. Ferriar of Manchester, in a late communication which I have received from that learned physician, that " dilution with atmospheric air is now ascertained to be the most effectual mean of destroy- ing contagion, and of controlling the ravages of this disease."* Were it necessary, I might adduce a volume of additional testimony on this subject. I cannot, however, omit the follow- ing pertinent remark of Dr. Haygarth, who, like another How- ard, has devoted his life to the investigation of this interesting subject ; and to whom Great Britain is indebted for the first establishment of institutions specially devoted to the important purpose of arresting the progress of contagious diseases. In his remarks on the nature of the contagion which produces putrid fevers, he observes : " I soon discovered that their infec- tious atmosphere was limited to much narrower extent than even the small-pox. So manifestly I observed this to be the case, that in a clean, well-aired room, of a moderate size, the contagious poison is so much diluted with fresh air, that it very rarely produces the distemper, even in nurses exposed to all the putrid miasms of the breath, perspiration, faeces, &c. ; whereas, in the close, dirty, and small rooms of the poor, the whole fa- mily generally caught the fever. Hence we may conclude, that in well-aired and clean apartments, the air is seldom so fully impregnated with the poison as to acquire an infectious quality."f * See American Med. and Phil. Register, vol ii. f Proceedings of the Board of Health in Manchester.— Letter from Dr. Hay= garth to Dr. Percival, p. 8. CONTAGION, AND ITS LAWS. 197 The observations of the late Dr. Willan are also in point on this subject. " Formerly," says that accurate observer, " the typhus, with petechia?, &c. often occurred in our prisons, and proved fatal to those who were under confinement in close cells, or who lodged in crowded apartments. Mr. Box, surgeon of Newgate, informs me that the fever has been rendered less frequent there, and less virulent, by removing the persons first affected into airy rooms, or wards, and by a general attention to ventilation, cleanliness, &c. ; so that, at present, petechia? do not appear in more than one case in thirty."* And of three hundred and seventy-nine patients committed into the London House of Recovery, says Dr. T. Bateman, nine only, or about one in forty-two, were affected with petechiae.f * Willan on Cutaneous Diseases, p. 469. t Ibid. 18 198 LECTURE XVI. CONTAGION, AND ITS LAWS. The facts which have been ascertained relative to the communication of yellow fever, furnish no less conclusive evidence that this disease, like those already noticed, is, or is not, generally contagious, depending on the qualities of the air to which it may be communicated. The history of every visitation of the disease in the United States, establishes this truth. It has not only regularly made its first appearance in our sea-port towns, and in those places where the air is most impure; at that period of the year, and in those seasons when such impurities acquire their greatest virulence; in those houses which are most crowded with inhabitants, and were there is the least attention paid to cleanliness ; but, wherever the same disease has been thence conveyed to other parts of the same city, or town, or into the country, it either was propagated or extinguished, according to the local circumstances of the place to which it was so conveyed. 1st. Dr. Lining, in his description of the yellow fever which was introduced into the city of Charleston in 1732, 1739, 1745, and in 1748, observes, that, although the infection was spread with great celerity through the town, yet, if any from the country received it in town, and sickened on their return home, the infection spread no further, not even so much as to one in the same house. He remarks, that the disease was generally more fatal to those who lay in small chambers not conveniently situated for the admission of fresh air.* * Edin. Phys. and Lit. Essay, vol. ii. p. 408, 427. CONTAGION, AND ITS LAWS. 199 2d. The yellow fever with which the city of New York was visited in 1791, and which was introduced by a vessel from the West Indies, and rendered memorable by the death of one of our most respected citizens, General Malcolm, who was the first victim to the epidemic of that season, is thus re- corded by Dr. Jonas Addoms, in his excellent dissertation on that disease : " About the middle of August, 1791, a contagious fever ap- peared in the city of New York, which first discovered itself near Peck-slip, a part of the city thickly inhabited, its houses generally small, and badly ventilated ; many of the inhabitants were in indigent circumstances, which is a frequent cause of the want of cleanliness. Here it raged a considerable time ; it then began to spread, as some attendants on the sick became infected who lived in other neighbourhoods. By this means it was car- ried to other families, and most generally could be traced to this source. It likewise proved more particularly fatal near the place where it first appeared, than in any other part. Thus at length it spread through the city, until about the middle of October, w T hen the weather growing a little cooler, the disease greatly abated, and in a short time totally disappeared."* Dr. Addoms, the author of that dissertation, since that time resided many years in St. Croix, and being associated with a celebrated physician of that island, the late Dr. Gordon, had ample opportunities of seeing the yellow fever in all its forms. During his last visit to this city, not long before his death, he informed me that the disease which he had seen in New York in 1791, w'as precisely the same which he afterwards saw in St. Croix, and which frequently prevailed during his residence there, more especially among Europeans newly arrived within the tropics. He also remarked, at the same time, that this disease always acquired new virulence, and was rendered highly contagious, when introduced among soldiers crowded in barracks, or on shipboard. 3d. In the yellow fever of 1793, which was introduced into the city of Philadelphia from the West Indies, it is conceded, on all sides, that the disease made its first appearance in Water street, and that all the cases of this fever were, for two * Inaugural Dissertation on Yellow Fever, p. 7. 200 LECTURE XVT. or three weeks, evidently traced to that particular spot. It is also a fact well ascertained, that in the vicinity of the place where the infection was first received, the air was, at the same time, in a very offensive condition, from a quantity of damaged coffee which was exposed upon the dock, and under circum- stances favourable to its putrefaction and exhalation. From that place the disease gradually infected a considerable part of the city, the Northern Liberties and district of Southwark, and did not subside until terminated by frost, after having been fatal to nearly five thousand persons. It is also to be remarked, that its ravages were chiefly confined to the poor, and to those parts of the city where the houses were small, and the least attention given to cleanliness and ventilation. In the language of Mr. Carey, " it was dreadfully destructive among the poor. It is very probable that at least seven-eighths of the number of the dead were of that class ; the inhabitants of dirty houses have severely ex- piated their neglect of cleanliness and decency by the number of them that have fallen sacrifices. Whole families, in such houses, have sunk into one silent, undistinguishing grave. The mortality in confined streets, small alleys, and close houses, debarred the free circulation of air, has exceeded in a great proportion, that in the large streets, and well-aired houses. In some of the alleys a third or fourth of the whole of the inhab- itants are no more. The streets in the suburbs that had the benefit of the country air have suffered little. It is to be par- ticularly observed that, in general, the more remote the streets were from Water street, the less of the calamity they expe- rienced."* " Though the disease," says Dr. William Currie, " was highly contagious, the influence of the contagion was circum- scribed to a narrow sphere."! As a further evidence that it did not depend on a general condition of atmosphere, the same author remarks, " that while this formidable disease was making such ravages in the city, the country, for some miles around, was never more healthy. "J In another work Dr. Currie has very explicitly * Carey's Account, 4th edit. p. 61, 62. t Treatise on the Synochus Icterodes, p. 8. X Ibid. p. 11. CONTAGION, AND ITS LAWS. 201 admitted the qualified contagiousness of yellow fever, observ- ing, " that it is only contagious in situations where the air is confined, and the exhalations of the sick are permitted to accumulate, through neglect of frequently changing the bed and body linen of the patient."* 4th. Similar facts are recorded of the visitation which New York experienced of the same disease in 1795. Upon another occasion I shall make public the evidence which is in my possession, indisputably proving the importation of the yellow fever of that season from Port-au-Prince. In that year the disease appeared upon the east side of the city, first affecting some seamen who had received the infection from a brig directly from Port-au-Prince ; from thence it spread in the vicinity from Dover street to Peck-slip ; but throughout that season it was confined, in a great degree, to that part of the town where the local condition of the atmosphere w r as peculiar- ly favourable to its diffusion ; for not only an unusual quantity of filth was accumulated in Peck-slip, but at that very time a great number of emigrant poor had arrived from England, Ireland, and Scotland, so that the numerous lodging houses, especially in that neighbourhood, w r ere unusually crowded; add to this, that the weather was uncommonly moist, and thereby particularly calculated to spread the infection. Accord- ing to the statement made by Dr. Bayley, it was especially fatal to the emigrants of that very summer ; for " out of nearly eight hundred persons who died," he observes, " not more than one hundred and fifty were citizens of New York."f In another part of the same statement he remarks : " So limited was the operation of the contagion, that the number of those taken sick in low situations, compared with those re- siding in more elevated parts of the city, may be computed as twenty to one."J 5th. In 1798 New York was again visited with this scourge of our sea-port towns : during the months of August, Septem- ber, and October, about two thousand persons fell victims to this disease, at the end of which time a keen frost put an * See Observ. on the Yellow Fever, in the Philad. Med. and Phys. Journal, vol. ii. part 1. t See Bayley on the Epidemic of 1796, p. 90. t Ibid. p. 80.— See also Letters to Dr, Buel by E. H. Smith. 18* 202 LECTURE XVI. almost instantaneous termination to its progress. The disease of that season first appeared at the ship-yards, in the neighbour- hood of New-slip, and, as in former years, was introduced from the West Indies.* After cutting off several persons in the neighbourhood in which it commenced, the same vessel was removed to the CofYee-House slip, also on the east side of the city; from thence the disease was communicated by those who worked on board to a thickly-settled part of the city, where the houses are small, the streets narrow, and chiefly occupied by the poor ; viz. Cliff street, John street, Ann street, Fair street, Eden's alley, and Rider street ; at the same time, however, it still continued to extend its ravages in the vicinity of the place to which the poison had been first communicated; and to some other thickly-settled parts of the town, to which it was subsequently conveyed. In a short time afterwards it was introduced into Pearl street, and in that part of it be- tween Burling and Peck slips, where it spread very extensive- ly. In that season a number of circumstances occurred to diffuse the contagion in that part of the city ; a great quantity of rain had fallen, so as to overflow the cellars in Pearl street, which were, at the same time, stored with salted provisions ; these were soon afterwards spoiled, and loaded the atmosphere with a highly offensive vapour; the disease raging at that time in that neighbourhood, acquired new virulence, and, for the most part, followed the course of the vitiated atmosphere ; " beyond the limits of which," says Mr. Webster, " the disease exhibited little infection :" indeed the extension of this disease, as has already been frequently observed, was so circumscribed within the limits of this impure air, that it became very gene- rally believed that, in that season, whatever may have been the case in former years, the disease exclusively arose from those domestic sources, more especially from the putrid provisions. But that the yellow fever of that season did not derive its origin from the spoiled beef is evident, not only from the fact that the disease had already previously appeared in other parts of the town, and even in that very neighbourhood, before those heavy rains had fallen, and their pernicious effects * See Statement of Facts on this subject by the Rev. Dr. M' Knight, in the Amer. Med. and Phil. Reg. vol. iii. CONTAGION, AND ITS LAWS. 203 were perceived ; but also that those tainted provisions, un- accompanied with the specific poison of the disease, did not of themselves communicate infection to those who were con- stantly exposed to their effluvia. Mr. Edmund Prior, the inspector-general of beef at that time, informed me, that of forty persons whom he had employ- ed in examining the beef, and in removing and emptying such barrels as were found in a putrid state, not one was taken ill of the yellow fever. But Dr. Chisholm and Dr. Stewart have abundantly shown, that decomposed animal or vegetable matters will not, of themselves, produce the pestilence ; and that this disease is generated in the human system, and com- municated from one person to another, by a peculiar secre- tion from the morbid body. My object is to show, that when such virus is introduced into a certain state of atmosphere, the disease is readily multiplied and communicated, but that be- yond that atmosphere it is rarely infectious. Although the diseases which have been noticed are rarely communicable in pure air, and are not generally contagious in the country, it is not less true, that in some few instances it appears either that the virus, as secreted from the diseased body, is alone in sufficient quantity, or possesses a sufficient degree of virulence, to reproduce such diseases; or, that by means of the impurities collected about the diseased individual, occasioned by inattention to cleanliness and change of clothing, the retention of his excretions, or the confined air of his apart- ment, the virus itself becomes multiplied, and thereby the means of communicating the disease from one to another are in some degree increased: for it is a fact not to be questioned, that instances of yellow fever, as well as of the plague, dysentery, and typhus fever, have been occasionally infectious, even in the more pure air of the country, though it must be acknowledged that such cases are of rare occurrence. It is observed by Dr. Rush, whose records of the several visitations of the yellow fever in the city of Philadelphia will be lasting monuments of the facts which they contain, as well as the impressive and eloquent manner in which they are related, " that out of upwards of one thousand persons who have carried this disease into the country from our cities, there are not more than three or four instances to be met with 204 LECTURE XVI. of its having been propagated by contagion."* Such instances, however, have occurred in New Hampshire, as related by Dr. Spalding ;f in Connecticut, as stated by Dr. William Moore, of this city;J on Staten Island, in 1798, as recorded by Dr. R. C. Moore,§ now the venerable bishop of Virginia; at Huntington, on Long Island, in 1795 and 1798 ;|| and at Germantown, in the vicinity of Philadelphia, as related by Dr. Wistar.H But these very exceptions, if they can with propriety be denomi- nated exceptions, manifestly prove the specific character of those diseases, and that they are propagated by a specific secretion peculiar to each disease, whether it be plague, dysen- tery, or yellow fever. Indeed, to use the emphatic expression of the Edinburgh Reviewers on this subject, " In the present state of medical knowledge, it would not be at all more absurd to deny the existence of fever altogether, than to maintain that it is not propagated by contagion."** But, in the language which Dr. Mead has applied to the plague, we may say of all the diseases of this class, " that a corrupted state of the air is, without doubt, necessary to give these contagious atoms their full force."ft If it were necessary, I might go on to cite every return of the yellow fever with which the United States have been visit- ed, to show that the progress of the pestilential poison has ever been commensurate with the impurities of the atmosphere, and that, when sufficiently diluted with pure air, it ceases to propa- gate itself. It is probably owing to this impure condition of the atmo- sphere that the various fevers, and the greater mortality of diseases in general, are to be ascribed, which physicians have frequently observed to precede the appearance of pestilential disorders, and to announce their approach, and which have led many to conclude that the pestilence itself was thus engen- dered by local circumstances, and not imported. * Observations on the Origin of the Yellow Fever of 1799, p. 12. t Med. Repos. vol. iii. p. 8. X Addoms's Disser. p. 7. Amer. Med. and Phil. Reg. vol. ii. p. 177. § Ibid. vol. ii. p. 22. II Ibid. vol. iii. p. 191. f Additional Facts and Observations by the College of Physicians of Philadel- phia, p. 30. ** Edinburgh Review, vol. i. 246. ft Mead's Medical Works. CONTAGION, AND ITS LAWS. 205 Facts of this nature have served to mislead the editors of the Medical Repository, and many other late writers, who thus confound the exciting and predisposing causes of disease; who do not discriminate between the inflammable materials, and the spark which lights the flame; but have identified the domestic circumstances which have served to diffuse the poison of yellow fever, with the peculiar virus itself, by which that disease has been introduced into the various cities of the United States. The same local circumstances, I believe, will go far in accounting for the " pestilential state of the air," the " secret constitution of atmosphere," so often recorded by writers on epidemics; at the same time that they teach us, that the diseases now under consideration are only epidemic in as far as the vitiated state of the air is itself epidemic. I however wish it to be understood, that I do not exclude the influence of bodily predisposition, the passions of the mind, and many other circumstances, in aiding the propagation of pestilential diseases. Having, as I trust, shown, by the facts that have been ad- duced, that the plague, dysentery, typhus and yellow fever, constituting the third class of contagious diseases, require an impure state of the air to diffuse and multiply them, the ques- tion next presents itself, in what manner does such impure air operate in spreading those diseases ? Upon this part of the subject I have the misfortune to differ from Dr. Chisholm, no less than I do as to the necessity of such an atmosphere to propagate the peculiar poison of each of those diseases. Dr. Chisholm observes, that if the proposition had been advanced, " that those diseases, particularly the pestilential yellow fever, are rendered more violent in the action under the circum- stances stated of an impure atmosphere, that no possible objec- tion could be made to it, inasmuch as it is supported and proved by all experience ;" and he proceeds to express the opinion that such an atmosphere may have an effect " by rendering the system of the healthy person, who receives the poison from the sick, more susceptible at the moment of its introduction, of its peculiar action ;" but that this multiplying power does not proceed from any action of the air upon the peculiar virus of those diseases ; that " it does not proceed 206 LECTURE XVI. from the impure atmosphere becoming assimilated to the poison introduced." That air, deprived of its due proportion of oxygen, and load- ed with mephitic materials, especially the confined excretions of the human body, will vitiate the mass of circulating fluids, and impair the functions of the nervous system, cannot be denied ; that the febrile diseases with which the system may be affected while in this state, will acquire an extraordinary degree of malignancy, will also be readily conceded ; but that such condition, either of the atmosphere or of the human system, increases its susceptibility to be acted upon by the virus of those contagious diseases, composing the third class, does not correspond either with the facts which have fallen under my own observation, or with those I have been enabled to obtain from the writings and observations of others. The well known facts relative to the communication of " jail fever" to the judges presiding at the Black Assizes, in 1577;* and a similar infection being communicated to the judges on the bench, and other persons present, at the sessions held at the Old Baily, in 1750, while the prisoners themselves remained in health, insensible to infection, furnish incontestible evidence of the effects of habit in diminishing the insensibility to the poison of fever. And with regard to the yellow fever, it assuredly has not been the case in the United States, that those who are most accustomed to the impure air of the place in which the disease prevailed, were more susceptible of the disorder than those who had recently arrived from the pure air of the country, or from the more elevated parts of the town. On the contrary, those who were least accustomed to the impure air of the city, or of the infected spot, were uniform- ly observed to be most susceptible of the contagion. Those, too, who enjoyed the most vigorous health, and the most ro- bust constitutions, the reverse of that condition of body which would be the effect of residence in impure air, were more readily infected upon coming into the atmosphere impregnated with the contagion, than those who had remained constantly exposed to its influence. Whatever differences of opinion have existed among the physicians of the United States as to * Bacon's Works, vol. ii. Stow's Chronicle. CONTAGION, AND ITS LAWS. 207 the origin of the disease, they all perfectly agreed relative to the facts which I have just stated. Indeed, Dr. Chisholm him- self inadvertently admits the same to be true ; for he observes, that, in the West Indies, sailors, soldiers, and young men, especially those who had recently arrived from Europe, and are least accustomed to the climate, were more obnoxious to it than others.* Dr. Gordon, and indeed all the most distinguished practical writers on this subject, concur in the same observation. " New comers," says Dr. Gordon, in the appendix to Dr. Chisholm's late valuable letter to Dr. Haygarth, " were infected with the pestilential fever, while the old seasoned soldiers had only the tropical remittents ; and this was universally the case whenever both diseases were at the same time epidemic."f A similar and still more general observation on the predisposition of those who are unaccustomed to impure air, is made by Dr. Blane. " Infection," says he, " like some other poisons, does not so readily affect those who are accustomed to it, and there- fore those who are in the habit of being exposed to it frequently escape its bad effects." For the like reason, he adds, " physi- cians and nurses are less susceptible than others ; and strangers, who are accustomed to a pure air, are the most susceptible of any."J With these facts and observations before us, we are compelled to conclude, that the impure air necessary to propa- gate the contagion does not operate in the manner Dr. Chisholm supposes, by " increasing the susceptibility of the system to the action of the poison introduced." On the contrary, I believe that it produces its effects by some chemical combination with the peculiar virus secreted from the diseased body, and that thereby the contagion becomes more or less extensively multi- plied, according to the extent and virulence of such vitiated atmosphere. I shall not attempt to define the precise nature of the chemi- cal union which takes place under such circumstances. But I wish it to be distinctly understood, that in such combination, I do not believe, with those writers who contend that a tertium quid is produced ; or, as Dr. Adams of London, in his late * Chisholm's Letter to Haygarth, p. 182, &c. t Ibid. p. 220. X Diseases of Seamen, p. 223. 208 LECTURE XVI. publication on epidemics, has reiterated the same idea, " that a new kind of air is generated."* On the contrary, as far as I am enabled to view the subject in connexion with the facts usu- ally observed during the prevalence of the diseases which have been noticed, I am inclined to believe, that in this combination the peculiar virus of those diseases is in no way changed, but multiplied ; and that this multiplying power is a process very analogous to that which we observe to take place in the assimi- lation of the fluids of the human body to the peculiar taint which may be introduced into the system, as for instance, in small-pox and syphilis ; or, perhaps, that it more nearly resem- bles the process of fermentation, as it occurs in inanimate mat- ter. By both these processes such an assimilation takes place in the fluids acted upon, whether of the living body or in dead matter, that they partake of the same properties with the virus or ferment introduced, and are thereby rendered capable of renewing the same process in other bodies under similar cir- cumstances. This process has very properly been denominated by Dr. Walkerf the assimilating fermentation,J and has been no less successfully employed both by him and by Mr. Cruik- shank,§ as well as by Dr. Cullen, to explain the changes which take place in the living system, acted upon by small-pox, and the virus of other contagious diseases, than it has been by Sir J. Pringle,|| Macbride,^ and Alexander,** to the phenomena of fermentation, as it occurs out of the body. The history of plague, dysentery, and typhus fever, as well as the recent ob- servations in animal chemistry, furnish a variety of facts which may be adduced in illustration of such fermentative process taking place in the atmosphere, and in watery fluids loaded * Adams on Epidemics, p. 11. t Walker's Inquiry into the Small-pox. t This assimilating process is, I perceive, adopted by Dr. Good in his late very learned work, (see vol. ii. p. 546-7.) "All," says he, "concur in evincing the ex- istence of morbid and specific poisons in the blood, acting the part of animal ferments, converting the different fluids into their own nature, exciting the com- motion of fever, and being eliminated on the surface, as the best and most salu- tary outlet to which they can be carried by the very fever which they thus excite." § Anatomy of the Absorbing Vessels. || Diseases of the Army, Appendix. IT Experimental Essays. ** Experimental Essays and Experimental Inquiry. CONTAGION, AND ITS LAWS. 209 with the excretions of the human body, or the vapours of veget- able and animal substances in a state of putrefaction. Similar facts, illustrative of the fermentative process con- tended for, have been observed whenever the yellow fever has prevailed in any of the cities or towns of the United States. I have already stated, that this disease has always prevailed in proportion to the presence of such fermentable materials. It. is no less true, that whenever the disease has been introduced, it has spread in the greatest degree in those seasons when the air was unusually moist : this was remarkably the case in New York, in 1795* and 1798,f and in Philadelphia, in 1793 and 1798 :J and that the yellow fever has prevailed in the United States in those seasons when the heat, combined with moisture, was most favourable to such assimilating or fermentative pro- cess, is also proverbially true. It is also to be observed, as universally admitted, that the same disease has uniformly been extinguished by the approach of frost, which destroys such fer- mentative process. Another argument in favour of this explanation is derived from the fact, that this disease has, in several instances, been introduced into our cities without extending beyond the indi- viduals who have introduced it ; manifestly owing to the active exertions of a vigilant police, at the same time that every at- tention was paid in preserving cleanliness about the persons of the sick. This was remarkably the case in the year 1804, when the yellow fever was introduced at the Wallabout, on Long Island; and in 1809, when the same disease prevailed at Brooklyn. In each of those years the fever was introduced into this city by -persons who had received the infection on Long Island; but, owing to the circumstances just mentioned, it was not communicated to others : "while the same disorder, owing to local circumstances, spread in the vicinity of those places on Long Island where it had first appeared. § During the year 1811, the yellow fever was also introduced into the city of Amboy, New Jersey, from the Havana, but did not spread beyond those persons who were first attacked in * See Bayley on the Yellow Fever of 1795. t Hardie on the Yellow Fever of 1798. t See Rush and Carrie. § American Med. and Phil. Reg. vol. ii. p. 95, &c 19 210 LECTURE XVI. consequence of their immediate exposure to the air of the in- fected vessel. The local circumstances of Amboy, its elevated situation, its dry and sandy soil, its wide streets and spacious houses, their distance from each other, and the remarkable cleanliness of the town, most satisfactorily account for the sud- den extinction of the disease, while the evidence of its importa- tion must be admitted to be conclusive.* But there is another circumstance which particularly merits attention. In every epidemic visitation of the yellow fever, several days, viz. from eight to twelve, or fourteen, have gene- rally elapsed between the first cases that appeared, and the communication of it to other persons, even in the same neigh- bourhood : insomuch that not only our citizens, but our physi- cians themselves, have been led to doubt the existence of the disease, and to stigmatize as alarmists those who first announced the deadly visiter. I can never forget the occasion, in 1795 ? when that venerable and experienced physician, the late Dr. John Bard, assembled the physicians of this city to announce to them the first cases of this disease which he had observed in the family of his friend, Mr. Jenkins. The physicians met ? but declared they had seen no other fevers than what they had been accustomed to observe every year, and even doubted, on that occasion, the correctness of Dr. Bard's observations, rela- tive to the nature and character of the disease to which he called their attention : but that accurate observer had been too familiarly conversant with the yellow fever as it appeared in New York in 1743 and 1762, and too well knew the pathogno- monic symptoms of that disease, to confound it with the fevers of our own climate : he, accordingly, in the most emphatic language, replied to their doubts; "Gentlemen, within a fort- night you will all see and acknowledge the West India yellow fever to exist in our city." The event is well known.f The same interval between the first cases of the disease, and its subsequent diffusion in the neighbourhood where it first made its appearance, is noticed by almost every writer who has re- corded the yellow fever in the United States. * See American Med. and Phil. Reg. vol. iii. Also, Edinburgh Med. and Surg. Journal, and the Med. and Phys. Journal of London. tSee Bayley and Hardie on the Epidemic of 1795.. See also Currie on the Fever of 1799. CONTAGION, AND ITS LAWS. 211 A similar interval has been frequently noticed in the history of the plague. Dr. Russel, in his account of the plague of Marseilles, in 1720, observes, " that from the 12th of June to the 23d there was a deceitful pause, during which the popular apprehensions began to subside. The physicians were re- proached with ignorance in having mistaken ordinary fevers for the plague. The disease, however, in this interval, had continued to spread in the Rue de l'Escale, w-here it made its first appearance."* It has also been remarked of the plague, as well as of the yellow fever, that the infection spread most rapidly when the atmosphere was not only heated and loaded with moisture, but when it was least agitated by wind or thunder-storms. During those calms, w T hen the air may be said to be relatively at rest, it has been uniformly remarked, that the contagion of the yel- low fever has multiplied itself most extensively, as was always very apparent by the greater number that were seized within five or six days after such close weather had been observed, all which circumstances certainly conspire to promote the ferment- ative process that has been contended for. This is not all : whenever the yellow fever has been intro- duced into the cities of the United States, its first extension has always been slow and gradual. Upon several occasions its boundaries have been accurately defined by our board of health. This, as I have stated on a former occasion, was remarkably the case in this city in 1805. The disease, in that year, was confined, for some weeks, to a small portion of the eastern side of the city, and, as stated by the board of health, " not a case occurred in any part of the town, that was not referrible to that as its source.'*f This fact being ascertained, the board accordingly forbade intercourse with the infected portion of our city, and ordered an abandonment of that part of the town, threatening violent measures if their orders were not immedi- ately complied with. In a short time after, the infection ex- tended a few streets further ; the board of health again defined its limits, and again declared that still not a case had occurred that could not be traced to this part of the city as its source. * History of the Plague. t Hardie's Account of the Malignant Fever of 1805. 212 LECTURE XVI. Will not the same assimilating or fermentative process furnish the most satisfactory solution of the fact noticed by Boerhaave, Cullen, Lind, Russel, and many others, that fomites are more to be dreaded than the excretions alone proceeding from the diseased body? Not, however, in the manner those authors suppose, that such fomites acquire greater virulence ; but, that by the same process, the specific poison has been more extensively multiplied by means of the atmosphere and foul ex- cretions which are involved in the clothing worn by the sick ; that by the same means the danger of the infection has been increased in the same degree that the poison has been multi- plied. As a further evidence, too, that the contagion is multiplied, but not more concentrated, as those writers have imagined, it is a fact established by every writer on those con- tagious diseases, that the first cases of every epidemic are uniformly the most fatal ; but that, as the season advances, the danger of taking the disease is increased, while the disease itself has, perhaps, become even milder than it was in the com- mencement. Let me further ask, do not the processes lately introduced for disinfecting the air by means of the fumes of the acetic acid, the oxygenated muriatic acid gas, the nitric and sulphuric acid vapours, operate by making new combinations with some of the ingredients constituting the tainted atmosphere, and thereby decomposing the morbid compound 1 According to Dr. Crawford, " the fluids which destroy the foetid odours most speedily are those which are acknowledged to contain the greater portion of oxygen, and it is, therefore, extremely pro- bable that this change depends on the union of the oxygen with animal hepatic gas, or some one of its constituent parts." But the explanation which has been offered by the late Dr. Garnett, of the manner in which the oxygen thus employed combines with the hydrogen gas which holds the morbid secretions in so- lution, appears to me the most satisfactory explanation that has been given of those phenomena.* From these facts I have been led to conclude, * Proceedings of the Board of Health of Manchester, p. 40 — 42. Robertson's Treatise on Medical Police, vol. ii. p. 127. Robertson's Natural History of the Atmosphere, vol. ii. p. 352, CONTAGION, AND ITS LAWS. 213 1st. That an impure atmosphere is indispensably necessary to multiply and extend the specific poison constituting plague, dysentery, typhus, and yellow fever. 2diy. That the impurities of the atmosphere do not produce their effects in the manner suggested by Dr. Chisholm, by in- creasing the susceptibility of the system to be acted upon by the peculiar virus of those diseases. 3dly. That, instead of predisposing the body to be thus acted upon, the reverse is the fact ; that the predisposition of those who are most exposed to such impure air is less, while those who reside in the pure air of the country are most liable to be infected when exposed to the contagion. 4thly. That the impurities of the atmosphere are fermentable materials, to be called into action by the specific ferment of those diseases, aided by heat, moisture, and a calm state of the atmosphere ; and that as far as such atmosphere extends, and the circumstances favourable to such fermentative or assimi- lating process continue, so far those diseases become epidemic, but no farther. The same idea of an assimilating process appears to be ex- pressed by Lucretius, when, speaking of the contagiousness of the plague, he observes, " Proinde, ubi se caelum, quod nobis forte venerium, Conmovet, atque aer inimicus serpere ccepit Ut nebula ac nubes paullatim repit, et omne, Qua graditur, conturbat, et immutare coactat. Fit quoque, ut in nostrum quum venit denique caelum Conrumpat, reddatque sui simile, atque alienum." Lucretius, de Nat. Rerum, lib. vi. Or, as it has been rendered by that learned surgeon and ac- complished scholar, John Mason Good, Esq. " But when the heaven of poisonous power to us, First moves remote, its hostile effluence creeps Slow, like a mist or vapour ; all around Transforming- as it passes, till at length, Reach'd our own region, it the total scene Taints, and assimilates, and loads with death." If the view which has been taken of this subject be correct, a still more important truth is the result ; that, while by a rigid 19* 214 LECTURE XVI. and well executed system of quarantine laws, we have it in our power to guard against the introduction of the spark that kin- dles the flame, we are also enabled, by means of domestic cleanliness and ventilation, to extinguish it when introduced. For this purpose our magistrates and guardians of the public health cannot be too attentive in their police regulations to have all noxious materials removed from our streets and our dwell- ings ; and, at the same time that they are ornamenting our cities by the erection of magnificent buildings, and the intro- duction of other important improvements, they should also avail themselves of every opportunity which may present of widen- ing our streets, and of reserving squares and other pieces of ground to be ever kept vacant, as among the most effectual means of preserving the health of our citizens, and guarding against the propagation of contagious diseases. to ni\ct», to inflame, denoting perhaps the extraordinary heat of this form of disease ; or it may be referred to the inflammatory stage that frequently precedes it. His eyes become insensible to light — they remain half closed. His senses, indeed, are variously disturbed, sometimes exces- sively alive to impressions ; at other times he is totally insen- sible — sight, hearing, taste, smell, feeling, are all morbidly affected ; indeed, all these senses are in a state of paralysis. Great restlessness, perhaps coma, succeeds. Subsultus tendi- num and delirium follow — even his sleep is disturbed by dreams. This determination is more especially troublesome at night, but not so early in the day. Involuntary discharges, too, take place by urine and faeces. These, too, become more offensive, as well as his breath, and the other discharges. The cause of this con- tinued irritation is now referrible to the first exciting cause, as miasma or contagion ; to the condition of the fluids, induced by the retention of the natural excretions; by the absorption of the vitiated secretions and excretions; and, possibly, by some change which may have been wrought by the vascular system itself upon the fluids. If the vessel operates upon its contents in the process of secretion, it certainly may also act upon the circulating fluids. Indeed, we have the evidence of some such action in the changes effected in the lacteals, and in the process of san- guification. The effects of climate and season are also to be taken into consideration, in accounting for the obstinacy and the duration of the fever, and the changes now taking place in the system. Another possible source of such vitiation is, perhaps, to be found in the atmosphere to which the patient 24 270 LECTURE XXI. may have been exposed, as in prison, on board ship, in a crowded hospital, or in a garrison. Puerperal fever at Aberdeen, and at Edinburgh, is thus ren- dered typhoid in the lying-in wards of the infirmary, owing to the presence of typhus fever, which gives that type or charac- ter to every inflammatory disease, especially puerperal fever. Hence the difference of opinion among writers, relative to the inflammatory or the typhoid character of that disease ; some contending for its exclusive inflammatory type, others that it is always of a putrid tendency. Even the want of cleanliness in some private families, gives a malignancy to a disease that is not otherwise of that character. Dysentery, by such neglect of personal cleanliness, is thus rendered contagious, even in the otherwise pure air of the country. The confinement of the sick to small and unventilated apartments, or want of personal cleanliness in the individual, will furnish a solution of the phe- nomena which are now exhibited in the typhoid state of fever. What, then, are the means of arresting its progress, and of counteracting this condition of the system 1 These will be the subjects of the ensuing discourse. 271 LECTURE XXII TREATMENT OF THE TYPHOID STATE OF FEVER The treatment of the typhoid state of fever now falls under our notice. Dr. Sims remarks : 'I shall ever fear a physician is in fault if a person dies of a fever, to whom he has been called whilst any degree of strength remained, and the patient could be obedient to his directions."* But notwithstanding this obser- vation of Dr. Sims, there is no situation where the judgment, the skill, and the attention of the physician are in greater demand than on this occasion. There is no stage of fever more embarrassing for the young practitioner, than that which is now to be considered. But I hope to give you some facts on this subject that will prove useful to you at the bedside of the sick. I very early found them so to myself, and have since had good reason to be confirmed in their correctness. How is this typhoid state of body to be counteracted ? — In what does it consist? You will remember it consists — 1st. Of debility, the effect of the long-continued preceding excite- ment ; and consequently, as the attendant upon that debility, an increased susceptibility to impressions. 2d. In a certain degree it is constituted by a putrescent state of the system ; for both of these conditions of body exist at the same time. The indications then corresponding with this state of the solids and fluids are likewise two-fold. I. To counteract the debility which keeps up the irritable or excitable state of the system. * Sims' Observations on Epidemical Diseases, &c. p. 87. 272 LECTURE XXII. In this disease, as before remarked, the heart and arteries are more susceptible to impressions, owing to the debility of the system. Hence it appears, that the least bodily exertion of the patient, or the least mental irritation, excites his heart and ves- sels to more frequent action. Under these circumstances, the hasty observer prescribes the means of depletion, and those narcotic and other medicines usually denominated sedative, as for a disease of supposed simple excitement. But this sensi- bility of nerve, this hurried circulation and quickened respira- tion connected with it, (for it shows itself in the heart and vessels no less than the other parts of the system,) are only to be removed by stimulants, both diffusible and permanent: they only can counteract this state of the system. This is to be done, not by a continuation of depleting or evacuant medicines; not by the sedative effects of opium, camphor, digitalis, and other remedies of this nature, so generally resorted to in con- sequence of the stimulant operation which these narcotics are supposed to possess. Opium, administered as it is ordinarily given in typhus fever, like foxglove in dropsy and consump- tion, proves indeed an anodyne to your patient, for it is the passport to the grave. At least, such has been my observa- tion of its effects ; but examine for yourselves. Even opium and wine combined, and which are so frequently employed, are of doubtful effect ; it may however happen that the wine by its stimulant operation, if given in large quantities, may be suffi- cient to counteract the sedative operation of opium. Nor will camphor be found more useful ; on the contrary it is equally debilitating with opium. Its sedative and deleterious effects on the whole system are well ascertained. I have therefore proscribed them both from my practice in the advanced state of fever, with the exception of administering opium as an occa- sional anodyne, or for the purpose of restraining diarrhoea ; but the repeated doses of it which some physicians are in the habit of prescribing, on account of its supposed stimulant effects in preserving the tone of the system, cannot in my opinion be too severely reprobated. Nor is this febrile excite- ment to be removed by persisting in the use of mercury, so frequently and so indiscriminately prescribed in this state of body. Small doses of calomel and antimony may be advan- tageously administered as alteratives before great prostration TREATMENT OF FEVER. 273 has taken place, and especially when the bowels are confined : but if they afterwards be continued, they should be given in conjunction with small doses of opium to secure their opera- tion upon the surface, and to prevent their effects upon the bowels. But if you depend upon the mercury's salivating the patient at this period of the disease, you will be frequently dis- appointed. The evacuations it occasions from the bowels will alone frequently run off the strength of the patient ; and even where salivation takes place, I have known the fever, neverthe- less, to prove fatal. The late Dr. Laurence fell a victim to the fever of 1798, notwithstanding a salivation was obtained. In some instances, too, it has happened that although salivation has been effected, the patient has sunk under diarrhoea, which has succeeded to this use of mercury. But it must be acknow- ledged that it is a very rare occurrence, that the patient has not recovered where salivation was induced ; but in nine times out of ten, nay nineteen out of twenty, you will fail to induce a sali- vation in this state of the system, in which case the remedy pro- duces irreparable injury. The debility then of the solids is only to be safely counteracted by the free use of stimulants, including both the diffusible and those permanent stimulants called tonics. The diffusible stimuli advisable in this state of things, are the vol. alkali and aether. In case of stupor or coma frequently attendant on the typhoid type, and in the typhoid state of peripneumony, the vol. alkali is particularly indicated. I had a case of the former in the state prison, where the pressure on the brain was such as to reduce the pulse to twenty and thirty strokes, and in all other respects the symp- toms of this state of fever existed in an alarming degree. In this case, the vol. alkali was followed by the most decidedly good effects. In like manner, in every obstinate case of perip- neumony, the most beneficial effects were obtained from the use of this medicine. In the typhoid form of that disease, this medicine may be given in various forms ; it may be given in bolus of v. gr. or vi. gr. of the carbonate of ammonia made up with the conserve of roses ; or dissolve 3i. in gvi. of mint water, and add gss. of lavender to the mixture — ^ss. to be given every two hours ; or it may be administered in the form of aq. ammon. xv. gtt. or xx. gtt. every two or three hours in the drinks of the patient, or in sweetened water. Or it may be 24* 274 LECTURE XXII. prescribed in the sp. ammon. or the sp. amnion, aromat., which is the most elegant form of giving that medicine, and is most grateful for internal use. iEther, either the sulphuric, or that form of it called the anodyne liquor of Hoffman, may also be given in the typhoid state of fever, especially for the removal of delirium and sub- sultus tendinum, with the best effects — from twenty to sixty drops of this liquid should be frequently administered, say every two or three hours, in a little sweetened water. From its temporary effects in this agitated state of the system, it is called the ano- dyne liquor. The lavender compound is another valuable sti- mulus to be administered under such depression of the vital powers as above, and aether may also be combined. But we must not rely upon the diffusive stimulants alone. Tonics are also to be given in this prostration of the system. Bitters, in the form of the infusum amarum, prepared with water, or the tinctura amara, (i. e. tinct. gentianse composita, consisting of gentian root, orange peel, canella alba or cardamom, seeds,) rendered more grateful by the addition of a small quantity of the sp. lavand., should now be given. This last form, with children, and in persons of a very delicate state of the stomach, is that preferred ; but under other circumstances you will find the following formula to embrace all the advantages to be ex- pected from bitters. You will recollect the propensity to fer- mentation in the stomach, when thus debilitated, and you will also keep in mind the necessity of regular evacuations from the bowels. The formula referred to combines all the means ne- cessary for the purpose of controlling such fermentation when excessive, and of preserving the peristaltic motion of the intes- tines. The formula is as follows : quassia-wood, columbo root, aa. 3ij. ; cort. aurant. 3i. ; rhubarb root bruised, from 9 to 3ss. ; carbonate of potass., or soda, from 9 to 3ss. ; water, §xx. ; boil to gxvi. and strain; and to make it more acceptable, add 3n\ or iij. sp. lavand. Of this mixture, when cold, let the patient take a wine-glassful every two hours. In summer add gij. of tinct. amar. to the mixture, to preserve it. You perceive I com- bine different bitters in the same prescription. It is believed by most practitioners, that the combination of two or more of the bitters is more useful than any one alone, and is more grateful to the stomach. That remark was originally made by Syden- TREATMENT OF FEVER. 275 ham ; it has since been confirmed in the practice of the expe- rienced Fordyce ; and the observation is repeated by Dr. Clarke, in his Observations on the Diseases of Females, p. 98. " Bitter medicines," says Dr. Fordyce, " which tend to strengthen the system, as far as my experience has gone, sit easier on the sto- mach, and tend more to strengthen the system, when mixed together, than when any one of them is employed singly." See paper by Fordyce, 2d vol. of the Trans, of the Soc. for Med. and Chir. Knowledge. Another compound, very useful under similar circumstances, is an infusion of chamomile flowers or orange peel, and the Vir- ginia snakeroot — an advantage in which is, that it has a con- siderable operation upon the surface of the body, and to which the antiseptic qualities of the snakeroot in particular are usu- ally ascribed; 3ij. of the chamomile and snakeroot, with Si. of orange-peel, are sufficient to make a pint of tea — of this cold, a wine-glassful should be taken frequently. Valerian, in some cases, is a useful addition. The Peruvian bark is also frequently had recourse to by practitioners, in typhus fever. For the most part, however, except in the more advanced state of typhus fever, it is too astringent, unless when combined with snakeroot in decoction. In this form, it may be advantageously prescribed in many stages of typhus fever, when such state is clearly marked. The bark in substance is also frequently administered ; but it very frequently proves too irritating to the stomach and bowels in this form ; and when it is so given, it should be controlled by five drops of laudanum being combined with each dose ; but on the contrary, it may prove too astringent to the bowels. In that case, as many grains of rhubarb may be given with the bark. External stimulants are also indicated in this state of the system. With regard to blisters, usually directed by physicians, there are various opinions. Lind, Cullen, and others, are in favour of their use ; but they are objected to by others, except- ing when they are applied to remove local affections attendant upon typhus fever, as of the brain, the lungs, the stomach, the bowels, or the uterus. In affections of the brain, Sir John Pringle and others have borne testimony to their use. They are also found useful in 276 LECTURE XXII. the typhoid stage of peripneumony, or the peripneumonia typhodes, produced by contagion. But in those diseases they should not be applied the same length of time as on other oc- casions ; i. e. not exceeding six or eight hours, or sphacelus will frequently be the consequence in this broken state of the system. And in the irritations of the stomach attendant on yellow fever, and which frequently usher in that fatal symptom the black vomit, they have frequently been found extremely useful ; and should another yellow fever be unfortunately introduced among us, blisters would be among my earliest prescriptions, to prevent that deadly symptom. They are in like manner no less beneficial in the removal of the inflam- mations of the intestines, attendant upon dysentery, and in counteracting the inflammation of the uterus and peritoneum, which characterize puerperal fever ; both of which diseases, viz. dysentery and puerperal fever, are usually attended with fever of the typhoid character. But in all these, as well as in typhus fever, it is a very prevalent error, that the application of blisters is delayed to too late a period — applied early, they are beneficial ; but they are never serviceable in the advanced state of fever, with the exceptions that have been noticed. On the contrary, they distress the patient and waste his powers. So also says Dr. Moore in his Medical Sketches, p. 531.* Blisters at this period can certainly be of little use in trans- ferring the irritation of the whole system to a particular part, (which is the object we should have in view,) for when the fluids become the seat of disease, the causes of the irritation existing are too constant, and they are too extensive to be thus controlled. And as general stimulants, others are preferable, even of those used as external stimulants, and without destroy- ing or impairing the texture of the parts acted upon. With this view, rubefacients, sinapisms, and other stimulant applica- tions, are had recourse to, and in my opinion with most ex- cellent effects. Burdock leaves dipped in vinegar, sinapisms of mustard, vinegar and meal, or the toasted bread covered with vinegar and mustard. Salt herrings, garlic, onions, applied to the soles of the feet or wrists, frequently afford great. * " Notwithstanding," says Dr. Moore, " my having watched the effects of blisters with all the attention I am capable of, I cannot assert that I ever knew vesicatories of much use." TREATMENT OF FEVER. 277 relief to the head, and sometimes counteract a ferocious deli- rium. II. The system is to be excited, and its tone supported, by means of the diet and drinks of the patient, and especially by the liberal use of wine : this may be either given alone, or in the form of wine-whey, moderately strong : two or three glasses of the best Madeira to a pint of milk ; or it may be given in panada, sago, salep, arrow-root, tapioca, cassava, also barley- water or caudle, rendered still more stimulant and grateful by being combined with some of the spices, as cinnamon, or nut- meg, or mace, with the addition of loaf sugar. In this form, either of these articles is rendered both grateful to the taste and acceptable to the stomach, which has its taste too on these oc- casions, and should be particularly consulted by the physician. Vegetable nourishments, too, you will recollect, are now to be preferred, not only as most grateful and most acceptable to the stomach, but on account of their greater antiseptic quality, and their having a less tendency to the putrescent fermentation than animal food, to which the patient, in this septic state of body, has even an aversion. But we place an equal, if not our chief dependence, upon the use of wine. The physician, there- fore, should attend to its quality, as w^ell as direct its quantity, as much mischief may be done by acid wines. As it regards strength, old wine is certainly to be preferred — we all know it is generally most agreeable. Madeira and port wine are the preferable wines for the sick, as they are less apt to become acid, and possess more strength than claret, which is preferred by some ; and among others, by Dr. Moore ! ! (See p. 523.) He, however, admits that he has seen the same good effect from Port, Madeira, arid other wines* But if you cannot procure wine, brandy or rum diluted with water, and sweetened or made into milk-punch, may be substi- tuted in its place. Ardent spirits are indeed more grateful to a certain class of patients than the best wines ; and where they have been accustomed to the use of them in health, they are to be preferred. In this case, as well as in some nervous diseases, wine and ardent spirits are both proper, and should be retained in the Materia Medica, notwithstanding all the prohibitions en- joined by temperance societies. When you first administer wine to a patient who is delirious, 278 LECTURE XXII. give it a little warmed and sweetened, otherwise he may refuse it. For the most part, however, this is one of the few articles that men will swallow, whether delirious or in their senses — mad or sober they will drink wine. What quantity shall be given to a patient in this delirious condition, attended with all the other symptoms denoting a confirmed state of typhus 1 I answer, from one to five bottles a day — observing, however, to give it most freely during the remissions in the early part of the day, and less during the ex- acerbations, which usually are most violent in the evenings and at night. A case was communicated to me by Dr. Farmer, of Charles- ton, of a gentleman in S. Carolina, who drank eleven bottles of Maidera wine in one night, and six the succeeding morning — he recovered. Porter is another drink frequently made use of in this state and character of fever. It certainly combines many valuable qualities. It is stimulant, though less so than wine. It is tonic from its bitterness ; nutritious, from the materials entering into it ; and from the fixed air it contains, it is among the best anti- septics we can administer. When typhus prevailed on board the Mohawk, among one hundred passengers, I gave to the sick porter, as the chief food and physic. Yeast, too, for the same reasons, has come into use as a powerful antiseptic and anti-emetic in typhus fever ; of this a table-spoonful is given every hour. Upon the same principle with bark, spirits and wine, yeast is useful in foul ulcers, as in anthrax, exciting them to healthy action. But as both porter and yeast have a tendency to run through the bowels, where the strength is much expended, and especially if the patient be already inclined to a loose state of the belly, the purgative ef- fects of either would render them dangerous prescriptions. On this account great caution becomes necessary. It will perhaps be a good rule, where the patient is costive, to give porter; but where the bowels show a tendency to diarrhoea to prefer wine ; and if diarrhoea actually exists, give the patient spiced wine or mulled wine. And it is important to have this properly made. Have the spice, either alspice or cinnamon, boiled in a tea-cupful of water. Boil a pint of wine. Let three eggs be well beaten up with sugar. To this add your spice water, and TREATMENT OF FEVER. 279 pour them gradually into the boiling wine. This is the very best mode of preparing mulled wine ; and as you will often be asked for directions, it will be well for you to remember the form. But upon other occasions the bowels may be so confined, that instead of these astringents to restrain a diarrhoea, you find it necessary to administer to them laxative medicine; otherwise the accumulation in the bowels will become an additional source of irritation and of vitiation to the whole system — this is a fre- quent occurrence. For this purpose an enema should be given once in twenty-four hours ; or at most a small dose of rhubarb and magnesia; but avoid salts and active purges, especially such as operate at the expense of the whole system. Avoid Hamilton's jalap and calomel, which are too active at this stage, and too apt to disturb the stomach. His observations on pur- gatives in typhus I confess have astonished me ! I should just as readily think of putting a lancet in a patient's arm in this advanced state of fever, as empty his vessels by the active purges he has directed. His observations on chorea are an equally exceptionable part of his work ; yet his .work is the work of an elegant scholar, and one of the most accomplished physicians of the age. Such I considered him at the time I knew him. I had an opportunity of witnessing his practice at the In- firmary of Edinburgh. Although it is sometimes necessary to ad- minister cathartic medicines in this malignant form of fever, it is more frequently necessary to restrain the evacuations than to solicit them ; and that too, even where the contents of the bow- els are offensive. And here let me make a remark deserving your attention, that you cannot remove the putrid contents of the bowels, and that the more you purge your patient the more offensive the contents of the bowels become ; for the weaker the patient the greater is the putrefactive tendency in the contents of the bowels; for the digestive process being impaired, the less is its control over that fermentative process that induces this oppressive state of the contents of the bowels, the tendency of which is to induce a diarrhoea. Anodyne medicines become necessary to correct these excessive discharges. A convenient formula for this is the following : 3i. laudanum ; §i. sp. lavender; Siij. mint or cinn. water — a table- spoonful every hour, or after every large evacuation : spirits of lavender alone is also useful. 280 LECTURE XXII. Sir John Pringle recommends the chalk julep in these cases, to be given in conjunction with a few drops of laudanum, after every loose evacuation. The following is a very good and agreeable formula : Gum Arabic, 3i. ; chalk, 3i. ; aq. menth. giij. ; elix. paregor. gss. M. Coch. mag. post. sing, sedes. Or laudanum may be given in warm wine, mulled with cinnamon and sugar. Burnt brandy and water, with cinnamon, a flannel bandage to the bowels, and spirituous applications, occasionally renewed, will be found valuable. In some instances, this disturbance or irritation is not confined to the bowels, but involves the stomach, producing an immoderate vomiting. The means to be employed for the purpose of restraining this, are various. 1. Riverius's mixture, with mint-water ; 2. Mint-water and laudanum ; 3. Soda-water, mead or spruce-beer ; 4. Lime-wa- ter and milk, equal parts ; 5. Milk alone ; 6. Porter — alone or with lime-water ; 7. Spirits or brandy and water, made strong ; 8. Cayenne pepper; 9. Ice, in pills; or, 10. Give nothing. Let the stomach rest. By thus withholding drinks or medicine, the tone of the organ may be recovered. III. A third means of improving or preserving the strength of the patient, is to prevent every unnecessary waste of his excite- ment : his room should be kept dark, lest the light of the day, of the fire, or of a candle, should keep him watchful. All noise should be avoided — loud speaking in his chamber especially, though it may not awake him, still disturbs his sleep, occasion- ing dreams. Do not suffer him, in this exhausted state, to waste his powers by getting out of bed ; and in all his movements assist him. Instead of going to his night-chair, let him use a pan or a dirty sheet ; and provide him with a urinal, that he may have no occasion to rise for the evacuation of his water. Even in giving him his drinks or his food, do not allow him to waste his strength by his exertions to assist himself; — support him ; — and in changing his dress, the same assistance should be rendered. The same system of economizing the strength of the patient in convalescence, should also be carefully observed. 281 LECTURE XXIII. TREATMENT OF THE TYPHOID STATE OF FEVER, II. A second indication in the treatment of the typhoid stage of fever, is to counteract the putrescent state of the system. which more especially appears in the fluids, though not exclu- sively so; for the solids, too, more or less lose their cohesion and powers of contraction. The means of fulfilling this indication are, 1st. To continue the various excretions by the remedies which have already been mentioned, especially attending to the important function performed by the skin, inasmuch as it is the office of the function of perspiration, in health, to convey out of the body noxious, saline, and other materials. It is doubly necessary when the fluids are in a diseased condition. The accumulation from the want of this excretion must conse- quently be highly dangerous to the constitution, and an aggra- vating cause of the existing disease. Continue, therefore, the use of such remedies as act upon the surface, but at the same time employ those which are the least debilitating. Of these the aristolochia serpentaria is among the best. The dorstenia contrayerva was once much in use as a cordial sudorific, but it has given place to the Virginia snakeroot. Small doses of antimony especially, combined with a small quantity of opium, merely sufficient to prevent them from affecting the bowels, may also be administered, if the debility should not otherwise forbid the use of these medicines ; but usually this is a hazard- ous prescription at this period of the disease, particularly with- out the opium. The sp. mind, and laud, is less so, but even this should be given with great caution ; for it is not only the ob- 25 282 LECTURE xxm. ject in view to administer sudorifics, but also at the same time to excite, and stimulate, and to preserve the tone of the sys- tem. Wine-whey is one of the best means we can direct in addition to the others which have been mentioned, to effect this object, in this state of body. It is also important to attend to the bow T els — the lower intestines in particular. They should be regularly emptied, once in twenty-four hours ; otherwise diar- rhoea may be the effect of the irritation produced by their acrid contents, as well as by their mechanical accumulation. This is not all : by their retention, the whole state of the fluids may be rendered still more malignant by the reabsorption of the malecontents, particularly of the lower tract of the intestines. For the purpose of relieving the bowels in the typhoid state of fever, I have been much in the habit of using the following form of an enema, which I consider peculiarly calculated to correct the septic contents of the bowels, as well as to evac- uate them. Vinegar, §i. (i. e. coch. ij. mag.) ; yeast, gi. to gij. molasses, gi. to gij. (coch. i.) ; water, gviij. M. To be admi- nistered cold or milk-warm. 2dly. A second means of fulfilling the indication now under our consideration, is frequently to cleanse the surface of the body itself, by washing it with vinegar and water, (applied at a mo- derate temperature ; i. e. from 40° to 60°,) three or four times a day, w r hen the body is much heated, and the skin dry. It is necessary, however, to observe two exceptions to this rule. 1st. When the heat of the body is too low — reduced below the natural standard — and the power of generating heat is at the same time much impaired. 2d. Another exception to the use of cool, or cold applica- tions, is the presence of local diseases, conjoined with this typhoid state of body, as in dysentery, peripneumony, puerperal fever. In those cases, cold applications are injurious— tepid washings with vinegar and water, or with spirits and water, should then be employed.* And it is to be remarked, that tepid water, applied to the body, conveys off the caloric as well as the cold affusion, and partly in consequence of more speed of evaporation. * By tepid water is meant warm, not hot water — not hot to the sensations- say from 87° to 97° of the scale of Fah, TREATMENT OF FEVER. 283 Dr. Currie also observes, that he has made use of tepid water with advantage in many of those cases where the oppression might be dangerously augmented by the sudden stimulus of the cold affusion ; but its effects he considers to be not so perma- nent as the cold; still he admits it to be as useful in diminish- ing the heat, but not as a stimulus to rouse the system at the same time into a violent reaction. 3dly. If the heat of the body is much reduced, and the body itself exhibits a livid appearance — if the extremities are cold, and the powers are greatly exhausted by which the heat should be restored, in that case let the body be frequently sponged with warm or hot spirits, and afterwards diligently rubbed with a coarse towel or with flannel. Make use of a bath rendered stimulant by its temperature, and still more so by the addition of spirits, Peruvian bark, and the aq. ammon. occasionally, adding the last article while the patient remains in the bath. 4thly. Be careful to remove all excrementitious discharges from the apartments of the sick ; with the same view, too, fre- quently change the bed, the bedding and the dress of the pa- tient ; (for this purpose let a cot and bed be introduced into the room to lay the patient upon, that his strength may not be wasted by setting him up in a chair.) It will also be well to make use of flannel shirts instead of linen ; for flannel not only preserves a uniform temperature about the body, but it also excites the skin to more vigorous action ; and it absorbs the offensive and noxious materials discharged from the surface in this state of disease ; and it is by many physicians believed that the vinegar shirt, as it is called — that is, a flannel shirt, after it is washed, being dipped in vinegar and dried, is preferable to flannel without this process. I have seen it used so often, with benefit to the patient in this disease, that I really believe it has advantages from the acid even thus applied. The vinegar, too, may render the flannel more stimulant to the surface, and like the vinegar and other acids acting upon the air, it may in this way perhaps have some good effect by decomposing the nox- ious materials as they are discharged from the surface of the body. But whatever opinion we form upon this subject, we doubtless must all unite as to the benefits at least of frequent changes of dress, and the preference to be given to flannel over linen, inasmuch as it is more stimulant to the surface, and bet- 284 LECTURE XXIII. ter calculated to absorb the discharges from the skin, and to preserve a uniform temperature about the body of the patient. 5thly. Preserve the air of the room as pure as possible, by- ventilation ; for, as Dr. Fordyce observes in a letter which I received from that learned and distinguished physician, a short time before his death, " dilution with atmospheric air is the great means of destroying contagion, not only as it regards the individual, but his attendants and friends." This should be in- scribed over every door of the wards of a fever hospital, and no less strictly observed in the private apartments of the sick. With the same view attend to the size of the room in which the patient lies sick — put him in the largest room of the house — attend also to its temperature. Be careful, however, not to let the bed be too cool at this advanced period of his disease. And should his heat be too low, the addition of more clothing may become necessary ; but too hot an atmosphere is more to be apprehended ; for in our climate, at least, this disease is most prevalent in the hottest seasons of the year. So also in the southern states, and in hot climates. In a hot climate, and m the hot seasons of the year of temperate climates, cool the air by frequently sprinkling the floor for the benefits of evapora- tion. And that you may purify the air at the same time that you cool it, sprinkle it with vinegar ; and if the air be very im- pure, as in hospitals, or in courts or prisons, make use of the acid gases in general, as they have been lately recommended by Guyton de Morveau and Carmichael Smyth, for the pur- pose of disinfecting the atmosphere. You will find that the fact was known to Sir John Pringle, as early as 1750, that the mineral acids will destroy contagion. Johnstone of Wor- cester, in 1758, made use of it for this purpose. Guyton de Morveau and Carmichael Smyth, at Winchester, have the merit of bringing them again into use, and have received the grateful acknowledgments of the world for this truly important service. They certainly are entitled to thanks for what they have done. Nevertheless they cannot justly have ascribed to them the merit of originality. Dr. John Johnstone of Birming- ham, in his " Account of the discovery of the power of the mineral acids in a state of gas to destroy contagion," pub- lished in 1803 ; and in his " Reply to Dr. J. C. Smyth" in 1805, has triumphantly shown that the disinfecting property of the TREATMENT OF FEVER. 285 acid gases was known and employed by his father in 1758. And if you will read a paper, entitled " An attempt to show that the use of Acid Fumigations was known before the time of Morveau, Smyth, &c." published in the American Medical Recorder, (vol. iv. p. 133,) by its then editor, Dr. Ducachet, you will see that it was well known to Boerhaave and his commentator Van Swieten, half a century before Dr. Smyth laid claim to the discovery ; and that the celebrated Dr. Mead, who lived at the same time, understood it well. In his six hun- dred and fifth Aphorism, Boerhaave speaks largely of the virtue of acid fumes ; and in his Elementa Chemise, torn. ii. p. 269, expressly says, " totus acidus vapor totum aera emendat" His annotator, too, was evidently perfectly acquainted with the disinfecting power of acid vapours. Indeed you will find it clearly demonstrated in that paper, that it was not unknown even in ancient days. Dr. Ducachet shows conclusively, that it was known to Homer, since the bard represents Achilles as resorting to the use of sulphurous fumes to purify a vessel, in which he intended to offer a libation to the gods for the success of his friend Patroclus ; and as he tells how Ulysses, on his re- turn to Ithaca, fumigated his house with sulphur, to free it Of its pollution by the blood of certain troublesome visiters who had been slain there. " With fire and sulphur, cure of noxious fumes, He purged the walls and blood polluted rooms." Odyssey, book xxii. lin. 529. Indeed, the existence of the verb d-mooi, in the Greek language, which signifies to purify with sulphur, sulphure lustro, shows that the value of acid fumigations by means of volatilized sul- phur — in other words, by the sulphurous acid, was known familiarly to the Greeks. But I must refer you to the disserta- tion itself. The following are the compounds which are employed for the purpose of supplying these two gases, viz., the nitrous acid gas of Smyth, and the oxygenated muriatic acid gas of Guy- ton de Morveau. The first is prepared as follows : Take of the nitrate of potash pulverized, gss. ; put it into a saucer ; pour upon it the same quantity of the sulphuric acid : 25* 286 LECTURE XXIII. by exposing it to heat upon a chafingdish, the decomposition will be facilitated ; the sulphuric acid generated is immediately extricated and diffused through the apartment. The oxygenated muriatic acid gas, the chlorine gas, as now called, is prepared in the following manner : Common salt, ^iv. ; oxyde of manganese, 3L ; sulphuric acid, gij., diluted with water, gij. ; put over a chafingdish of coals. See Proceedings of the Board of Health of Manchester, p. 42. But the Professor of Chemistry will give you every detail upon this subject. As I before explained to you, the mode in which these gases operate in disinfecting the air, and in destroying the odour of putrid materials, is supposed by Crawford and by Dr. Garnett to be by combining with the hydrogen gas, which is believed to hold these noxious matters in solution, or at least which holds a very close and intimate connexion with them. The air, it is known, is rendered instantly pure. The effluvium which arises from the decomposition of animal and vegetable matter, and which so sensibly affects our smell, has been ascertained to consist either of sulphur, phosphorus, or ammonia, or these combined, and held in solution by union with hydrogen. None of these combinations are offensive when uncombined. Hence, then, it is our object to separate them. This is effectually ac- complished by these acid gases. The oxygen they contain combines with the hydrogen, and the material or materials held in solution or in combination are precipitated, and consequently rendered harmless. And that these gases are no less useful in destroying the matter of contagion, has been most abundantly established. 6thly. Tonic medicines furnish another means of counter- acting the putrescence of the system. With this view the bit- ters already noticed, both in their watery and spirituous forms, viz. the infusion of columbo and quassia, or of chamomile and orange-peel, or in the form of the tinctura amara, may still be continued, as among the best means of giving tone to the sto- mach and other organs concerned in the digestion and assimila- tion of our food, at the same time that they lessen the morbid sensibility of the whole system. The addition of the mineral acids is no less beneficial in this septic state of the system. Not only as tonics, but by their chemical agency, they may TREATMENT OF FEVER. 28? also be useful in their action on the system — at least upon the contents of the intestinal canal, in which the putrefactive fer- mentation predominates while the digestive process remains impaired. Bark, in its various forms of substance, infusion, decoction or tincture, and especially in combination with snake- root or the sulphate of quinine, should also be given in this stage of fever — in a hot climate particularly, it is indispensably necessary ; so much so, that the practitioners of the West In- dies introduce it in every possible manner, by the stomach, by the skin, and by injection, and frequently all combined. And so tenacious are they on this point, that when administered by injection, if it should be rejected by the irritable bowel, and laudanum is not sufficient to cause it to be retained, they have recourse to mechanical pressure upon the intestine to secure its retention. It is a common practice, I am told, for Mingo to sit by the half hour with his compress, plugging up the anus, after a dose of bark has been thrown up. " When a dangerous debility, and a train of malignant symp- toms are threatened," says Dr. Moore, (Med. Sketches, p. 507,) " the bark is found the most powerful means of preventing those symptoms ; and notwithstanding its astringent qualities, frequently promotes a salutary diaphoresis more effectually than any of the medicines which enjoy, from prescription, the title of diaphoretics." He adds, "When the patient is out of danger, you may account for this in the best manner you can, and settle the point at leisure. Whether in producing these effects it has acted in the character of a tonic, diaphoretic, or antiseptic — the nature of the disease being ascertained, and the alimentary canal entirely cleansed, the bark should be given without waiting for very distinct remissions. To wait for such when the disease appears to be the nervous malignant fever, is to wait for what will not happen — depriving the patient of a probable chance of recovery, and allowing him to incur the risk of sinking suddenly into such a state of weakness as will render the bark, and all other medicines, of no avail." Medical Sketches, p. 507-9. 7thly. Vegetable nourishments are at this time peculiarly in- dicated ; and animal food, even in the form of soups, should be rigidly avoided. Very fortunately, however, nature herself rejects them as offensive — even their smell is disagreeable to 288 LECTURE XXIII. the patient in this state of body. On the other hand, the appe- tite for acids is strong and eager. Fresh fruits, as strawberries, grapes, oranges, limes, lemons, in their season ; or roasted ap- ples, currant-jelly, cranberries, when fresh fruit cannot be obtained, will also prove a very grateful and valuable addition to the nourishments of the sick — but like the yeast and porter, they must be given with great caution, lest they prove too pur- gative in their effects. But while you can command the juice of the grape, you need be at no loss for a very effectual means of preserving the tone of your patient. This, at least, is my sheet-anchor on these occasions. Attend, too, to the time and manner of administering food, as well as the quantity given. Food, in many cases, should be given every half hour. In cases of stupor, arising either from an accumulation of blood, or of serum upon the brain, or from an exhausted state of the sensorial power, or where there is a great propensity to sleep without such apoplectic pressure, the patient, in that case, must be roused frequently to take his nourishments or his drinks. Insensibility takes place to such a degree sometimes, that the patient takes the food or his medicine into his mouth, and retains it there without swallowing it : in that case, excite him by loud speaking, and actually commanding, in a loud tone of voice, directing him to swallow it. Present another spoonful, and another — he then swallows. This degree of insensibility is a very unfavourable symptom. In this critical situation of your patient, food or medicine should be given in small quantities, but frequently. Recollect that in large quantities you produce great irritation — vomiting, purging, oppression, restlessness ; a renewal or increase of fever are oftentimes the consequences of such excess. Remember, however, to continue the use of wine or porter, preferring one or the other as circumstances may point out. But suppose the stomach rejects nourishment or medicine, or both ; in that case make use of enemata for conveying both medicine and diet. We told you of the skin as an important medium of com- munication, a sort of second stomach ; the lower bowels may be considered as a third stomach, and prove a valuable re- source on many occasions. Milk punch, arrow root, starch or sago, in wine-whey, may thus be administered as well as medi- cines. Another observation deserving your attention is, that TREATMENT OF FEVER. 289 in this extreme prostration of the system, the patient is fre- quently unconscious of many of his sufferings, and only signi- fies them by his moanings, but without intelligence sufficient to refer them to the particular part which may be affected. Of this he is indeed himself insensible. In some instances it may arise from an accumulation of faeces ; an enema will in such cases afford him relief; or it may proceed from a collection of urine in the bladder, which the patient should be urged to evacuate. In case of inability to do so, the catheter should be employed. The irritation of a blister which requires dressing, soreness of the mouth or throat from the use of mercury, or from aphthae, not unfrequently the attendant upon the last stage of fever, may be the source of the patient's distress. In the latter case, yeast with honey and borax, are among the best applications, either in the form of a gargle, or a wash, if the patient has not strength to gargle his throat. It is proper for me to state to you, that Dr. Bard in such cases is fond of small doses of mercury, i. gr. two or three times a day • — perhaps the very excitement produced by mercury may be useful in doses of this sort. Soreness from long lying in bed, and from the pressure of particular parts, in consequence of remaining long in the same position, will not only occasion pain, but in some cases active inflammation and sphacelus, de- pending upon the condition of body, are the consequences, and require the prescriptions of the physician. In this debilitated and vitiated state of the body, the most stimulant dressing and applications become necessary; such as cloths wet with yeast: lint moistened with the pyroli^neous acid ; the yeast poultice, or a dressing of the basilicon ointment, may be useful, preserv- ing the parts very clean by repeatedly washing them with hot water, with the addition of a proportion of rum or brandy. To all these varied sources of suffering, the attention both of the physician and the nurse should be given in the sick room. The symptoms of recovery and convalescence next fall under our consideration. How is the patient known to be convales- cent? This may be known — first, by attention to his vital functions. The pulse is calm, more full, soft, and generally slower than natural, and more regular, excepting in yellow fever. But quickness frequently remains sometime in con vales- 290 LECTURE XXIII. cence from fever. The respiration is more regular, but also, like the pulse, slow, and sometimes attended with sighing. Secondly. The natural functions manifest a change which indicates a solution of fever, and the commencement of reco- very. The tongue and lips show the returning secretions ; they now become moist, and the tongue clean, especially at its edges ; it is also of its natural colour, losing the crimson or brown hue. The fur upon the middle of the tongue too, appears more loose, and easily to be detached. The teeth, gums and lips appear cleaner, and freed from the sordes that were ob- served upon them during the continuance of fever. The skin likewise shows a returning natural temperature, with a general moisture upon its surface. Indeed, the vessels upon the sur- face sometimes become so patulous, that there is a great pro- pensity to a profuse discharge by sweat, especially during sleep. This, however, for the most part, is a favourable symp- tom, and shows a more complete solution of the fever, than almost any other single symptom, except when that sweat is attended with coldness of the extremities. The kidneys too, manifest the change induced in their secre- tion. The urine deposites a large sediment, and is frequently discharged in greater quantities. The appetite returns, not only for food, but even the artificial one for snuff, coffee, and other accustomed stimuli. The bowels too, become more regular; the stools take place spontaneously ; they assume their natural colour ; they are less fluid, the thinner parts of the contents of the bowels being taken up by the returning healthy action of the absorbents. They also acquire more consistency, assum- ing a " figured shape," as Dr. Home denominated it. Not unfrequently, too, this returning tone of the intestinal canal is manifested by an occasional discharge of wind, and that too accompanied with a loud report. This circumstance shows not only the contractile state of the sphincters, but that the bowels are now sensible of their contents ; that they can now make distinctions ; whereas, before they did not distinguish what was passing, but let all go indiscriminately. On this subject let me tell you a little anecdote, which I had from Dr. Rush. The Doctor had a patient extremely ill, in the Pennsylvania Hospital, and for whose recovery he experienced great anxiety. He left him very low, not expecting his recovery. TREATMENT OF FEVER. 291 The old nurse of the house was no less attentive to his situa- tion ; her anxiety kept pace with the Doctor's. She watched the patient very narrowly ; nothing escaped that she did not know. In a short time a change was effected. In a little time, down came old Molly, the nurse, who felt as much anx- iety on these occasions as the Doctor himself. The old lady impatiently asked for the Doctor. — " Well, Doctor, our patient is out of danger !" "Ah ! indeed ! how do you know, Molly?" " Ah !" says she, " I have one sign, Doctor, that never, never deceives me." " Well, tell me nurse, what is that V- " Oh ! you must excuse me, Doctor, but I know he is a great deal better." " I must know that secret, nurse." The Doctor was determined to sift Molly to the bottom. " Well, saving your presence, Sir, if I must tell you, he just this moment let go a most terrible ." When you get this signal, this " signum salutis," you will remember that your patient is in a good way. In some instances the patient, in convalescence from fevers, has a great propensity to sleep, and which to the family or friends is a source of some uneasiness. This circumstance is favourable to the recovery of his strength, as it prevents that waste of excitement which otherwise takes place. Though it be excessive, I still call it natural sleep ; that is, when the other symptoms are favourable which have been enumerated. Be careful, however, to distinguish between this propensity which is so common in the advanced state of fever, from stupor or coma. This will readily be done, by examining the iris and its power of contracting ; attentively observing the other func- tions of the system, such as the state of his pulse, and his breathing, which are natural. His natural functions too, as well as the vital, go on very regularly, and when he is awak- ened, it is done with ease, without much exertion of his at- tendants, and he awakes composed. It will also be necessary to rouse the patient frequently, even from this natural sleep, to give him the necessary medicine and nourishment. Be par- ticular too, to change his position in bed frequently. By this means you relieve one set of muscles while you exercise another. This leads us to notice the treatment proper to be employed during convalescence. 1. Of medicines. Tonics are now manifestly necessary, for the purpose of aid- 292 LECTURE XXIII. ing the digestive and assimilating process, and thereby to cor- rect that tendency to fermentation which still exists, and indeed which predominates, while the tone of the stomach and of the whole system remains impaired. With this view, I usually direct the bitter infusion — either the simple, viz. composed of gentian gss., orange-peel 3ij., water gxx., boiled to ^xvi., or the more compound one mentioned before, with a combination of rhubarb and the carbonate of soda, or in the form of tinc- ture. If the debility is excessive, and is attended with profuse sweating, I generally direct the elixir of vitriol to be taken in combination with the bitters ; about xv. or xx. drops four times a day, but not with the rhubarb and soda, these now should be omitted. Some recommend the muriatic acid in doses of gtt. x. or xij., to be given in each dose of the bitter infusion, or of the tinctura amara, every three or four hours ; and if they prove purgative, five drops of laudanum are combined with each dose. In the practice of physic of Dr. Wm. Fordyce, you will see this acid particularly recommended in malignant fevers, and as a gargle in the sloughs and ulcers of cynanche maligna. Not long since a reward was bestowed by the king of Prus- sia upon Professor Reich, of the University of Erling, in Fran- conia, for the disclosure of his secret, which proved to be no more nor less than the muriatic acid. Can it have effect in this state of body in guarding against those combinations in the bowels, and in the circulating fluids of the system, which take place in a typhoid state of body ? or of breaking up those com- binations when they are already formed ? If these acids are useful in decomposing fluids out of the body, assuredly they may be equally salutary in decomposing morbid compounds within the body. Be no less attentive, at this time, to the condition of the intestines ; and for this purpose, occasionally administer an enema, or a small quantity of rhubarb or of magnesia, particu- larly of calcined magnesia, which is freed from its fixed air. In this respect it is preferable to the carbonate, which contains seven-twelfths of fixed air. Or a single pill composed of a grain of gamboge and of aloes may be administered ; or the addition of the elixir proprietatis to the tinctura amara, say of the former Si., to Sij. of the latter. 2d. The food of the patient should also still fall under the TREATMENT OF FEVER. 293 physician's special direction, during the period of convalescence — his food should be of easy digestion. Accordingly, too, as the vitiation of his system may have been induced, and as it may still continue, let him in that case employ a large propor- tion of vegetable nutriment — I mean of those articles abound- ing in mucilage, as the arrow-root, rice, tapioca, sago, salep, with a due quantity of wine or brandy and aromatics ; at the same time allowing him the moderate use of the fresh fruits of the season. Let him return gradually to the use of animal diet, and then, as before observed, let it consist either of game, such as quail, pheasant, and other wild fowl, or venison ; or a roasted oyster may be given — not raw. The old meats, too, such as beef or mutton, are preferable to chickens, lamb, or veal — roasted and broiled are also preferable to boiled, as they con- tain more of the nutritious juices of the meat ; and they should be taken in this state of the meat, well seasoned with the usual condiments of the table, pepper, salt, and mustard. Avoid pork, or meats dressed with much oil or butter — they are not only in themselves oftentimes offensive to the delicate stomach, but being difficult of digestion, they readily become the means of occasioning some derangement of the digestive organs, and of renewing the febrile irritation. His food should be taken frequently, but in small quantities. Let him eat four or six times a day, but moderately at each time. The neglect of this rule has led practitioners to disapprove of the use of animal food, especially taken in a solid form, during convalescence ; but under this restraint it may be taken with safety, and indeed is more easy of digestion than most other nutriment. His drinks should be Madeira wine and water, porter, spirits or brandy and water. Let him avoid table beer, cider, and lemonade ; they are too acid and acescent, and consequently debilitating. Tea and coffee, too, should not now be employed ; they take the place of more substantial, more stimulant, and more nutritious articles of diet. Chocolate is more nutritious, and on this account more proper ; but it should be carefully prepared, and freed from the grease and oil which enter into it, and which are frequently blended with it by the manufacturers of that article of diet. 3d. The exercise of the patient, the proper time of taking it, the kind of exercise, and the degree of it, should be directed by 26 204 LECTURE XXIII, the physician. As soon as the patient can take exercise with- out fatigue, he should go out into the open air ; this stimulus is no less necessary than useful. Riding in an easy carriage is the best mode of exercise while he remains debilitated ; but it should be so moderate that he can return without fatigue ; otherwise it will do him more injury than benefit. He should be careful, too, to avoid excess of bodily exercise, even in his chamber. The very exertion of dressing, writing, or of shaving himself, should all be done with great caution at this time. Mental exercise also should be guarded against, as in conversation, reading, attention to business, company, &c. Excesses in any of these occupations readily induce a relapse, while the body remains in this irritable state. Remember the brain is a gland ; therefore, economise its excretions, whether in thought, word, or deed — whether in mental or in bodily ex- ercise ; for the least indiscretion or excess in these respects has been known to induce a return of fever, and which is always more formidable in its symptoms and in its consequences than the original attack. The sequelee of fever, the consequences of it to the body and mind, merit your attention. 1st. The most usual of these, after a long-continued fever, that the physician is called upon to prescribe for, is a swelling of the legs and ankles ; but in some cases an accumulation of fluids in various cavities of the body, producing hydrothorax and ascites, is thus induced. A temporary anasarca, thus in- duced by loss of tone in the absorbents, and debility of the heart and arteries, and nervous system, is of very frequent oc- currence after fever. An occasional and very mild cathartic may be administered, if the bowels be not in a regular state ; this should be succeeded by the use of iron and bitters. There are different modes of exhibiting the iron ; it may be given in rust ; taken mixed in syrup of ginger, gr. x. three times a day. Others prefer the filings of iron made up into pills, with the ex- tract of gentian, two pills of gr. v. each, to be taken three times a day. Chalybeate wine is another form of administering this powerful tonic ; gss. of the filings should be infused in a bottle of old hock ; after standing a few days in a proper tempera- ture, occasionally shaking it in that time, half a wine-glassful should be taken three or four times a day. This is one of the most effectual, and one of the most agreeable modes of taking TREATMENT OF FEVER, 295 iron, to those who like a glass of hock. In some instances I have administered with good effect an electuary composed of bark, iron, and cloves, in the proportion of gij. bark, 3ij. iron filings, 60 cloves, q. s. syrup ; a tea-spoonful of this may be taken alone or mixed in a glass of Port or Madeira wine, three or four times a day. The tincture of gentian, called also tinc- tura amara, or the bitter infusion, may also be occasionally continued. A flannel roller applied to the legs and ankles — friction with a flesh-brush, and bathing the limbs with brandy or rum, or these all combined, are among the best local appli- cations which can be employed. Blisters, applied to the inside of the ankles, I have also made use of with benefit, in cases of this nature, where the swelling of the limbs remained more than ordinarily tedious. A Mr. C. from the West Indies, in 1795, was a remarkable instance of this kind. He was pale, and his whole cellular membrane loaded with water. Blisters and the chalybeate electuary, with aloes, with the free use of gin toddy and other stimulant diuretic drinks, were his reme- dies. In his case the stimulant effects of blisters upon the sluggish absorbents and circulating vessels were obviously beneficial. But much also may be done by attention to diet and exercise. Not only animal food, but the free use of condi- ments, should now be recommended in this state of body — mus- tard, horse-radish, and Cayenne pepper, should be taken freely. The following stimulant and diuretic drink may now be taken with peculiar advantage : it is composed of horse-radish, mus- tard seed, parsley roots, of each a handful — these are infused in a gallon of hard cider — not acid cider. This infusion is to be made in an iron pot, or if in an earthen one, add an ounce of iron filings or rusty nails ; let it stand near the fire, where it can have the benefit of a moderate degree of heat — to be strained after standing two or three days and bottled ; a wine-glassful three or four times a day. Gin and water, or an infusion of juniper berries, may occasionally be substituted. This species of dropsy, however, is not to be treated in the manner recommended by Dr. Moore in his Medical Sketches, viz, by jalap, nitre, and other depleting remedies ; for such accumulation of fluid in the cellular membrane is not referrible to increased effusion, but to loss of power in the absorbent ves- sels, and diminished action of the extreme arteries, and conse- 29G LECTURE XXIII. quently retarded circulation in the veins — not the increased ac- tion of the exhalents, proceeding from an increased excitement and plethoric state of the arterial system. Dr. Moore does not appear to have been apprised of this important distinction, and which is especially important as it regards practice. 2d. Glandular swellings, ending sometimes in inflammation and abscess, are among the consequences of long-continued fe- vers, especially in hot climates and the southern states. These originate in debility of the small circulating and absorbent ves- sels, producing congestion in the glands — for glands are made up of a congeries of small vessels, which in such debilitated habits of body are apt to become affected. These congestions sometimes appear in the glands of the neck — of the axilla — in the groins — but more frequently in the liver and the spleen. Tonics, especially the mineral tonics, are among the most effectual means of removing such obstruction ; but if inflam- mation be induced and suppuration be the consequence, they should be opened as early as possible, to prevent or to remove hectic fever, and followed by the free use of the Peruvian bark, the nitric acid,* and other tonics ; at the same time that stimu- lant dressings should be made use of, to excite the healthy action of the vessels of the part affected. 3d. Biles are in some instances the consequences of fever, and the vitiated state of the system. These are only to be coun- teracted by improving the digestive process, (not upon the principle that all diseases originate in the stomach, as is main- tained by many writers, particularly Broussais of France, a late innovator and reviver of the Brunonian doctrines,) but by enabling the organs concerned in that process to furnish the blood with a healthy chyle, at the same time that the tone of the other functions is restored by a stimulant and nutritious diet. It is also a good rule in this case to discharge the con- tents of such imposthumation as soon as possible. 4th. The mind as well as the body remains debilitated, and manifests this debility in all its faculties — in a deranged condition of the internal senses, in a loss of the memory, a diseased state * The manner of giving it is thus: nit. acid 3i., water feij., sweetened; a wine-glassful every two hours; the acid is to be gradually increased to 3ij. to a quart ; not that the nitrous acid has any specific operation upon the liver, as many have supposed. TREATMENT OF FEVER. 297 of the imagination, and an enfeebled condition of the under- standing. Such was the situation of a reverend gentleman under my care. That gentleman is naturally of a very sensi- tive nervous system — a man of fine taste, distinguished both for his capacity and his acquirements. After a tedious remit- tent, and typhoid fever supervening, all these morbid effects re- mained in the mind when his bodily functions had become comparatively restored. Such was the critical state of his imagination, that he had very nearly been led to commit an act of violence upon himself. But by time, by the use of tonics, and a journey, he has fully recovered both his mental and his bodily powers. In such cases in general, recovery may be predicted from the prudent use of the means that have been pointed out. In the communication to the physician (D* Bard) by whom I was consulted in the case referred to, I ex- pressed this prognosis with great confidence. This hypochon- driacal state of mind is especially to be counteracted by exer cise, in which the mind is to be gratified at the same time — as by a journey through a variegated pleasant country, and par- ticularly when attended by a cheerful and intelligent com- panion. A return, too, to ordinary business, when the strength will permit it to be done, is also among the most important means of restoring the mind to the healthy exercise of its functions. These observations finish our view of general fever. I hope it has not appeared tedious to you; if it has, my sense of its importance must be my apology. We shall next proceed to call your attention to the different forms or types of fever, and to point out their discriminating characters. 26* 298 LECTURE XXIV. DIVISIONS AND CHARACTERISTICS OF FEVERS. We have seen fever as consisting in an irritation of the whole system ; as affecting the brain and nervous system ; as showing itself in the moving fibres ; as deranging all the func- tions both of the body and mind, and at last affecting the fluids ; and these again reacting upon the system, producing secondary or typhus fever. The general symptoms of fever have been described ; its various causes have also been pointed out, whether predisposing, exciting, or proximate, with the manner of their operation, as far as facts have enabled us to trace the connexion between causes and their effects ; a sub- ject always involved in obscurity, but peculiarly so as it regards the phenomena of the animal economy in a state of disease. The general treatment of fever has also been laid before you, corresponding with the various forms and stages which fever assumes, whether consisting in a state of simple excitement, or that which involves a morbid state of the fluids, which we have denominated the complicated excitement of the system. We shall now proceed to notice the various forms of fever, and to enumerate the characteristic symptoms of each. A pre- liminary explanation of two or three terms becomes necessary on this subject. When speaking of particular fevers we make use of the term paroxysm, by which we mean that period of the disease in which the fever is present, as opposed to apy- rexia or intermission, when fever is absent. We also use the term remission, to denote merely a sensible abatement of fever, as opposed to the increase of fever called exacerbation. Crisis is another term much employed when speaking of fever and other acute diseases, and denotes the tendency to a DIVISIONS AND CHARACTERISTICS OF FEVERS. 299 perfect termination or solution of the fever, meaning more especially continued fevers ; but does not apply like apyrexia or intermission to the conclusion of a single paroxysm. This name crisis is derived from the Greek word */»«.«w, to pass through. It therefore also has a reference to the discharges from the system of a supposed morbid matter, or something noxious, which had been the cause of fever, or may have been engendered in the system as the effect of the fever. These salutary discharges, so terminating the disease, whether by hemorrhage, by vomiting, by urine, by stool, by sweat, or by eruptions, or by creating a new local inflammation, were ac- cordingly called critical discharges, critical eruptions, &c. In some instances, indeed in most cases, these events are favour- able, producing a complete solution of the fever ; but in others, they produce a contrary effect, and not only fail to remove the disease, but are followed by an exacerbation or aggravation of all the symptoms of fever. Crisis, accordingly, is sometimes considered as favourable ; and, under other circumstances, un- favourable — perfect and imperfect. A judgment must then be formed from the circumstances attendant upon such inordinate changes which occur in the progress of a disease ; hence some have derived the term crisis from Kgiva, to judge, because a favourable or unfavourable prog- nosis or judgment of the event is now to be formed, dependent upon the discharges or symptoms which are now presented. The days, too, when such changes occur, are hence called critical days, and from the last mentioned etymology they are also called judicial days. Those days on which such occur- rences take place, and on which diseases are particularly apt to terminate, received great attention from Hippocrates, Galen, and other ancient physicians ; but at that time, when dis- eases were less under the control of human reason than they are at present — when nature, not art, directed the progress of diseases, those changes were deemed of more importance in making up a prognosis of the event, whether favourable or otherwise, than they are at this day. Still, though these violent changes are of less frequent occurrence at the present time, the study of them is important with the view to the prognosis. The days which Hippocrates has pointed out as those on which fevers are most apt to terminate, or when changes most 300 LECTURE XXIV. frequently occur, are the 3d, 5th, 7th, 9th, 11th, in those cases in which the tertian type of fevers appears to show a prevailing influence ; and on the 14th, 17th, and 20th, in those in which it assumes the quartan character. Even among the ancients, the correctness of this view of the tendency of fevers to terminate on particular days was called in question. Herophilus denied it in toto. Asclepiades considered the whole doctrine of critical days as idle and nugatory. Celsus even derides it as not only grossly inconsistent with itself, but as originating in the cupidity of physicians, who for the sake of gain were desirous of pro- tracting their attendance, and multiplying the number of their visits.* Langius observes, " If a crisis is to be expected, medi- cine is superfluous." Some again have imagined that Hippocrates, in his adoption of this doctrine, has been influenced by the harmony of num- bers, according to the Pythagorean philosophy. In that case the irregularity in the changes noticed by Hippocrates would not have been admitted, and which Celsus considered as con- stituting their inconsistency. Van Swieten very properly urges this fact as an evidence of the correctness of Hippocrates, and that he has made a faithful record of what he saw in that cli- mate. Some, too, suppose the works bearing the name of Hippocrates to be written by different hands, and that the doc- trine of critical days, with some other doctrines, were not writ- ten by the sage. But Dr. Rotheram very properly contends, from the uniform style, and the same provincial dialect running through those writings, that they are all the production of the same hand. Among the moderns this subject has received comparatively little attention from the practitioner ; for diseases have under- gone so much change in their character by climate, by mode of life, and especially by the more active treatment that is now pursued, compared with that of former days, that they are ne- cessarily more irregular in their terminations : whereas, in the earlier ages, diseases were seldom interrupted in their progress by medicine, and the means employed w r ere comparatively in- efficient. Still, however, this tendency in fevers to such critical terminations on particular days, is doubtless to a certain extent * See lib. iii. cap. 4. Divisions and characteristics of fevers. 301 well founded, and merits attention. We have further evidence of the correctness of the observations of Hippocrates, as they were made in Greece and Asia Minor, that the same have since been confirmed by Cleghorn on the shores of the Mediterranean, by Balfour in the East Indies, by Jackson in the West Indies, and other writers on the fevers of hot climates. As far as they have been attended to in northern latitudes, and in temper- ate climates, they have also been verified. The experience of Dr. Cullen, Dr. Fordyce, and of Dr. Willan, also concur in the support of this doctrine. The periodical movements which take place in the human constitution are no less favourable to this explanation. If habit governs our appetites, our excretions, our hours of sleep, the return of diseases, &c, we ought not to be surprised at the tendency to the termination of diseases at certain definite periods. The observing physician will at least keep them in view, and as far as possible render them subservi- ent to his purposes, not only in predicting the event of a dis- ease, but in directing his prescriptions to promote a favourable termination, or to counteract any unfavourable result that may be expected. Fevers have been variously divided, first, according to the extent to which they spread, as, 1st. Epidemic, i. e. when diffused through a country — as influenza, dysentery, scarlatina, cynanche maligna; that is, as connected with a general condition of atmosphere. 2d. Endemic, circumscribed within certain limits, indepen- dently of any general condition of atmosphere. Secondly. Fevers have been divided according to their causes, as into marsh fevers, contagious fevers. Thirdly. According to their character, as it regards their symptoms, whether inflammatory, bilious, nervous, putrid or malignant. And, again, they are divided according to the distinctness of their paroxysms, into intermittents, remittents, and continued. These are the least ambiguous denominations ; whereas the distinctions of putrid or malignant cannot be appropriated to any particular form of fever. In the nosological arrangement we have adopted, you will find that we divide fevers into, 1st. Intermittents — that is, such as recur at regular periods, but which also have as regular periods 302 LECTURE XXIV. of intermission, or perfect apyrexia or total absence of fever. 2d. Remittents, in which there is a sensible abatement, and which return with great regularity, but not amounting to a perfect apyrexia or intermission. 3. Continued fevers, which have no intermission, nor a regular remission, and are fre- quently without even an evident abatement for many days together, as typhus, yellow fever, plague, dysentery, &c. This distinction, you will perceive, is not admitted by Dr. Cullen. On the contrary, intermittent and remittent fevers are considered by him as one and the same, because they fre- quently run into each other. The same union has been made by Wilson; but we might with the same propriety include con- tinued fevers under the head of inter mittents, for intermittents not unfrequently end in remittents, and then proceed even to typhus or the continued form. Dr. Cullen remarks, (see note in his Nosology, vol. ii. p. 45,) that intermittents and remittents arise from marsh effluvia; that they both appear in the same places or situations, and at the same season of the year ; that they are equally epidemic, and that they are cured by the same means ; that they change type in the same person ; and he adds, that for these reasons they should not be in different orders, nor even in different sections ; but that they should both be included in the same section, as modifications of the same disease ! ! Even if all his premises were true, while the two diseases differ in their cha- racters they should hold a different place in a well-formed noso- logical arrangement ; otherwise, let us abandon all nosological distinctions. The same reasons, as far as they do apply to intermittents and remittents, might be extended to continued fevers, and remittent and continued be made one, as they were by Vogel. The typhus fever, as it appeared at the Walkill, commenced as an intermittent, then become remittent, and at length ended in typhus. The same thing has been fre- quently observed of the Lake fevers. They commence for the most part in an intermittent form, but by their duration they become remittent, and at length terminate in typhus. They are not originally of the continued form, much less do they assume in any stage the character of yellow fever, as stated by certain late writers. The malignant Walcheren fever, as described by Davis, also frequently commenced under the guise of an inter- DIVISIONS AND CHARACTERISTICS OF FEVERS. 303 mittent. Still, such is the difference of the character in the pro- gress and termination of the two diseases, that they should be kept separate. But Dr. Cullen is not correct in his premises. They do not all arise from marsh miasma; he should have qualified his definition with a plerumque " miasmate paludum ortte." Even intermittents, as I have already observed, do not always arise from miasma, but from cold, moisture, debility, and other causes. Relapses are especially induced by debility as the predisposing cause. Galen observes, that acid drinks will bring back intermittents. Debilitating medicines will, in like manner, renew an intermittent. A case occurred to me some time since, in which venesection, mercury, and other means directed for the cure of hepatitis, brought back an intermittent. Tartar emetic, given for the cure of croup, to a child who a short time before was cured of an intermittent, reproduced that disease. I have related to you another case in which mental distress revived the paroxysms of an intermittent. Inflamma- tory complaints, it is well known, frequently terminate in inter- mitting fever ; every practitioner must have witnessed this fact. Besides, as I have already observed to you, intermittents have been met with in the city of New York at all seasons of the year. They cannot therefore be considered as exclusively arising from marsh miasma. Remittents in like manner are frequently generated in the system, without marsh miasma as their cause ; and frequently, too, they run into the continued form, becoming typhus. The state of the system, as well as the effects of seasons of the year, has I believe considerable agency in superadding the remittent character to an intermit- tent, as well as the typhus type to the remittent. It will also perhaps be induced, when the miasma may exist in greater quantity than usual, or when such miasma may be accompa- nied with circumstances calculated to debilitate the system ; as when miasma may be united with moisture, as at the Walkill, or upon draining marshes in general ; especially when the causes are combined with great heat of climate, as in the southern states. The swamps of North Carolina, we are told by Dr. Williamson, were remarkably healthy before the sun had access to the surface of the earth. But after the processes of clearing and draining, the sun then exhaled the most deadly 304 LECTURE XXIV. vapours. But it is also to be observed, that intemperance and the confined cabins of the poor, under such circumstances, also give this tendency to the remittent form of fever. Remittents on the other hand become intermittents, where the intestinal canal is well cleansed, and all irritation from this source has been removed, and nothing but miasma or the former habit of returning paroxysms remain. Nor are intermittents and re- mittents cured by the same means. An emetic, an anodyne draught, and the Peruvian bark will cure the one, but not the other. Bark and wine in the remittent will be injurious, and will frequently convert it into the continued form of fever, by the excitement they produce. It is important then, as it re- gards distinction of symptoms, to place these diseases under different heads, but still more so as to the cure, for we shall find very different and even opposite treatment called for, ac- cording to the causes producing them. Hence, then, I have made three heads. I. Intermittents, which I define to be those fevers arising for the most part from marsh effluvia, consisting of repeated (not many) paroxysms, with a manifest intermission, and re- turning with remarkable exacerbations, and in general with shivering, most usually but one paroxysm in a day. The first of these is, 1. The quotidian, which has similar paroxysms, returning about every twenty-four hours ; and the paroxysms generally in the morning, and under sixteen hours' duration. The inter- val, as it is improperly called, is considered as embracing the whole period of time from the commencement of one paroxysm to the commencement of the next. The quotidian, it is to be remarked, does not always occur in the morning. Dr. Good remarks that intermitting fevers, whether quotidian, tertian, or quartan, have their paroxysms recur regularly in the day time — the quotidian in the morning, the tertian at noon, and the quartan in the afternoon ; and that in no instance do the paroxysms take place at night. Dr. Good, with all his abi- lities and extraordinary erudition, and although an eminent surgeon and poet, has, I suspect, never been particularly con- versant with fevers. The second form of intermittent is the tertian, in which similar paroxysms return about every forty-eight hours. The DIVISIONS AND CHARACTERISTICS OF FEVERS. 305 accessions of the tertian take place, for the most part, at noon, and are under ten hours' duration. This is not invariably the case. A third form of intermittent is the quartan, in which similar paroxysms return about every seventy-two hours, and the ac- cessions generally in the afternoon, (paroxysm under eight hours' duration.) This form of fever is of less frequent occur- rence. I have seen but three or four cases in twenty years. There are, however, other forms noticed by writers, in which the intervals are still longer. Hippocrates notices quintans. Van Swieten mentions a quartan being changed to a quintan. Burserius quotes twelve physicians who have seen quintans. Septans, or septenaries, are also recorded in the books. Boer- haave expressly states that he has seen a fever which returned every seventh day ; and Burserius quotes nine persons who have seen septenaries. Octans I have seen frequently. A case occurred in my own family, in the autumn of 1812. My atten- tion was first called to this form of intermittent by the elder Dr. Bard, who had in his long practice met with it so frequently that he was led, in every form of intermittent, to continue the bark until the eighth day had passed by, counting from the day of the last paroxysm. Burserius refers to sixteen persons who have seen octans. Dr. J. Bard went still further ; he has re- marked that some fevers he has known to return at the end of fifteen days. But all these forms are considered by Dr. Cullen as only irregularities of the tertian or quartan periods. For- dyce, too, considers them as so many varieties of the tertian type ; that they are all tertians in disguise. Nay, he states, as you will see in his first dissertation, that all fevers, whether continued or intermitting, are but varieties of the tertian type of fever ; a doctrine calculated to destroy all distinctions, as well as those rules of practice which arise out of them. The most usual forms of intermittent are then, 1. Quotidians, occurring every twenty-four hours, coming on in the morn- ing, and lasting sixteen hours ; 2. Tertians, occurring every forty-eight hours, coming on at noon, and lasting ten hours : 3. Quartans, occurring every seventy-two hours, coming on in the afternoon, and lasting eight hours, and generally but one paroxysm on the day of the attack. It is also observed by- some writers, that the paroxysms do not often occur at night, 27 306 LECTURE XXIV, alleging as the reason, that they are counteracted by sleep. This is not true. In some of the cases already referred to, the paroxysms changing their hours of attack, they at length re- turned at one, two, and three in the morning, attacking the patients when actually asleep; and such is the effect of habit, that they as readily recur at these hours as the propensity to empty the bladder with those who are accustomed to evacuate water at a particular hour. This leads me to remark another distinction made by physicians, into anticipating and postpon- ing intermittents ; that is, that they regularly return either an hour or two earlier or later than the preceding paroxysm. They are hence called anticipating quotidians, tertians, or quar- tans, postponing, &c. It is important to attend to this fact. It aids our prognosis. In the anticipating the disease increases in violence. But in the postponing, the disease is becoming less violent and is more easily cured. Another distinction of inter- mittents is founded upon the number of paroxysms on the day of attack. Generally, you will remember, they have but one paroxysm on the same day — but in some cases they have more — they may have two, or even three paroxysms on the same day. A tertian or quartan is then accordingly said to be a duplicate or triplicate tertian or quartan. This distinction, you will remark, is not applicable to a quotidian ; for where the paroxysms recur so frequently it cannot be longer considered as an intermittent, but is a remittent, and soon displays the con- tinued type.* Tertiana duplicata, Tertiana triplicata ; i. e. hav- ing two or three paroxysms on the same day, but none on the intermediate. Another variety to be noticed, is that in which the parox- ysms return daily, but one day the paroxysms are severe, on the other mild. These are called, not duplicate, but double ter- tians, and double quartans. Tertiana duplex, i. e. the ter- tian every other day has similar paroxysms, equally violent ; but on the intermediate day the paroxysm is mild and in- considerable ; and by this circumstance they are distinguished from quotidians. This constitutes the hemitritseus of the * But Burserius, in describing his quotidians, gives to some of his varieties two or three paroxysms on the same day ; but these are merely continued fevers, for the paroxysms are then protracted into each other without an intermission ; yet he denominates them simple, double, and triple quotidians. DIVISIONS AND CHARACTERISTICS OF FEVERS. 307 ancients, the semi-tertiana of Cleghorn ; I. e. where the parox- ysms (according to their description of them) return daily, but where the interval between the first and second paroxysms, or rather the remission, is greater than that between the second and third ; that again between the third and fourth more con- siderably than between the fourth and fifth, &c. There is, therefore, I assert, no difference between the semi-tertian and double tertian ; for every other day the fit being more violent, the intervals between the different paroxysms will necessarily be different. In 1812, Dr. Post and myself both saw many cases of this double tertian type of intermittcnts. Another variety is the tertian a triplex, having two parox- ysms on one day, and one on the intermediate, but that a slight one. Tulpius goes still further — he gives you a case of a ter- tiana quadruplex, in which two paroxysms take place every day. What was this but a double quotidian ? Tulpius tells us, too, that it supervened upon a double tertian. Lommius and Eller describe their hemitriteus as corresponding with the tertiana triplex of this day. The quartan, too, may be duplex and triplex as well as du- plicate and triplicate. Duplicate, you will recollect, signifies where two paroxysms occur every fourth day, and none on the intermediate days. But quartana duplex signifies that the pa- roxysms every fourth day are similar ; i. e. only one paroxysm on the fourth day, but that a severe one; yet a slight paroxysm occurs on one of the intermediate days ; so that the patient has only one interval day. In like manner, we may have quartana triplex as well as triplicate. Triplicate, you remember, has three paroxysms every fourth day, but none on the intermedi- ate days. Quartana triplex has one paroxysm every fourth day violent ; but it has a slight paroxysm on both of the intermedi- ate days. Intermittents are also said to be subintrant or sub- continued ; i. e. where a second paroxysm begins as soon as the first is ended ; but in this case there surely cannot be said to be an intermission ; it only amounts to a remission, the re- currence is so frequent. Quotidians, tertians and quartans, are also said to be true and spurious ; they are called true, where the paroxysm is completed within twelve hours ; but if pro- tracted beyond that period, they are called spurious. The same is applied to double tertians, &c. The quotidian and tertian 308 LECTURE XXIV. are also distinguished into universal and partial — universal, when the whole system is affected — partial, when it shows itself only in a particular part of the body, as the head, (this form is of frequent occurrence,) the eye, &c. This leads me to notice the arrangement of Alibert, who makes many distinctions founded on a particular symptom or symptoms ; i. e. the convulsive intermittents ; the hepatic ; the choleric, syncopal, &c. Or he divides them according to the diseases with which they are associated, as hydrophobic, ca- tarrhal, exanthematic, rheumatic, epileptic, &c. I also remark, that in some intermittents there is a greater tendency to assume the continued type than others. The quotidian are most apt to run into the continued form ; the tertian next ; the quartan least. Quintans, and the more protracted types, Van Swieten remarks, he never knew to be changed into continued fever. The question next arises, Why is the quotidian most, and the quartan least apt to assume the continued type? In order to answer this question it is necessary to observe, that the quoti- dian has the shortest cold stage, but the longest hot stage, or stage of excitement ; and that the whole paroxysm is longer than the other forms of intermittent. That the tertian form has a longer cold stage than the quotidian, and a shorter hot stage, but that the whole paroxysm is shorter than the quotidian. That the quartan has the longest cold stage,* and the shortest hot, and that the whole paroxysm is the shortest of the three. The quotidian, therefore, having the longest paroxysm of excite- ment is most debilitating, for the interval being shorter there is less opportunity of giving either medicine or nourishment to restore the tone of the system — hence, therefore, the worn down solids and vitiated fluids tending to the continued form of fever; the system is consequently rendered more excitable by the original or additional causes of irritation. A further evidence of the correctness of this view is, that when tertians or quartans become continued fevers, there is first a reduplica- tion of their paroxysms on the intermediate days, assuming the quotidian character. In like manner the quotidian becoming * Dr. Grant, in his Observations on the Diseases of London, states that he has seen the cold stage of the quartan continue fifteen hours. It usually lasts but about two hours. Still it is remarked that the feeling of cold is not so severe and depressing as that of the tertian, though longer in duration. Hence, too, the quartan type is peculiarly severe and dangerous to those advanced in life. DIVISIONS AND CHARACTERISTICS OF FEVERS. 309 continued, its paroxysms are first lengthened into a remittent, when the chill is scarcely perceptible ; and in proportion, too, as fevers have this tendency, the cold stage diminishes at the same time that the hot lengthens ; that is, the system even dur- ing the period called apyrexia is under some irritation from the accumulation of the cause, or from the state of the system itself. Hence there is less chill' and more excitement; and when these changes are perceived, and a tendency to the con- tinued type appears, let it teach us to be more active in our treatment to prevent such fermentation, and to procure longer intermissions. In simple tertians and quartans we have a per- fect apyrexia, for the system is less debilitated. When there is a longer chill there is no additional source of excitement to rouse the vessels into immediate reaction, as in quotidians, or the double tertians. From the length of the chill, therefore, we may be enabled to foretell the nature or type of the inter- mittent that is to ensue, whether it be a quotidian, a tertian, or a quartan. When, therefore, Galen says a physician should know the type of fever from the first paroxysm, he speaks like a man of experience and great practical observation. His di- rections for ascertaining a quotidian, viz. " when the heat is joined with acrimony," indicate the same practical attention to the phenomena of disease ; i. e. the vitiated state of the system having taken place, Galen tells you that the continued type of fever is approaching. The body, he observes, then abounds in crude humours. I have also in this city, in the hot season of the year, seen in intermittents, especially on the days of attack, the most malignant symptoms indicating such deranged state of the fluids, but which on the intermediate days were relatively removed by a profuse perspiration, which took place in such paroxysms. I am therefore not surprised at the malignancy attached to intermittents by Cleghorn and other writers, who have witnessed their character as influenced by a hot climate. It is also observed by all practical writers, that vernal inter- mittents are less apt to become continued, and autumnal most so. This fact may be explained from the septic state of body, and other circumstances of season, state of the atmosphere, decomposition of animal and vegetable matters which occur in autumn, but not in the spring. Such are the observations we have to make on the character of intermittents. 27* 310 LECTURE XXV. TREATMENT OF INTERMITTENTS. The treatment of intermittents which is now to be attended to, may be divided into the treatment proper to be pursued during the paroxysm; and the means to be made use of in the inter- mission, to prevent its return. The remedies proper to be ad- ministered in the invasion of fever in general, or the cold stage, those proper during the state of excitement, or the hot stage, and those called for in the succeeding stage, have already been very fully noticed. The same indeed, which were then pointed out, are no less applicable in the treatment of the different stages of intermittents — as for example, our object is in the first stage, to quiet the irritation of the nervous system by means of opiates, warm bathing and warm drinks. To reduce the excitement of the arterial system which succeeds, by the different evacuations, which have been pointed out, according as the one or the other may be necessary; and by various tonics and stimulant nourish- ment to supply the loss of strength that may have been induced when the sweating stage has taken place, and the febrile excite- ment has subdued. On these subjects, therefore, I need not now detain you. I may, however, remark that, both in the treat- ment of intermittents and remittents, when you may be called upon during the paroxysm, you will administer very much to the comfort of the patient, by the exhibition of opiates, and that too, not only in the cold fit, but oftentimes also in the hot stage,* * It is a common opinion," says Lind, " that the cold fit is attended with the greatest danger, and that most who die of intermittent fevers expire during the TREATMENT OF INTERMITTENTS. 311 with the exceptions already pointed out, as in great fulness of habit, or an inordinate determination to particular parts of the body, as to the head or chest ; but, under the usual irritations which we meet with in intermittents and in remittents, we administer opiates with the best effects in the hot as well as in the cold stage. They dimin- ish the rapidity of the circulation, they usually promote dia- phoresis, they correct and lessen the heat, which is itself a source of great irritation, and they in all respects, compose the feelings of the patient ; they allay pain, they remove the anxiety and oppression which patients frequently suffer during the paroxysms of fever. They invariably shorten the paroxysm, and never augment its violence. Opium may be given if the stomach be much disturbed, in weak mint water, as its vehicle, or in case of much heat and excitement, the combination before mentioned, with sp. mind, is to be preferred, or the Dover's powder, grs. x. In a quartan of two years' standing, in St. Thomas' Hospital, Dr. Fordyce successfully prescribed a full dose of Dover's powder, with a sweating draught of the carbonate of ammonia two hours before the fit — the bark afterwards effected the cure. Dr. Lind, who was the first to introduce this practice, of administering opi- ates in intermittents, and which he did as early as 1766,t always considered them useful by shortening the paroxysms, and thereby bringing on an intermission. This fact is no less favourable to the doctrine, that irritation constitutes the proximate cause of fever. In cases of costiveness, it was his practice to blend a ca- thartic with his opiate ; that after the opium had produced its effect, the cathartic might leave the bowels in such a state that he might immediately after avail himself of the opportunity of ad- ministering the bark. This, inahot climate, became doubly neces- sary. The cathartic which Dr. Lind usually blended with the anodyne, was the tinct. sacrae. §ij.; but under other circum- stances, his opiate draught was as follows : xv. to xx. drops lauda- rigors. I never saw a person die in the cold fit, but have known several carried off in the hot one, by strong convulsions, delirium and other symptoms ; and am clearly of opinion, that it is the hot fit or fever, which most endangers the pa- tient's life, and by its continuance, weakens and impairs his whole habit of body. In old age, the cold stage is most dangerous. — See Lind, p. 318. tHot climates, p. 318, 322, 323. 312 LECTURE XXV. num; 5ij. syrup of meconium; 31J alexiter spirit : ?ss. aq. font. This was his draught in the hot fit. The next indication, therefore, is to prevent the recurrence of the paroxysm. The first means of effecting this object, is to avoid the remote causes ; to prevent the exciting cause from operating on the system, (that is, as far as that cause may depend upon ex- ternal circumstances.) With this view let your patient get out of the way of it, by avoiding the air; if in marshy and moist situa- tions, let your patient be removed to elevated grounds, to a dry and sandy soil. In like manner, let him go from the interior country to the air of the sea shore. Lind, (page 313,) speaking of the effects of sea air, observes, that this change of atmosphere is " one of the most effectual means of obtaining a cure ;" and adds " that the most obstinate intermittents he ever had seen, were thus cured" — that they did not experience a single fit after they were on board ship. In like manner, a little daughter of mine was thus cured of an obstinate quotidian by means of sea air. I took her to Long Branch after being much reduced by it; she had not a single paroxysm more, but returned in three or four days perfectly restored. I have known persons from Duchess county, members of Dr. Bard's family, where they were under the influence of an obstinate intermittent, to come to the city. And when the city is unhealthy, I frequently send my patients to the country, especially to places where the situation is elevated and dry. It is, however, more frequently my common practice to send children, with whom it is always more difficult to cure the disease by other means, to the sea shore, to Staten Island, and situations where they experience the sea breeze before it is much mixed with the land air. It is another proof, besides those I have already mentioned, that the salt atmosphere extends beyond the spray of the sea, that intermittents very rarely occur, even within some miles of the sea shore. In the treatment of remit- tents this stimulant effect of sea air is no less manifest; its stimu- lant effects are also very apparent in other diseases — as in per- tussis, chronic catarrh, bowel complaints of children, which in- deed I consider to be the remittent in disguise — the infantile re- mitting fever of Dr. Mann. — (See his Prize Dissertation.) Secondly: When the poison is in the system, when the habitual recurrence of the fever is established, and the hour of its return is ascertained, our object is still to prevent the system from suffer- TREATMENT OF INTERMITTENTS. 313 ing a return of the paroxysm. For this purpose, we have vari- ous resources : we may diminish the sensibility of the system to its action. This may be done, 1st by opium, administering it, say two hours before the fit is expected to return. But with this view it must be recollected, that a larger dose is necessary to counteract the irritation attendant on the paroxysm of this dis- ease, than is exhibited under ordinary circumstances : from 50 to 100 drops should be given to an adult to obtain its full effects. It should also be exhibited in some agreeable vehicle, lest it be rejected from the now irritable stomach. The patient, too, should remain in bed, and in a perfectly quiet and a dark room ; its ope- ration should also be aided by some tepid drinks, to secure its effect upon the extreme vessels, as a cup of catnip, or some other herb tea, or wine whey. It is a good general rule with regard to all medicines, that the patient should not know the medicine he is taking; in the present case, particularly, if the patient should neither know the medicine nor the dose he takes. The same pre- caution is necessary in administering arsenic, otherwise his preju- dices and his anxiety will counteract the effects we intend it to produce. Laudanum too, is preferable to opium, as it is quicker in its operation ; but another form, to secure its febrifuge effects, especially upon the surface, is to blend it with aq. ammon., say thirty drops aq. ammon. with from fifty to sixty or eighty drops of laudanum. This combined, I have found much more effectual than the laudanum alone. 2d. Put the system under a new and stronger irritation than the operating cause. " Every means/' says Dr. Blane, " of inducing a powerful excitement in the principal functions of the body, at the period of attack, seems to possess a power of preventing it." Bisset, in his Medical Constitution of Great Britain, recommends the vol. alkali to be given, in doses of xv. or xx. drops every hour. Various vinous or spirituous drinks are also recommended. Spiced wine whey, ffej. before the paroxysm, covering the patient warm in bed ; cider, made hot with ginger, and taken off too as hot as it can be swallowed. Rum, brandy, gin, whiskey, and usquebaugh, (the celebrated Irish potation, which is distilled with cloves or other spices,) are all prescribed as sovereign cures, or rather pre- ventives of the paroxysm of an intermittent. It is surprising too, the quantity that the system will bear under the irritation of this disease, and indeed, which under other circumstances would 314 LECTURE XXV. destroy life. A half pint of rum, brandy or gin, medicated toddy, with the addition of a tea-spoon full of pepper, or highly spiced with nutmeg, (a whole nutmeg is taken at a dose on these occasions,) grated into it, or other aromatics, is a common pre- scription to prevent the fit of an intermittent. I knew in one instance, a bottle of brandy to be taken off with this view; it cured the disease, but the man w r as deranged while under the influence of the remedy. Some again, have recourse to various other stimuli, as the spirits of turpentine, a table-spoonful before the fit; the juice of rue or of groundsel, a pint of the infusion of horse-radish, ^oz. of mustard seed in half a pint of gin as its vehicle, three mornings successively, or a large dose of capsicum, as recommended by Collins, Med. Com. vol. ii. Indeed, there are hundreds of prescriptions of this kind that are employed in this way ;* but they all resolve themselves into the same princi- ple, that of exciting a new and stronger irritation, which destroys or counteracts that of the disease. With the same view, porter has also been taken with the best effects, to prevent the paroxysm of an intermittent. In 1779 or 1780, after suffering a very tedious intermittent, for it resisted all the means that were then usually prescribed as bark, the infusion of lign. vit, &c, I had recourse to a bottle of porter, as directed to me by a sea-captain. In 1784 or 17S5, I had an attack of the same disease when at the academy of Hacken- sack, and was cured in the same manner. Lind throws out the idea, that some particles of arsenic may exist in the glass, which are given out when ignited, and are thus conveyed in the beer. This is improbable and unnecessary. Arsenic is not so immediate in its effects, but requires three or four days. At all events, porter is one of the best auxiliaries that can be made use of in the cure of inter- mittents. The practice of bathing, also deserves our notice — that of im- mersing the patient in a hot bath, both before and during the in- vasion, and keeping him in it until the fit passes over ; for this pur- pose, the bath should be heated to 96° or 98° at least, and you will also add to the stimulating effect of the bath by administering to your patient at the same time, a bowl of wine whey. * See Lind, p. 313, where indeed you will see a catalogue that will surprise and amuse you. TREATMENT OF INTERMITTENTS. 315 I have also made use of a cold bath with similar good effects, administering it a short time before the paroxysm is expected to return. Applied in the form of a shower-bath is the most pow- erful mode of applying it. Or, in case of a young subject, let him stand in a large tub, and a pail of cold water be suddenly poured over him a short time before the fit is expected to return. This secures the stimulant effects of cold. In this way, in the autumn of 1S11, I cured one of my sons, and other children in the same family in which I resided, in the neighbourhood of this city. But, as I have formerly observed, the effects of cold water, as the means of preventing the return of intermittents, depend both upon the state of body in which it is applied, and the man- ner of its application. It is, accordingly, a fact well ascertained, that at the sea-shore, both at Long Branch and Rockaway, it fre- quently happens that persons who go in to bathe, bring back the disease, although they may have been freed from it by residing at the shore. Yet omitting the bath, and continuing to respire the sea-air, they would soon escape the disease, and rapidly recover their strength. The solution of the fact is this: that many per- sons go there very much debilitated. The heat generating power being reduced, the cold-bath, especially when applied by immer- sion, and the patient perhaps remaining in the water a considera- ble length of time, debilitates him by carrying off his caloric : whereas, the salt air, exciting the system, and improving the ap- petite, immediately counteracts the return of the disease. But if the person using the bath be not greatly weakened, and sud- denly plunges into the bath without remaining in it, in that case its stimulant and beneficial effects will be secured to the patient. Its operation, therefore, depends both on the condition of body and the suddenness and duration of the cold that may be applied. The stimulus of exercise, as fast walking, running, or riding on horseback, a short time before, or when the fit is expected, has prevented the return of the paroxysm. The remedy as recom- mended by Asclepiades, of putting his patient on horseback to open the pores that are obstructed, is perhaps now admissible. Upon the same principle, powerful stimuli, applied to the more sensible parts of the body, have been found useful. Blisters, applied six or eight hours before the paroxysm, to the inside of the arms, thighs, wrists, or ankles, are remedies of great efficacy; or stimulating plasters — as the celebrated frankincence 316 LECTURE XXV. plaster, which is prepared as follows : Thuris, gij.; tacamahaca, 3i.; croci, gr. x. ; terebinth Venetae, q. s. Mesceantur ut fiat emplastrum carpis applicandum. (See Lind, 312.) 2d. Plasters of Burgundy pitch, either alone or combined with a proportion of blistering ointment, say one-eighth, or one- tenth, constituting the emplastrum calidum. Or, 3d. Lind recommends, among other applications, common salt, beat up with the whites of eggs, (Lind, 312,) to be applied to the wrists or ankles. 4th. Garlick, beat up with hog's-lard, is applied with the same intention, either to the wrists, or as sinapisms to the soles of the feet, or rubbed upon the spine. 5th. The oleum succini, oil of amber, is also made use of, and is among the best of the external applications. This may be ap- plied to the wrists, or it may be made use of by anointing the spine with it. 6th. Among other stimuli, made use of to prevent the return of the paroxysm, is directly exciting the heart and larger vessels, by arresting the flow of blood into the extremities, generally one of the upper and one of the lower, by means of tourniquets. This remedy was, I believe, first recommended by Mr. Kelly. You will see an account of it in the 2d vol. of the Annals of Medicine. To produce this effect, it is directed to be applied from ten to fif- teen minutes either before or during the cold fit But we have yet another resource, that of impressing the nervous system through the medium of the mind — calling into operation the principle of faith — and which Dr. Rush introduces almost as a distinct faculty of the mind. It is upon this principle, probably, that the celebrated amulets (abracadabras) and little bags suspend- ed about the neck, containing a few grains of camphor and saf- fron, operate in counteracting the nervous irritation constituting the habitual return of fever. And with all deference to the learned gentlemen of the great metropolis, who have been of late so earnestly engaged in the discussion of the principles upon which this disease is cured by the late fashionable prescription of sourbugs, bruised spiders, cobwebs, gr. x., and the snuff of a candle, I believe we must seek for the solution in their operation through the medium of the strong mental impression which these disgusting substances are calculated to produce. Shakspeare's cauldron of the witches exhibited to Macbeth, is not made up TREATMENT OF INTE11MITTENTS. 317 of more strange and terrific materials than are exhibited in this disease. His cauldron, you know, is made up of " Root of hemlock, dig'd in the dark ; Maw and gulf of salt sea shark ; Toad, that under the cold stone, Days and nights has thirty-one ; Eye of newt — toe of frog ; Wool of bat, and tongue of dog ; Adder's fork, and blind worm's sting ; Lizard's leg, and howlet's wing." In ours, The herb of wormwood, dried in the dark ; Wool of hat ; Juice of rue — snuff of candle ; Spider's web, and crawling bug — " Make our charm of powerful trouble. '' But although the various stimuli, we have enumerated, fre- quently prevent the return of the paroxysm, we are sometimes disappointed. I have even known, in the case of a quotidian, an abscess to form of considerable size, and to be opened on the morning of the fit, and yet that irritation was not sufficient to prevent the return of the fit! Whether we succeed or not, it will be proper, in the interval of fever, to administer the more permanent stimuli, or some medicines, as provided for in the third indication, which is, 3d. To produce a permanent state of excitement, and to di- minish the sensibility of the system by tonics. By tonics are not meant diffusible stimuli, which are indicated in cases of sud- den exhaustion of the nervous system; but such remedies as are calculated to make more durable impression upon the whole sys- tem, and at the same time to give vigour to the muscular as well as the nervous fibre. Diffusible stimuli are addressed more espe- cially to the nervous system. Tonics, or permanent stimuli, to the muscular as well as the nervous system; i. e. to the circulating, the exhalent and absorbent vessels, as well as the organs of volun- tary motion. Tonics are also distinguished by their not being followed by the depression that most usually succeeds to the dif- fusible stimuli. The impression of tonics is more slow and grad- ual, while that of stimulants is quick, but transient. Tonics, when 28 318 LECTURE XXV. long continued, we know lose their effect, and become inert, but they do not leave debility behind them. Their effects are, 1st. To excite the nerves of the stomach; to promote the ap- petite; to increase the secretions of the stomach; to improve their quality, as well as to increase their quantity ; to quicken the solu- tion of the food; to promote the peristaltic motion of the whole intestinal canal ; accordingly we find some persons incapable of digestion, or of performing other functions of the intestines, without their use. With this view, a patient of mine who labours under a dyspeptic stomach, cannot digest her food without taking her habitual dose of bitters an hour or two after eating. Others I know who are in the habit of taking a dose of bark daily, as a cathartic. 2d. Their operation is to excite the lacteal system. 3d. To promote the action of the heart and arteries ; and, 4th. Of those tonics which are not astringent, to excite the excretions, as we see in the effects of iron in promoting the men- strual discharge; but, not so with bark, except in cases of extreme debility. 5th. Tonics also have the effect of exciting and contracting the exhalent vessels when relaxed by debility, as in cases of exces- sive menstruation, or an inordinate excretion by sweat. 6th. They promote the action of the absorbents. With this view we prescribe iron and bitters in that form of dropsy whicli succeeds to long continued fevers and other diseases. 7th. They operate upon the nerves throughout the system by quickening their power of action; and, 8th. They also, probably, operate through the medium of the fluids, as well as by the nerves, upon every part of our frame. This is especially rendered probable by some of the late experi- ments of Sir Everard Home, showing the action of various sub- stances through this medium of communication. The medicines prescribed with this view to their permanent to- nic operation, are of various kinds. They are of two classes, viz. vegetable and mineral tonics. Of the first class are Bitters. These again are divided into, 1. Such bitters as are pure; i. e. as containing the bitter prin- ple, unaccompanied either by aromatic or astringent matter; for it is now ascertained, as you will see by consulting Thomp- TREATMENT OF INTERMITTENTS. 319 son, that there are certain plants which possess this exclusive cha- racter, and are hence denominated pure bitters. 2d. There are bitters which possess, in addition to this bitter principle, more or less of an aromatic quality, residing in an essential oil, which the plants referred to contain ; and, 3d. There is another description of bitters which are blended with an astringent matter, or tannin, as it is now denominated. The plants which fall under the head of pure bitters, and which are in most general use, on account of their tonic qualities, are, 1. The marrubium vulgare, or horehound of the class of plants called in the Linnean system, didynamia, gymniospermia. Natu- ral order, verticillatae. The whole herb is made use of in infu- sion — to be taken cold — an excellent tonic, not only to the stom- ach but the whole system. Hence, too, it has come into general use in chronic catarrh; not that it possesses any specific effects upon the lungs. 2. Tanacetum vulgare, or tansy. CI. syngenesia. Ord. polyga- mia superflua. Herb and flowers, used as a tonic in intermit- tent fevers, and as a vermifuge. 3. Ruta graveolens — rue. 4. Eupatorium perfoliatum; is also used as a domestic bitter, and certainly with excellent effects. 5. Artemisia absenthium. 6. Anthemis nobilis — chamomile. Possesses the same proper- ties. A small quantity of essential oil, sold in the shops — useful in a voyage — in small compass, yet powerful. Useful in diseases of the stomach, but less active in diseases of the whole system. The cold infusion preferable. A tea- cupful of the flowers — boil- ing water, ffeij. when cold, ad libitum. But the most powerful are the three following. 7. Gentiana lutea — root. Infusion with orange-peel. Tinct. compos. Tinctura amara.* A grateful bitter, with orange-peel. It is a basis of the infusum amarum. 8. Quassia amara, or excelsa. Colomba plant, not much esteemed ; is supposed by Professor Willdenow to be a species of Bryonia. Formerly said to be * Its composition. — Rad. gentian, ^xij. ; cort. aurant, §vj. ; canell. alb. gij. ; coccinell, gss.; boiling water, ifei., digest one day. Brandy, ibxv. Digest seven days, or filter. 320 LECTURE XXV. brought from Ceylon, but lately found to be the produce of South- ern Africa; and is a great article of trade with the Portuguese at Mosambique, in the province of Tranquebar. Aromatic smell; bitter taste; powerful and grateful stomachic. Infusion — Columbo, gij.; quassia, 3ij. — orange-peel, 5i.; rhu- barb, 9i. ; soda, 3ss.; water, fjjiss. — boil to ffci. — strain — take cold. 2d. Bitters, with aromatics, uniting the stimulant and tonic qualities. 1. Dorstenia contrayerva, commonly used like serpentaria, as a stimulant in typhus, gr. v. to 9i. — it has fallen into disuse. 2. Aristolochia serpentaria, Virginia snakeroot. It is a stimu- lant, formerly much used in the typhoid type of fevers. Diapho- retic and tonic. 3. Citrus aurantium, the orange and Cit. medica, lemon, usually combined with the purer bitters. An ingredient in the bitter in- fusion of the shops. The 3d class of tonics, now to be noticed, are bitters, blended with the astringent principle that is in combination with tannin. I may just remind you, that there are certain tests by which the presence of such astringent principle is ascertained. The prin- cipal are the following. 1st. Astringents strike a dark purple or black colour, when acted upon by the salts of iron. 2d. They possess the property of corrugating the animal fibre, as is evident when they are applied to the tongue ; and 3d. Some of the most powerful astringents show the presence of the peculiar acid called the gallic acid, or that kind which is obtained from galls ; these are the produce of an insect, and as their place of growth is the bark of the oak, which is remarkable for its astringency, this acid, and the astringent principle, have been considered as one and the same thing. It was also discovered that the gallic acid in connection with the salts of iron, strike a dark colour. This circumstance afforded still stronger evidence that the gallic acid constitutes the astringent principle. But it has been ascertained that the acid alone possesses very little of this astringent quality, and that it is scarcely perceptible ; that the colour is not so dark as that created by astringents; and still further, it has been found that some of the most powerful astrin- gents are wholly destitute of the gallic acid, as the gum kino and catechu. TREATMENT OF INTERMITTENTS. .321 Seguin has discovered that the astringent principle is consti- tuted by a totally different material. He has ascertained that by mixing gelatin with an infusion of the substance containing the astringent principle, a precipitation takes place, containing the astringency, and leaving the liquor above altogether destitute of it. To this precipitate he has given the very appropriate name of tannin, so called, from the great application which is made of it for the purpose of tanning leather. And in this he has made a discovery of very great importance, particularly in that art, for by this process of concentrating the astringent matter by means of gelatin, leather may be tanned in fewer weeks than it formerly took months, and thereby an immense capital saved. The process consists simply of adding a quantity of fish glue to the vat containing the bark, in a state of infusion ; the astringent matter instantly falls to the bottom, where it is brought imme- diately in contact with the hides to be tanned, whereas by the former process it required a great length of time, at least eight or ten months, to produce that change which is now effected in the course of six weeks. The most important of the class of tonics possessing that astrin- cy in connection with its other properties, is the Peruvian bark, or cinchona officinalis. It was introduced into Europe in 1632. There are at least twenty-five varieties of cinchona well known, besides the recent additions made by Humboldt and Bonpland. The cinchona officinalis, or Peruvian bark, is the produce of different plants. They all, however, belong to the class, Pentan- dria, order, Monogynia, and to the same genus. It is the growth of South America. There are three kinds of it used commonly for medicinal purposes, viz : the cinchona lancifolia, (the pale,) the cinchona cordifolia, (the yellow,) and the cinchona oblongi- folia, (the red.) The pale comes in small quilled twigs, and thin. The yellow in flat pieces, and the red in large flat, thick frag- ments. And they vary in colour as their English names indi- cate. Of these three kinds, the pale is the least powerful, and the yellow the most. But the red is the least offensive to the taste. The yellow is so intensely bitter, that it is apt to nauseate. But as it is the most efficacious, and more readily yields its bitter and astringent principles to both alcohol and water, than the others, and as the red bark is so very frequently adulterated, and withal is so expensive, the yellow bark is generally preferred in prac- 28* 322 LECTURE XXV. tice. The yellow is said to be the genuine, original febrifuge of Spanish America. Before you give the bark, take care thoroughly to cleanse the stomach and bowels, and freely to open the skin. This is highly important. In hot climates, it is often necessary to administer the bark before the apyrexia : there is no time to lose. But in our climate, it is proper to wait for the entire solution of the paroxysm. It should be given soon after the apyrexia has taken place, and discontinued some time before the expected cold fit, otherwise its administration will aggravate the succeeding parox- ysm. It is not safe or proper to give it when there is any visce- ral obstruction, or a strong tendency to local inflammation. The most effectual mode of giving the bark, is in substance, in doses of ^ss. to 3i. (i. e. about a tea-spoonful) every two or three hours. To give less is to trifle with a valuable remedy, Lime juice is a convenient and agreeable addition to it. The following is an excellent form : R. cinchon. ^i. ; succ. limon. 5i.; elixir paregoric, 3\j.; aq. com. §viij. M. This quantity will make eight doses ; or it may be given in milk, in coffee, or in wine, being rubbed up into a paste. It is sometimes given in the shape of an electuary, thus : R. cinchon. pulv. §i. ; super-tart, potass. §i. ; carioph. aromat. gij. ; syrup, q. s. M. A very good way of exhibiting the bark in substance, is to wrap up the dose in a large wafer, made of a paste composed of two teaspoonsful of wheat flour in a teacupful of water, and passed between two hot irons well waxed. Let the wafer be moistened with a little wine, and then folded over the powder. It will then readily pass down as a bolus, especially if taken in a" spoonful of wine*. In this way, this nauseous article will be retained upon the stomach, which will reject it in every other shape. The bark may also be given in infusion. R. cort. cinchon. 5i. ; magnesias calcin. 3i.; aq. pluv. distillat. 5x. filter. This is to be taken cold, as when warm it is offensive and nauseating, and lime juice may be added to it with advantage. I do not think this mode of administration very efficacious, though in some cases it may be the best you can adopt. But generally it cannot be depended upon in intermittents. Next to the actual substance, the decoction has been long found the best mode of giving bark. In making the decoction care should be taken to boil it in a close vessel, and but a short time, TREATMENT OF INTERMITTEXTS. 323 otherwise you evaporate its virtues, and destroy its strength. The decoction should he made with one ounce of the bark to a pint of boiling water ; and of this from two to four ounces should be given at a dose. To this, the serpentaria, (gij, to the above,) may be added, especially if the stomach be very irritable, and the patient has some remnant of fever, and is much debilitated. Another mode of giving bark is the tincture ; and this is an elegant, and often a very powerful, prescription. Huxham's tinc- ture is the best form. I frequently have given it alone, and some- times in the infusion or decoction. Indeed, in the summer sea- son, it is very frequently necessary to add the tincture to the watery preparations. The bark may be given in extract, in doses of from five to fifteen grains. But this is a very uncertain form, as it is rarely properly prepared. The heat injudiciously applied in the phar- maceutical operation, frequently drives off or destroys all the vir- tues of the article. You may find it necessary sometimes, when the stomach will retain nothing, to resort to the administration of the bark by ene- ma. In this way it may be thrown up with milk ; or the follow- ing form may be used every four or six hours. Take of the pow- dered bark ^ss.; laudanum 3L; starch ^ij. M. After the first injection, thirty drops of laudanum will be sufficient ; and for young children, ten drops will be quite enough to produce the torpor of the bowels necessary to retain the injection. I have sometimes, and with great advantage, applied the bark externally, by means of the bark waistcoat, the endermic method, as it is called in modern phrase. With children especially, this may be used with benefit, w T hen it is found impossible to make them swallow any thing. I have mentioned these different modes of administering the bark, because you may sometimes find it necessary to resort to them, and may be placed in situations in which you can do nothing else. But they have all been superseded, to a great ex- tent, by the quinine, a preparation introduced some years ago. containing all the essential virtue of the crude material, with- out its disadvantages. It has been said that there are cases which the sulphate of quinine will not cure so readily as the substance itself. But its efficacy, under the circumstances in which the bark in other forms is indicated, is now well established. It may 324 LECTURE XXV. be given in pill, in doses of one or two grains, three or four times a-day. It may be given in solution. I have generally used the following formula: R. sulph. quin. 9i.; elixir vitriol, 3^ j syrup of ginger ^ij. M. A tea-spoonful every hour, or every two hours during the apyrexia. Or it may be given by enema. Children will seldom swallow the pills, and will frequently refuse the solution. The extreme bitterness of quinine will revolt them. You must then resort to the injection. Dissolve four grains of the quinine in three or four ounces of water, and add to it eight or ten drops of laudanum, and administer it. From some curious experiments very recently made in France, it would appear that quinine applied in the endermic mode, that is, externally applied, is very efficacious in curing intermit- tents. I have no experience whatever as to its virtue in this way. But it is said that quinine rubbed up with cerate, and applied to a blistered surface, is productive of very striking curative power. It is even said that it manifests its activity, when thus used, in a few minutes. Should further experiments verify these assertions, it certainly will be an invaluable remedy, because sometimes it cannot be taken internally, except with great difficulty ; and in some cases, as for instance when there is a strong tendency to local determinations, and perhaps a disposition to gastric and in- testinal inflammation, it cannot be internally administered with safety. But from what I can judge of the experiments which have been thus made with it, it does by no means appear very clear, that the quinine effected the cures. In all the instances, I believe, blood-letting was first resorted to. But still it is worthy of a trial. Sometimes you may find it best to give the quinine in con> paratively small doses frequently repeated. There is, I have found, frequently an advantage in this. But generally the best way is to begin with large doses, to be given at more distant in- tervals, so as to produce a strong impression at once. Even eight or ten grains have been given at a dose, and the Italian physicians give even more. But their fevers require very decided and peculiar treatment. The introduction of the quinine is an invaluable acquisition in the practice of medicine. Combining as it does all the curative properties of the bark, it has the vast advantage over every other form of it, that it may be given in such small bulk. TREATMENT OF INTEEMITTENTS. 325 A variety of other vegetable tonics, most of them of the cin- chona family, have been recommended as substitutes for Peruvian bark, such as the cinchona carribsea, the cinchona floribunda, (St. Lucie bark,) the cusparia febrifuga, (called by Humboldt, the Bonplandia trifoliata,) the Swietenia febrifuga, and the Swietenia mahogani. But they are all greatly inferior to the Peruvian bark. I, therefore, shall not dwell upon them. You may learn their properties from the books ; and the Professor of Materia Medica will tell you how they are to be administered, and what they are respectively worth. I have, myself, no very great confidence in any of them. Certain mineral tonics have been recommended for the cure of intermittents. The chief of these are arsenic and iron in various forms. Of the arsenic, Fowler's solution is the best : this is made by dissolving sixty -four grains of the white oxide of arsenic in §xvi. of water, and adding to it sixty-four grains of the sub-carbonate of potash, and Jss. of sp. lavend. compos. It is given in doses of from two to five drops, three times a-day, gradually increased to eight or ten drops. But, although I know it will cure intermit- tents, I cannot recommend it to you. It is a very dangerous remedy ; and often leaves consequences far more formidable than any ague. A liability to rheumatism, most distressing derange- ments of the digestive organs, violent headaches, wonderful ema- ciation, and not unfrequently, unmanageable dropsies, are the sad consequences of its use. Indeed, for months and years, patients who have taken arsenic for the cure of fevers, suffer serious injury to health. Never use it, unless the disease should resist other means, or you should be placed in situations where none others are at your command. Iron is far the safest of the mineral articles used in fevers. It is given in filings, in doses of from five to ten grains; in the form of carbonate, or rust, in doses of from five to fifteen grains ; in the form of the sulphate, in doses of from one to five grains ; in the shape of the muriated tincture, from ten to fifteen drops in wine, water, or syrup. But the best form of iron, and the one now most in use, is the Prussiate, (Prussian blue.) It is highly valued by some practitioners, and I have seen very good effects from it. It may be given in doses of from five to ten grains, gradually increased, three times a-day. Its being an inoffensive 326 LECTURE XXV. article, and its being a very cheap one, are its chief recommenda- tions. On this account it is very well adapted for use in large public institutions, where economy is required. I have used it a great deal in the New York Hospital, and have not been disap- pointed in it. But with the quinine at your command, you need not resort to the use of any thing else, unless in some few cases, where some peculiarity in the disease, the patient, or the circumstances, may demand a preference for some other article. I must remark that while you are thus building up the system, you must pay great attention to the diet and regimen of your pa- tient. Improprieties in these particulars, will counteract all that you are doing by remedial means. I need not dwell on these points, as I have already spoken upon them so fully. I merely remark in conclusion, that a judicious physician will never lose sight for a moment of the great importance of a vigilant regard to what his patient eats, and drinks, and does. There is nothing, however seemingly small, which has reference to these matters, that ought to be considered unimportant, or even of trifling mo- ment. 327 LECTURE XXVI. REMITTENT FEVERS. Remittent fevers next come under our view. I have already remarked that remittents have been very improperly considered by many writers, and especially by Dr. Cullen, and by Dr. Philip Wilson, as well as by Fordyce, to be mere modifications of the intermittent type of fever—whereas, remittents differ from inter- mittents in many particulars. These are worthy your regard, especially as they lead us to adopt a different and more active treatment for their removal. In the first place, I remark the remittent fever has not the dis- tinct visible rigours and long cold stage that announce the inter- mittent form of fever. 2. The remittent has a much longer hot stage. 3. The sweating stage is inconsiderable and partial, and is fre- quently wanting altogether in the remittent. 4. In remittents there is no perfect apyrexia as after the paroxysm of an intermittent. 5. The causes, both predisposing and exciting, are usually dif- ferent. The intermittents most usually are the effect of external causes, particularly marsh miasma, of cold, and intemperance, or they are renewed as already observed, by debilitating causes. Whereas, remittents ordinarily occur in a vitiated habit of body, so deranged by neglect of the intestinal canal—perhaps proceed- ing from bad food, or occasioned by the debilitating operation of summer and autumn, by intemperance, exposure to excessive heat, &c. And as they arise frequently from internal causes, from the state of the system, they also occasionally appear in the winter season as well as at other times of the year. And hence those 328 LECTURE XXVI. who do not discriminate between a bilious remittent and a yel- low fever, will tell you, forsooth, and very gravely, that they have seen the yellow fever in mid-winter! It may be added, that it is very prevalent both in town and country — in the latter most frequently, occurring in the lowest situations. In a remit- ting fever when forming, the patient is oftentimes affected with- out the slightest chill ; and the disease is slowly and gradually formed. So say Lempriere, Sir Gilbert Blane, Lind, Pringle, Niell, and Pym — who have all contended for the peculiarities of this form of fever. One day the patient is slightly indisposed, another day he is better, on the third day he is worse again. Whereas, in the yellow fever you see none of these alternations — in that, the disease is uninterrupted from the moment of the at- tack until recovery or dissolution takes place. The bilious re- mittent is also distinguished by various symptoms, viz : a loaded and yellow tongue, a foul offensive breath — the patient complains of a disagreeable and bitter taste in his mouth, headache, hot burn- ing hands and feet, especially as night approaches. At this time, too, a degree of horripilatio takes place, giving a sense of crawling, like the impressions created by hairs on the body. In some it creates the sensation of cold water running down the back — pains in dif- ferent parts of the body are complained of — the appetite is im- paired — the biliary secretion is sometimes slow, diminished, or altogether obstructed — costiveness follows — his discharges be- come more offensive than usual, and of darker colour — his urine becomes yellowish and muddy, at least somewhat turbid. In a few days after struggling against these symptoms and feelings, he is confined to his bed — his fever is increased, and the physician is called. Twice a day sensible exacerbations now show them- selves — but no perfect apyrexia or intermission follows — each ex- acerbation, however, is preceded by a sense of coldness, but not the honest, undisguised shaking that ushers in the intermittent. Such is the condition of your patient — what is to be done ? His whole system is now diseased, not only proceeding from external causes, such as marsh miasmata and moisture, and these perhaps, combined, but from a vitiated state of his bowels, a torpid state of the liver, the season of the year, his diet, and other causes. His whole system now exhibits the evidences of more or less in- ternal derangement pervading the whole body, showing itself in the secretions and excretions as well as the solids of the system. REMITTENT FEVERS. 32 f) Our object then, must be, if possible, to simplify the disease by removing from the system every source of that complicated form of the disease which it now exhibits. In other words, to reduce it, if practicable, to the intermittent character, that is, to take away those internal causes, which give a peculiar malignancy to the disease. The means of effecting this are various. 1st. If the habit be full and the excitement considerable, the patient, perhaps, under the influence of the effects of habitual and previous intemperance, that is, when an imflammatory diathesis prevails, in that case venesection may be advantageously directed 5 but it is to be done with great caution, keeping constantly in view the tendency of this form of disease to the more continued form of fever, and especially to the typhus type. But when it may have assumed that character and the contagion of typhus superadded, constituting it the malignant bilious fever of authors, and in this complicated form is communicated from man to man, blood- letting is rarely admissible. Such was the case in the late typhoid form of bilious fever of Bancker street — vensection was altogether inadmissible in the cases that fell under my view. 2d. Emetics are especially important, not only from their effects upon the stomach and biliary organs, but upon the whole system. Emetics in the Bancker street fever were generally beneficial when early applied — with the exception of those cases where the stomach was previously impaired by intemperance or active inflammatory symptoms of the stomach, liver, or intes- tines, had supervened. Some few instances of this nature occur- red, attended with black discharges as in typhus. But from a report, published by the Medical Society, it would be inferred that many such cases occurred. Not so. A more gross imposition on the public mind, I do not recollect to have witnessed. They would also lead to the inference that it is yel- low fever they describe ; but this is at once contradicted by the fact that it continued throughout the winter ; and I also know that some of the same committee who have lent their names to this fraud, this imposition, did not believe it to be yellow fever. They declared this to me themselves — you then will judge. The same disease among the blacks occurred at Philadelphia. See Dr. Chapman's observations on this subject, who also considered it totally distinct from yellow fever. An emetic, says Stoll, fre- quently strangles it at a blow, 29 330 LECTURE XXVI. 3d. In like manner, active cathartics, to cleanse the intestines of their offensive and putrid contents, should immediately be prescribed. 4th. Relax the surface by sp. mind, and laud, or by antim. and calomel combined. "Of all things," says Lind, "it is im- portant to relax the body into an intermission." 5th. Apply blisters early in the disease, and thereby concen- trate as far as may be practicable, the irritations of the system to a particular part — as far as practicable, convert the general into a local irritation. 6th. If the habit of body be plethoric, and the system is much excited, the skin obstinately dry and hot, make use of cold wash- ing and cold drinks. But if the system be greatly debilitated, use tepid applications, in the form of fomentations to the limbs, and cataplasms to the feet; not stimulant, composed of mustard, nor applied hot, but emollient ones, consisting of vinegar and water, and applied moderately warm. In this case, too, the tem- perature of the patient's drinks should correspond with that of the external applications. Continue, also, mild aperient medi- cines, viz., magnesia, small doses of salts, an occasional dose of calomel and James' powders, or an enema daily ; also attend to the skin, directing sp. mind., or the saline mixture, as the con- dition of the stomach may admit ; also repeat the blisters either for the relief of particular symptoms, or as a general means of re- moving fever. 7th. In hot climates the bark is resorted to during the remis- sions. There the septic tendency is so great and the powers of life are so rapidly prostrated, that this practice may be justifiable, and doubtless is proper ; but in temperate climates the early use of bark is less necessary, and indeed is generally injurious before an apyrexia is obtained. If, however, the system be greatly de- bilitated, the milder tonics, as bitters, snake root, chamomile, may be safely employed. 8th. Attend to the air of the apartment and the temperature of your patient We have remarked that even intermittents, by multiplying their paroxyisms, have a tendency to become remit- tents, and ultimately to end in typhus. So remittents are much more prone to assume the typhoid character, if attention be not paid to personal cleanliness and ventilation ; this is not all, they become contagious, especially in apartments where many persons REMITTENT FEVERS. 331 are crowded together. And in RussePs Aleppo, it is observed, " that intermittent or remittent fevers of the more malignant kind, are seldom seen at Aleppo, unless when imported by persons who have contracted them in other places ;" the author thereby clearly denoting their tendency to the continued form and their contagious character. See Russel's Aleppo, Vol. II., page 302, London, 4th edition. 9th. When remittents are unusually obstinate, if possible, re- move your patient to the sea shore, i. e. in the hot season of the year ; for this change, from a higher to a lower temperature, this new impression upon the sj'stem, frequently carries off both heat and fever, as in the remittents of children or diarrhoea infantum. When a crisis is obtained or an intermission only, then administer tonics, especially the bitters and stimulant nourishments ; but during the continuance of fever, the diet of the patient should be simple, and then chiefly consisting of vegetable nourishment and dilution, with the least stimulant drinks. The admission of fresh air into the chamber of the sick, and moderate exercise in the open air, then, also will be useful ; but if ending in the typhoid form of fever, then the treatment is to be pursued which has already been detailed when speakiug on that subject. Allow me here to repeat the observation already expressed in favour of the effects of opiates given to prevent the return of the exacerbations. As in preventing the return of the paroxysms of an intermittent, they in like manner prevent the chill and coldness that an- nounces the returning exacerbations of the remittent. This may be administered in the form of the Dover's powder, or in the fol- lowing combination, which is in some instances preferable — R tinct. opii, sp. ammon. aa zi., aq. menth. ^ij. M.; a table-spoonful every two hours, especially before the exacerbation is expected. INFANTILE REMITTENT FEVER. To this disease the attention of practitioners was long since directed by the valuable publication of Dr. Butler ; and recently by the excellent practical observations on the same subject, by Dr. Colly. The profession has again been called upon to notice this form of fever, which, although of daily occurrence at the bed-side, has not been sufficiently regarded by physicians. In this country, as I was early taught by my preceptors, Drs. Rush 332 LECTURE XXVI. and Kuhn, and as I have witnessed in my own practice since the year 1794, the remittent fever of children is more frequently met with than perhaps any other disease of infancy or childhood, if we except croup, pneumonia, and the diarrhoea, attendant upon teething. Nor is the infantile remittent confined, as observed by Dr. Thomas, to children under six years of age ; it is frequently met with between that period and the twelfth year. As in the bilious remittents of adults, it may be remarked of this fever, that it is very generally traceable to derangement of the digestive or- gans as its primary seat and source. This is evinced by the loss of appetite, the foul tongue, the offensive breath, and the confined state of the belly, in the forming stage of this disease. These symptoms in a few days are succeeded by those of fever, which is of very uncertain duration and violence, and not unfrequently vents itself either upon the chest, producing oppressed respiration and cough resembling pneumonia, or upon the brain, followed by the evidences of phrenitic inflammation, and ultimately termi- nating in hydrocephalus internus. This last termination, such is the natural tendency and force of the circulation upon the brain at that early period of life, may very generally be anticipated, if active means be not early employed to empty the stomach and intestines, and to unlock the surface of the body by the free use of antimony and other diaphoretics, warm bathing, or by blisters, to create a new and relatively safe seat of irritation upon which the febrile symptoms may vent themselves. Indeed, so con- stantly is hydrocephalus the sequela of other diseases, that it may, with very few exceptions, be considered as exclusively sympto- matic. I have even known pneumonia to be its forerunner. Teething is frequently productive of fever, ending in phrenitis and hydrocephalus; and I believe, as I have already intimated, the arterial excitement occasioned by the use of mercury, so gene- rally and so indiscriminately given in the diseases of children, has been a prolific parent of this fatal malady, and which has oftentimes been remarked to have greatly increased in frequency and mortality since the very general prescription of that metal. Blackall, Pemberton, and Willan, have all noticed the increase of hydrocephalus since the more general use of mercury. In as far, therefore, as increased arterial excitement of long continuance, whatever may be its type or its source, has a pecu- liar tendency to oppress the brain at this period of life, the same REMITTENT FEVERS. 333 consequence is to be apprehended from the remittent form of fever now under consideration ; and on this account not only calls for the most active means of obtaining a solution of such fever, but in an especial manner suggests the employment of such remedies as are calculated to divert the current from the brain to the other parts of the system. When, therefore, in the progress of fever, the brain begins to manifest irritation by pain or by stu- por, blisters to the extremeties, and active cathartics, such as an infusion of senna manna, and cream of tartar frequently adminis- tered until plentiful evacuations are obtained, are among the most effectual means of arresting the progress of the fatal train of symptoms now to be apprehended. I notice in a particular man- ner, the infusion of senna, having administered it in many cases of approaching hydrocephalus, and one in which the disease was confirmed, with the most decided advantage. The formula I recommend to your notice, and which I am in the habit of direct- ing, consists of the leaves of senna, cream of tartar, and manna, of each 5ss. infused in half a pint of boiling water — a wine-glassful every two hours, varying the dose with the age of the child, 29^ 334 LECTURE XXVII. CONTINUED FEVERS.— SYNOCHA.— CHARACTERISTIC SYMPTOMS. —TREATMENT.— SYNOCHUS VEL TYPHUS. The order of fevers which is next to be considered, is distin- guished by having no intermission, nor even a regular remis- sion, or sensible abatement. That is, whatever remission may take place, it wants that regularity of return that we have ob- served to belong to those fevers which are denominated remit- tents. Synocha, or inflammatory fever, is of this description. It is so called from the Greek word cwsxu>, to continue. Synocha, or inflammatory fever, may be said to be a state of pure, general excitement of the system, without local inflammation, and with- out vitiation of the fluids. When a particular part becomes the principal seat of disease, synochal fever loses itself in one of the phlegmasia, according to the part affected ; and when the fluids assume the typhoid type, it also ceases to be the pure, unmixed inflammatory fever which we have now in view. Inflammatory fever commences with a very slight degree of chilliness — some- times none. We have already observed, with regard to the chill which ushers in fever, that there is a regular grade of chill, from the quartan form of fever, through all the variety of remittent forms, to that of the continued type. That is, the greatest in the quartan, less in the tertian; still less in the quotidian. And again, that it is still diminished in the remittent and continued fevers. Accordingly it happens, that in the plague, in yellow fever, and the various forms of typhus, as in jail, hospital, and ship fever, there is frequently no chill to be perceived whatever. It was also observed, that as the chill and shaking are less, heat and excite- ment are greater. 2. In inflammatory fever the pulse is quick, strong, and hard. When the fever affects particular parts, as in the local phlegmasia. CONTINUED FEVERS. 335 especially if seated in the more sensible organs of the body, the pulse is not only frequent and hard, but peculiarly contracted and corded. In typhus fever, again, except in the forming stage, the pulse is small, and oftentimes feeble, and attended with cold- ness of the extremities, owing to the depressing and deleterious effects of contagion ; 'but in synocha, it is full and hard from the commencement, even though a sense of chilliness be present. 3. Inflammatory fever is attended with hurried, and oftentimes laborious respiration; but not that anxiety that characterises fever from contagion, which primarily affects the nervous system by its deleterious operation. The face is flushed, and the whole surface hot and dry; but in local inflammation, as in enteritis, the face is frequently pale, and the extremities cool. The heat of the sys- tem, too, differs from the pungent and peculiar heat of typhus. The eyes also manifest this high excitement. They become load- ed with blood, and impatient of light. The impulse of the cir- culation created upon the head, produces violent headache, and a manifest throbbing of the temporal arteries. And with these symptoms there is also a sense of burning on the brain, which some compare to coals of fire on the head. In some instances, coma, or delirium is the consequence of the force given to the circulation. The urine is high coloured, and diminished in quan- tity. The bowels are costive ; the secretions more or less impair- ed. The tongue dry and covered with white fur; and upon thrusting it out, the great heat of the body is manifest, even in that organ, by the rapid production of vapour from its surface. This form of fever is but imperfectly described by Dr. Cullen. " Calor plurimum auctus; pulsus frequens validus et durus; urine rubra; sensorii functiones parum turbetae." And in the last part of it, we (at least in this country) know it to be frequently incor- rect, inasmuch as it is oftentimes immediately destructive of the sensorial functions, and thereby proves fatal even in three, four, or five days. Sometimes inflammatory fever appears as a mere ephemera from indigestion. But intemperance in the use of spi- rituous liquors, exposure to great heat, violent exercise, fatigue, sudden suspension of perspiration, and the other excretions, by exposure to cold; as plunging in the river when heated, or expo- sure to a shower of rain after labour, upon a warm day, are among the most usual exciting causes of synocha. This form of fever occurs sometimes in cold climates, and in cold seasons of the 336 LECTURE XXVII. year, but then it frequently runs into the local phlegmasia, there- by losing its general character. We see synocha most usually in hot climates, or in hot seasons of temperate climates, and then it most generally attacks such as are of full, sanguineous ha- bits, especially those persons who may have recently changed their climate, by coming from a northern to a southern lati- tude. The impulse given to such habits of body by the causes which have been enumerated, is not only violent, but soon produces an engorged state of the brain, of the liver, the stomach, the uterus, &c, and if not immediately relieved, the system is broken down by hemorrhages, either from the vessels of the brain, or from the liver, or the intestines. In the torrid zone it assumes a greater malignancy of character, constituting a peculiar form of fever, from the typhoid state of body which it there assumes. This is not all. Under peculiar circumstances it is constituted a contagious disease, and propagates itself by con- tagion, in this new character, which it puts on in the tropics. Under these circumstances of climate, it is known by the appel- lation of yellow fever; and as I think has been already shown, it is or is not contagious, depending upon the condition of atmosphere in which it originates, or into which it may be introduced. In our own climate, in the hot seasons of the year, we have also an ardent fever, or causos, but which exhibits the symptoms of a pure, unmixed synocha. In the southern states, this indigenous fever is known by the name of the stranger's fever, because stran- gers to the climate, especially from the north, are most usually the subjects of it ; and to them, too, it' is frequently fatal in a few days. In the torrid zone, when the heat is above 85°, for a long con- tinuance, the same synocha in the stranger becomes a yellow fe- ver, and ultimately a contagious disease; i. e. in a foul state of the atmosphere, so rendered particularly by concentrated human ef- fluvia. The first is the effect of climate ; but its contagiousness depends not merely upon the condition of the patient, but the state of the air surrounding him — if pure, the disease is extin- guished in the individual — but if foul, as from confined human effluvia, as on ship-board, in hospitals, in garrisons, in camps, or in confined dwellings of any sort, the disease is communicated to other persons, who may be thus exposed, particularly the full habited stranger from the north. Every summer we have the causus or ardent fever in the form of synocha, and if it proves CONTINUED FEVERS. 337 fatal, ends in local congestions of the brain, the lungs, liver, &c, and in hemorrhages from the stomach, bowels, nose, or some of the organs mentioned. A sort of general sphacelus of the system is the result of this general inflammatory action, which in our climate, may with great propriety, be called pure or simple in- flammatory action, compared with the compound character it assumes in the tropics, and which is rendered thus compound by the septic condition of body, the effects of heat, and other causes. Accordingly, we find in our synocha, where it proves fatal, pete- chae and the yellow skin are rarely produced; but in the tropics, a peculiar state of the fluids is induced, exhibiting great malig- nancy in their quality, besides the waste of energy, the effects of simple excessive action. Then the humours secreted are peculi- arly modified, and by this specific quality become capable of re- producing precisely the same disease in those who may be pre- disposed to fever — especially the northern man — and indeed, sometimes it is communicated to the native of the tropics; but this is comparatively of rare occurrence. In the northern lati- tudes, synocha is not usually communicable. I mean that form of it which is engendered here. It is not communicable because that peculiar condition of the fluids, and those peculiar secretions, the effect of it, are not produced. Synocha, with us, breaks down the whole system by simple excessive action, like phleg- mon, which ends in the destruction of the part, and simple ulcer is the consequence. But in a hot climate, the phlegmon fre- quently ends in vitiated and malignant ulcer, spreading fresh in- flammation wherever its matter extends. The fever of the tro- pics, in like manner, terminates in a malignancy of the whole system, which, under the circumstances before mentioned, engen- ders the pestilence . Even in temperate climates, sometimes, syno- cha is protracted (but rarely) into typhus or synochus. But this is the effect of other causes, to be hereafter noticed. When the tem- perature of the atmosphere is as high as 80°, and for a long con- tinuance, the foreigner becomes the subject of ardent fever ; and which, too, perhaps proves fatal in a few days, exhibiting many of the characters of yellow fever of the tropics; and, indeed, if his system was in the septic state, as on ship-board is the case with seamen and soldiers, yellow fever would doubtless be the product ; i. e. ardent fever with the typhus malignancy of the system superinduced, would constitute the yellow fever, as it 338 LECTURE XXVII. appears in the tropics. But typhus alone is of a different charac- ter, and synocha alone is different; but the two being compounded in an athletic habit of body, in a climate where the heat is gene- rally at or above 80°, and in a septic state of the air, yellow fever is not only generated, but is communicated to others, especially to the men of the north, and even sometimes to the native. For these requisites, then, we need not go to Siam, but to any part of the tropics — to the coast of Africa, to the West Indies, or to South America. In this climate, synocha is more simple and pure in its character, except when introduced by contagion. The treatment of it is also simple, for we have but one general indi- cation, which is to reduce the excessive action of the system, duly regarding, however, the habit of body, the season of the year, climate and tendency of the disease. The means of fulfilling this indication are, 1st. Venesection, general and local, directed by the tone of circulation and strength of the patient's constitution, the dark colour and viscid consistency of the blood, but not the buffy coat. 2d. Open the bowels, especially by the use of saline purga- tives, Glauber, Rochelle, sulphate of magnesia, &c. 3. Sudorifics — sp. mind., and antimonials. 4. Cold washing — if no local inflammation exists, and the skin be hot and dry. I have objections to the clay-cap, prescribed for the relief of the pain of the head, and other affections of the brain. The advocates for the constant application of cold washing and the clay-cap forget the function of perspiration, and its office of carrying off the heat of the body, when by their applications they suppress this important discharge from the surface of the body. Instead of constantly covering the head with clay, as is done by some physicians, they may as well extend their prescrip- tion by covering the whole body at once with clay, for this will be the consequence of their practice, sooner or later. I have never known it otherwise than a fatal practice. .5th. Warm, or rather tepid bathing, as a means of relaxing the surface by its emollient effects, and for the purpose of conveying off the excessive heat of the body. 6th. Blisters, to convert it into a local inflammation, and for the relief of particular symptoms, as violent headache, delirium. Diet of the patient. — Bread and water; acid fruits; fresh, do. as oranges, &c. ; lemonade; toast- water; cream of tartar; cream i CONTINUED FEVERS. 339 of tartar, with tamarinds; cream of tartar whey; buttermilk whey. Regimen. — Clothing light, but sufficient to keep the skin re- laxed; covered from the air. SYNOCHUS OR TYPHUS. The next subject, agreeably to our arrangement, is synochus or typhus, which we consider as one and the same disease, though they are made different genera by Dr. Cullen. The word typhus, is a term of Greek derivation ; it comes from the verb tv^, to inflame. Dr. Cullen thus defines typhus fever : Nosology, p. 71. " Mor- bus contagiones; calor parvum auctus; pulsus parvus, debilis, plerumque frequens ; urina parvum mutata ; sensorii functiones plurimum turbetse; vires multum imminutae." How far does this correspond with the disease at the bed-side ? It differs from it in several particulars. Dr. C. states, that the heat is but little increased in typhus ; on the contrary, for the most part, in a cer- tain stage of the disease, the heat is very much increased and much more intense, and a very peculiar biting heat too. It is acer digitori que urens : so say the best practical writers, and such is the fact, as you may all daily witness in our hospital and our alms-house. Dr. C. also observes, that the urine is but little changed; on the contrary, it is frequently very turbid, like small beer, especially as the disease advances. With these excep- tions, his definition expresses the most prominent features of typhus. Dr. C. next proceeds to divide the genus typhus into two spe- cies, which he denominates typhus mitior, or mild typhus and typhus gravior, that which is more severe and violent. This, in my opinion, is an useless, and indeed an incorrect divi- sion. It is making a distinction where there is no difference. He himself admits in a note,* (which frequently, as I have said before, is at variance with his text,) that it is wrong to distinguish diseases by different names, that differ only in degree. His expression is "morbos gradu solum differentes, nominibus diversis insignire, nequequam convenit ;"' and he fur- ther subjoins, that he has not perhaps arranged them accurately, as the limits are by no means settled. " In hac re autem, cum * See Nosologia Method, p. 71. 340 LECTURE XXVII. limites neutiquam accurate ponere disunt me accuratum fuisse non dixerim." Under the one species, viz. the mitior, he professes to place the milder form, called nervous fever ! and under the latter species, the gravior he wishes to be considered as placing putrid fever, that is, where the humours more particularly show a diseased or putrid state. Still again in his notes, he unfortunately adds, that in every species of typhus, he thinks there is a tendency in the humours to putrefaction. " In omni typho humorum in putredinem proclivi- tatem adesse puto." A very strong expression certainly, of his opinion on the state of the fluids, in fevers; and it is to be regret- ted that in his first lines he had not given less attention to the nerves and more to the fluids. There is certainly, as you must perceive, and as Dr. C. himself in so many words admits, no foundation for these distinctions of typhus : they only serve to embarrass without leading to any possible good, either as it regards the nature of the disease or its treatment; for every nervous fever is attended with a putrescent state of the fluids; and every putrid fever is attended with a de- ranged state of the nervous system ; and this too is the case, whether this typhus state be the effect of long continued action producing the morbid state of the fluids, or it be produced by a taint introduced into the system, the produce of other diseased bodies. But strange to tell, Dr. Cullen with all his scruples of con- science, relative to the distinctions we have noticed, is not even contented with those two forms of typhus, and has accordingly constituted another genus ; another twin brother of typhus, which he calls synochus ! ! This he defines to be, " morbus contagio- sa, febris ex synocha et typo composita, initio synocha pro- gressu et versus finem typhus!!" A contagious disease, com- pounded of synocha and typhus, first synocha, afterwards as it proceeds,, and towards its termination, a typhus. But, let us ask, is he himself satisfied with this new genus, as distinct from ty- phus ? Let us again look, for I have already said that Dr. Cullen, in his notes, deposites all his doubts of the correctness of his text, and indeed he frequently here gives us more truth than he does in his text. Here again, in a note, he candidly observes, that be- tween typhus and synochus, he is unable to ascertain the exact CONTINUED FEVERS. 341 limits, and is in doubt whether they are really different genera. or if different, to which of them the synonyms of authors apply. The following is his own language : "Inter typhum tamen et synochum limites accuratos ponere non possum : et an revera pro diversis generibus habenda, vel positi^ diversis, utrieorum synonyma auctorum referenda sunt dubito. ,? A very honest doubt ; and if he doubts, we surely may be per- mitted to doubt the correctness of his distinction, as he admits himself, that it is a distinction in which he cannot find the differ- ence. You will therefore, gentlemen, not be surprised that I have made these* two genera of Dr. Cullen, one and the same, calling them typhus or synochus, for neither we nor Dr. Cullen himself, can distinguish between them. On this subject we have already been so free, that I have few observations to make at thi? time, and these will be very short. Typhus or synochus we remark, is very generally more or less inflammatory in its first stage : i. e. when the poison creating the disease, first acts on the system ; whether gendered within it or introduced from without, it excites irritation, manifesting that stage of the disease which may properly be denominated the in- flammatory stage, or the stage of remittent ; that is, it is synocha in its commencement, though it is typhus in its progress and its termination. Armstrong too, takes this view of this subject. The symptoms, as it affects the brain, nerves, heart, arteries, exhalents and the excretions, the absorbents and the fluids of the system, have all been very fully detailed. The causes also of this form of fever have been particularlv * Dr. Dumar, I observe too, in a late publication, refuses to admit Dr. Cullen's distinction between typhus and synochus. The following is Dr. Dumar's obser- vations : " I have not used Dr. Cullen's distinction of synochus and typhus ; because I do not believe that the distinction exists in nature. I have never seen an in- stance of typhus fever according to his definition. "All our severe fevers begin with excitement and terminate in debility, or are instances of synochus : although in truth, they are the identical diseases from which Dr. Cullen drew his description of typhus, and are genuine examples of the only typhus fever which exists." Dr. Cullen's system, says Dr. Good, like himself, is a work of no ordinary stamp ; it is full of immortality, but mixed up with weak and perishable materials. — Good, vol. ii. p. 119. 30 342 LECTURE XXVII. enumerated, viz. marsh effluvia, under peculiar circumstances ; confined human effluvia, decomposed animal matter, salt provi- sions, want of fresh vegetables, &c. and contagion. Of the first, we have seen examples at the Walkiil, in the newly cleared grounds of our southern states, and in the wet marsy grounds of Walcheren, in the island of New Zealand. The typhus of Great Britain, which occurs in their large cities, and in their manufacturing towns, are the products of confined human effluvia, the results of the filthy mode of living, unavoida- ble among the poor, where the resources of life are so scanty, compared with their population. Ship and jail fever are of the same description, only assuming if possible, a still greater degree of malignancy, as we have seen exemplified on board of the Irish ships which have been employed in bringing the sons of St. Patrick to this country. And that typhus or synochus is also produced by contagion, as well as gendered by the causes we have enumerated, I trust is admitted by all who are practically acquainted with disease. Closet physicians may speculate about it, and because they cannot comprehend the why and where- fore, cut the knot by denying the existence of contagion in toto. But, while the works of Huxham, Lind, Blane, Pringle, Rush, Saunders, McGregor, Gregory, Home, Cullen, Lempriere, For- dyce, Cleghorn, Chisholm, Heygarth, and Armstrong remain, the positive testimony which they give you on this subject, is not to be affected or overturned by the breath of speculation, or the airy nothings of imagination. I may indeed refer you, passim, to every practical writer, whether at home or abroad, for the evidence of the contagious character of continued fever under the peculiar circumstances which have been enumerated ; the hospitals of London, of Edin- burgh, of Aberdeen, furnish to their pupils continued examples on this subject ; and it is to be regretted, that some of their American pupils had not spent their time more profitably, and brought with them to this country, more correct knowledge of this subject, more facts and fewer speculative opinions. We see it, according to Drs. Young and Gordon, even com- municated to the lying-in women, giving even to puerperal fever this contagious character, not ordinarily attached to that disease. Nor is it confined merely to fevers and other diseases of the whole system ; but this state of the air influences the character of many CONTINUED FEVERS. 343 local diseases — hence indeed has arisen the peculiar form of ul- cer, called hospital ulcer, noticed by practical writers. " Every ulcer," says that accurate observer, Dr. Blane, "acquires pecu- liar malignancy when such a state of the air taints the bodies of those who labour under them." But we need not go from home for illustration, we see it in our public institutions, and occasionally in our private families. In my own family, in the present winter, I have witnessed the intro- duction of this disease by contagion ; this fact alone, must con- found all who could have before entertained a doubt on this subject. The most malignant form of typhus fever, as it prevailed among the soldiers stationed in the neighbourhood of this city, was intro- duced into my family by a son of one of my servant women. I could not send him from my house to deprive him of his mother's services during his sickness : the consequence was, that my chil- dren, who frequently went to- his room, took the disease from him, and they had nearly perished with it. And in all, it put on the same character, the same malignant form of typhus, attended with all those effects of the nervous system, and the vitiation of the fluids and broken texture of the solids that have been noticed, bleeding gums, bleeding blisters, blood boils, and unceasing de- lirium. I still look back with horror at the destruction 1 had nearly witnessed, by the visitation of that disease, and cannot but cherish the strongest feelings of gratitude for the preservation of my children on that distressing occasion. The indications of cure in this form of disease, and the means of fulfilling them, have been also minutely pointed out, as consist- ing, in the first stage, of the means of reducing the excitement produced, at the same time keeping in view the termination of the disease, and the debility which ensues. We have especially pointed out the use of venesection, emetics, cathartics, sudorifics, and the alterative treatment, to prevent the poison from wasting the system by its action, i. e. by counteracting, by means of evacu- ations, the irritation it occasions, until the poison creating the dis- ease, shall itself be worn out, and the putrescent state of the sys- tem be removed. This is an important idea to be kept in view, and that our remedies be so directed, that thereby the poison of the disease should do the system as little harm as possible. In the treatment of the second stage, our attention has been 344 LECTURE XXVII. directed to the means of counteracting the debility induced in the solids, and the diseased condition of the fluids. Stimulants and tonics, both in the form of medicine and diet, have been particularly directed for the first of these objects ; while the most powerful antiseptics which the materia medica or our food can furnish, and other means of counteracting the putres- cent state of body, including the use of external applications, ven- tilation, aand other means of purifying the air, &c, have all been so minutely detailed, as, I trust, to make any further observations at this time wholly superfluous. 345 LECTURE XXVIII. DYSENTERY. Dysentery being a disease of frequent occurrence, and being always attended with danger, is highly important. It is especially important during war, when the disease usually assumes a con- tagious character, and, superadded to the danger to the individu- al, is that of communicating it to others. The term is derived from 8d$, difficult, and svtspov, intestine; thereby denoting a de- ranged state, more immediately, of the intestines. Dr. Cullen has very properly denned dysentery to be " Py- rexia contagiosa; dejectiones frequentes, mucosae, vel sanguino- lentae, retentis plerumque foecibus alvinis; tormina; tenesmus:" a contagious fever, attended with frequent mucous or bloody stools, (or rather, he should have said, with frequent efforts to go to stool, and then very inconsiderable discharges.) " The foeces," he adds, " are for the most part retained, attended with gripes and tenesmus." By tenesmus is meant a straining and frequent inclinations, but unsuccessful efforts to discharge the contents of the bowels. From the bloody discharges attendant upon dysentery, it is commonly known by the vulgar name of the bloody-flux. As I formerly observed, Dr. Cullen has strangely placed it among his profluvia; whereas it is most frequently the very reverse of pro- fluvia, being most usually attended with diminished instead of increased discharges. Remember, I refer more particualrly to epidemic dysentery, not only because it is a highly contagious disease, but also to distinguish it from that local affection of the bowels, consequent upon diarrhoea, or the effect of mere local irritation in the intestines, such as is occasioned by aloes, or mer- 30* 346 LECTURE XXVIII. cury, or teething, and which is unaccompanied by the typhoid form of fever, that characterises this disease. In the disease re- ferred to, under the appellation of dysentery, I mean the dysen- tery of camps, as described by authors — the " febris intro versa" of Sydenham, and which is not merely a disease of the intestines, but a disease of the whole system. The circumstances under which it occurs, the causes which give rise to it, the character of the fever attendant upon it, the season of the year at which it most generally appears, have all induced me to place it among the continued fevers. In other words, to consider it as a disease of the whole system, and not as a mere local affection of the bowels. The treatment, too, which is founded upon this view of the disease, is more likely to be successful. Otherwise our attention may be directed to the bowels alone, while the state of the whole system is neglected, and the disease is thereby rendered fatal by those circumstances, having overlooked forms which give it ma- lignancy, and render it a dangerous disease. Dysentery, for the most part, occurs in summer and autumn; that is, about the same time with intermittent, remitting, and ty- phus fevers; and sometimes proceeds from the same causes. Ac- cording to Huxham, it has occurred as an epidemic in the spring, and it has also continued through the winter; but winter generally checks its progress, as it does the plague and yellow fever. Pure dysentery never assumes the intermittent or remittent forms of fever, but always the typhoid, except when complicated with them. Even in the same ship, in some instances, the two differ- ent diseases have been known to exist at the same time, without the one yielding to the other. A case is related by Dr. Blane, where two ships' crews were mixed — the one was affected with dysentery, the other with fever. In another place he observes, that even two different persons, owing to constitution, will be at- tacked, one with fever, the other with dysentery. Dr. Harty, however, is of opinion that dysentery is contagious only when combined with typhus fever; and that its contagiousness is only derived from the fever accompanying it. It is true that dysen- tery is only contagious sub modo, depending on the state of the surrounding air. In private families it is not always contagious, owing to cleanliness, state of the air, &c. ; but in an impure air, both the disease itself is rendered more malignant, the secretions acquire additional virulence, while the air itself is peculiarly fit- DYSENTERY. 347 ted as the vehicle of conveying, or rather of multiplying the con- tagion effused from the diseased body. Zimmerman justly ascribes to this cause alone its contagious- ness: " Hence," says he, " it prevails among the lower ranks, where their houses and their persons are filthy;" and observes, " that it is only infectious as cleanliness is disregarded." But although filth may generate it, and give malignancy to the dis- ease, a specific contagion will, in some cases, propagate it, even where cleanliness is observed, and in the pure air, too, of the country. This was remarkably the case in two families, some years since, in the country, on Long Island. The same fact has been remarked of yellow fever, jail fever, and other contagious diseases. That they acquire such malignancy that the disease is communicated from individual to individual, independently of the state of the air. This, however, is not usually the case; but these facts are important as they demonstrate the specific charac- ter of those diseases, and the communication of them by a speci- fic material. Others consider the peculiar mucous discharge, which takes place from the bowels, as the only contagious matter or vehicle of the disease! This is but one of the media of com- munication. In other contagious fevers, the various excretions of the bowels, the skin, and the lungs, all communicate the speci- fic poison of disease. Dysentery also appears more frequently in warm than in cold climates, especially in persons going from a northern to a southern latitude; and more particularly those who add to their septic habit of body by living principally upon ani- mal food, as is the case on ship-board, especially transports. The same thing is observed of malignant fevers in general. Hence dysentery, as well as those fevers, are so prevalent in hot latitudes, as in the West Indies, the East Indies, in South America and Africa. Dysentery appears also during and after wet seasons, in those cli- mates, especially when the rains succeed to great heat, and the body is consequently in a septic state — the perspiration being then suddenly checked, the bowels are immediately affected. The febrile affection, that is produced in this state of the system, and in the condition of the intestinal canal that is occasioned by the excessive use of animal food, the accumulation of human effluvia, and the want of fresh vegetables, is immediately turned in upon the intestines, which become the chief seat of its irritation; hence very properly called by Sydenham, " febris intro versa," or fever 348 LECTURE XXVIII. turned in upon the intestines. " This disease," says Pringle, " is always most numerous and worse after hot and close summers, especially in fixed camps, or when the men lay wet after a march in warm weather." Bontius, too, remarks that the hottest weather produces that disease when the nights begin to be cold. Upon the same principle, dj^sentery also frequently occurs in the hot seasons of temperate climates, as well as in the hot latitudes which have been noticed. An impure atmosphere, rendered so by many persons being crowded together in small apartments, as on ship- board, both predisposes to, and in some cases, gives rise to dysen- tery, especially in conjunction with the use of salted or putrid provisions: for, as before remarked, the excessive use of animal food, and the want of fresh vegetables, has great agency in indu- cing this peculiar condition of the intestinal canal, necessary to constitute dysentery. Putrid effluvia, i. e. exhalations from pu- trid animal matter, are also among the exciting sources of dysen- tery. Dr. Donald Monro says, it is always produced by obstruct- ed perspiration, and exposure to putrid effluvia. (See my letters to Dr. Currie, stating the cases of dysentery occasioned in 1798, by the effluvia of putrid beef.) Thirty-eight of forty persons en- gaged in removing and unpacking putrid beef, were attacked with dysentery, at the very time, too, that yellow fever prevailed in part of the city. Subsequently it was introduced in the neigh- bourhood of this putrid atmosphere, and produced the most deadly effects, extending itself as far as that foul atmosphere extended. Marshy and moist situations are among the causes of dysentery. They not only act by the vapours arising from decomposed ani- mal and vegetable matters, abounding in such situations, but also by the cold which such moisture produces, and the check of per- spiration which is thereby occasioned. " Accordingly" says Pringle, u armies thus encamped rarely escape." Cold is another powerful exciting cause of dysentery; " espe- cially," says Lind, " the alternate action of heat and cold." Dr. Blane remarks, " that exposure to cold produced dysentery in a vessel that had been perfectly healthy, and where the greatest cleanliness had been observed. Upon leaving New York," he adds, " the first cold weather induced a dysentery, which cut off sixteen of the crew." When dysentery may have been generated by any of the causes which have been enumerated, it is afterwards propagated by a DYSENTERY. 349 specific contagion. I say, a specific contagion, because precisely the same disease is reproduced, with all its peculiarities. The same peculiar affection of the bowels, and the same character of fever are the consequences. Whereas, obstructed perspiration alone would produce, under other circumstances, diarrhoea, or cholera morbus, or some of the phlegmasia; or, if the contagion was in the system, such check of perspiration would be an ex- citing cause of dysentery; but contagion alone produces dysen- tery, and few other diseases prevail when dysentery appears. Like other contagious epidemics, it generally takes the command and makes all other diseases obey; and it is reproduced in all with precisely the same kind of symptoms ; that is, in all who are predisposed to receive it; for in some it is more easily lighted up than others, as a man, labouring under dysentery, introduced on board ship, will spread the disease through a whole crew, be- cause that crew, by their habits of living and vitiated state of body, are rendered very susceptible both of the typhoid form of fever, and the irritation of the bowels peculiar to dysentery. This was the case, according to Dr. Blane, in the Torbay ship-of-war, in August, 1780. "The crew," he states, "were predisposed to acute distempers, as was to be expected at that season of the year; and a great number of them being crowded together, as is usual in ships of war. In this state of things a man was brought on board, ill of dysentery. Dysentery," says Dr. Blane, " be- came the prevailing disease.* But again," says Dr. Blane, u if instead of a dysentery any other fever had been introduced, such fever would have been the prevailing disorder." Different habits of life, and consequently different habits of body, have their influence in determining the character of a disease; the conta- gion of typhus fever being introduced among puerperal women, puerperal fever, with all its characteristic symptoms, is the result. In like manner, owing to a peculiar diet, in connexion with bad air, a predisposition may exist in the intestines to dysentery; while in others, not thus prepared, the same typhus taint will not produce dysentery, but typhus fever. This fact is stated to have occurred in a ship employed as a transport ship from England to New South Wales. The crew of the ship were ill of fevers; meaning ordinary typhus, or ship fever. But the convicts whom * Dysentery of Seamen, p. 44& 350 LECTURE XXVIII. they had received from prison, became the subjects of fluxes; i. e. dysentery, owing to something peculiar in their habits, predis- posing to dysentery. — (See Blane, p. 449.) These two diseases, therefore, it appears, are in some cases vicarious, depending on particular circumstances or accident, though arising from the same causes. Weak and exhausted habits are most susceptible of this disease. Fatigue, vexation, and fear, peculiarly prepare the body to become affected by dysentery as by other contagions; and hence tonics frequently are the means of preventing it in this, as in others. (See Sir George Baker's Treatise de Dysenteria.) Not only so, but these causes render it more violent in degree. The same fact is observed of the contagion of small-pox. The debilitating preparation, formerly fashionable, as preparatory to inoculation, almost invariably rendered the disease more virulent than it would otherwise have proved. (Example of Dr. Coch- rane's, the Surgeon General, of want of medicine to prepare the American troops for inoculation, during the revolutionary war, when stationed near New Brunswick. They all had the disease in so mild a form that the fact was notorious. See Thacher's Military Journal.) Contagion itself, is only in some cases a predisposing cause of dysentery, while cold, fatigue, intemperance, or other occasional causes, shall excite it into action ; as we have seen to be the case with intermitting and remitting fevers. But when dysentery is once generated, contagion in that case becomes the chief exciting cause. This is communicated, most commonly, though, as said before, not exclusively by the excrements, by moving of public privies, or by neglect of cleanliness in retaining the excretions in the apartments of the sick. Infected clothes are also oftentimes the vehicle of the contagion, and from which not only the wearer but those who come near, receive the infection. In some instances, according to Dagner's history of the disease, it has been as epi- demic as the plague ; " but it is generally true/' says Sir John Pringle, " that the infection spreads more slowly than most epi- demics." Dagner again observes that dysentery is not less infectious than the plague itself, (this, however, is somewhat questionable,) and that, like many other contagious diseases, it is oftentimes com- municated to the foetus in utero. Women thus situated, fre- quently, however, escape, as in the example of Mrs. Miller, and DYSENTERY. 351 women in the Hospital, mentioned to you some time since, who went on to her full time and bore a living and healthy child. But the most common of the exciting causes of dysentery, is the check of perspiration by cold in those who are prepared for the disease. Zimmerman accordingly observes, and which is in cor- respondence with this fact, that warm drinks and perspiration, with a moderate quantity of food, (which, by the by, he should have restricted to vegetable food,) and temperance as to liquors, are among the most effectual means of prevention, and, that they render the disease mild when its subjects are attacked. Wilson enumerates among the causes of dysentery, an unusual quantity of bile, and that of a dark colour, implying, says he, a vitiated state of that secretion. This, too, he remarks, is confirmed by the dis- ease spreading where this is the case. But it is very plain that Wilson does not understand the connection that exists between dysentery and the state of the biliary secretion. This obstruc- tion of the bile is doubtless the consequence of bad diet, that is, of an undue proportion of animal and salted provisions, or per- haps of the extensive uses of them and the want of fresh vegetables ; for as I have observed to you when speaking of the nature of diet, it is the effect of fresh ascescent vegetables and acid fruits, to promote the secretion of bile (as butchers tell us too, is the case with cattle living on grass instead of hay,) and of the want of them to diminish the secretion. This obstruction then proves an aggravation of the disease by retarding the peristaltic motion of the intestines, and thereby promoting the putrefaction of the contents of the intestines. It is also ascertained that bile present in the intestines has a directly antiseptic operation upon the contents. In that case its absence may assist us in accounting for the more rapid putrefaction and more virulent condition of its contents. — (See Wilson's Treatise.) We now come to the symptoms of this disease. The other characteristic symptoms of dysentery are well marked in the definition given of it by Dr. Cul- len. Notwithstanding his objections to the humoral pathology, he admits the putrefaction of the fluids and the contagiousness of diseases which derive their character from the circulating fluids and the excretions which take place from those fluids. And especially making the contagiousness of the disease an essential part of it ; for it is of all things an essential character of dysen- tary under the circumstances favourable to the propagation of 3.52 LECTURE XXVIII. contagious fevers in general, and ought always to be kept in view by the physician, and that too, whether the disease appears in the camp or the private family. Not so, says Wilson, adding that this part of Dr. Cullen's definition, calling it a contagious pyrexia, might be dispensed with altogether. Let me remark to you, gentlemen, that you will find Wilson's chapter on this subject a very heterogeneous one, and that the author has no correct view either of the nature of the disease or the treatment of it. He has merely strung together his remarks from the writings of others, and those not the best, without, as I believe, having him- self, the least practical knowledge of dysentery. He never had that opportunity. I knew him well as my fellow student, and know his pursuits to be those of the closet, not the practical phy- sician. His indications of cure, to be sure, would lead you at first view to suppose he had carefully examined the subject, for he very soberly makes two indications — but what are they? viz . to procure the evacuation of natural foeces, and as soon as this is accomplished, to restore tone to the bowels. A very local view indeed, and such, as in my opinion, shows his total want of essen- tial acquaintance with this subject. But Dr. Cullen's, you will find to be little better, for he makes spasmodic constriction of the bowels the proximate cause, and of course antispasmodics the chief remedies! Wilson, too, as you will find, evidently com- pounds the local irritation consequent on diarrhoea with the dysentery of camps. It is important then for us to attend to the symptoms of dysentery, that we may arrive at some general de- ductions relative to its nature, and that from thence we may ob- tain correct principles to guide us in its treatment. It may be remarked that dysentery appears in two shapes, that is, as it re- gards the part of the body first affected. When it is generated in the individual, the first symptoms of the disease manifest themselves in the bowels, producing pains, tenesmus, and conse- quently a febrile state of the whole system. But when it is the effect of contagion the whole system manifests its operation, and soon after the bowels, that is, exhibiting at first all the symptoms attendant upon the invasion of typhus fever, viz : chill, heat, thirst, a dry skin, and, in a short time, these are succeeded by irri- tations of the bowels, to which the subject is peculiarly predis- posed by the circumstances under which dysentery usually ap- pears. Wilson says that the fever of dysentery is sometimes a DYSENTERY. 353 synocha throughout the greater part of its course. Dawson, too, in his nosology, expresses the same views. He, however, ad- mits that it is more frequently of the typhus form, and that when this is the case the danger is very great. This, I would re- mark, is very true in every case of real dysentery — not that form of it which he states to begin with diarrhoea, which he says is often the case. From this assertion alone, I should suppose Wil- son had never seen a case of genuine dysentery. On the con- trary, so far from diarrhoea, it begins by the want of evacuations or rather frequent efforts, but attended with very small and very inconsiderable discharges. Another circumstance which would lead us to distrust his views on this subject, is his observation, that dysentery is sometimes a disease of many months duration. On the contrary, being a very severe and an acute disease, it is ne- cessarily a disease of but few days continuance. It is evident then that Wilson has confounded a mere morbid sensibility of the bowels, the consequence of diarrhoea or dysentery, with dysentery itself. In the first place then, the symptoms of dysentery are the symptoms of general fevers of the typhus type, manifesting considerable irritation of the nervous system, viz : chill, nausea, vomiting, frequent pulse, which is sometimes weak early in the disease, as after other species of contagion. This, however, is not oftentimes the case in the commencement, for generally the excitement of the arterial system is very mani- fest; but dysentery never exhibits the symptoms of typhus fever alone, as Wilson asserts, without an affection, or the usual irrita- tion of the bowels, for these very soon succeed. Where they appear late, Wilson calls it a complication of typhus and dysen- tery! I assert that true dysentery is always of the typhoid tendency and character ; and that, whether generated within or introduced by contagion. Nor do the general or constitutional symptoms depend on the local, as Wilson states, (p. 414.) On the contrary, both the general and the local irritation are to be considered as essential to true dysentery. Blane, however, is of opinion that the affection of the bowels is only symptomatic. But were this the case, we should see few cases of typhus fever with- out the local symptoms attendant upon dysentery. In addition then, to the general symptoms of typhus fever, this disease is at- tended with pain in the bowels, and which, as in enteritis, is increased upon pressure. This pain appears sometimes about the 31 354 LECTURE XXVIII. navel, affecting chiefly the small intestines which occupy that part of the abdomen. Most usually, however, it affects the stomach, and the part of the colon passing in its vicinity, attended with irritation in the rectum and anus. Not, however, confining itself to the anus, but extending to the hips and through the pelvis. In some instances, Cleghorn observes, that the pain extends to the ribs and lungs, resembling the pains of pleurisy, extending from one hypochondrium to the other. This will remind you of my ob- servations in the case of the bilious accumulation in Beekman street, resembling enteritis ; and that the same cause in other cases exhibits the symptoms of pleuritic inflammation. Another remark of Pringle, and other practical writers, deserves your at- tention ; that when pain and griping exist without much nausea, it is an indication that the large intestines are the seat of the dis- ease; and on the other hand, that when there is more sickness than griping, and the irritation is higher, the disease is pro- bably seated in the small intestines — so says Pringle. But you will perceive that this distinction must in some respects be equi- vocal, depending very much on the sensibility of the nervous sj'stem in the individual labouring under the disease. And in most cases, too, let it be remarked as a fact, that the disease is preceded by indigestion, showing itself in nausea, flatulence and eructations, which are to be expected from the costiveness con- stituting the commencement of the disease ; but the lower part of the intestines becomes the chief seat of its irritations, for there the cause of the disease operates with more force, for there is the greater malignancy of the contents of the bowels. The con- sequences are inflammation, followed by mucous and bloody discharges, and sometimes, says Sydenham, no stools at all. It is important for you carefully to distinguish between the mucous and bloody stools of real dysentery and those attendant upon diarrhoea, or which succeed to the use of mercury, or the bloody evacuations occasioned by hemorrhoids, and in children by teeth- ing. In some cases, too, of dysentery we meet with evacuations of mucous without blood ; but this is of so rare occurrence as to afford no foundation for the distinction which has been proposed, into mucous and bloody dysentery. When stools consisting of foeces are procured by art, in this disease, they consist of small dry, circumscribed, globular masses, denominated scybala. How are these formed ? By the irritation occasioned by the con- DYSENTERY. 355 tents of the bowels producing a spasmodic constriction of the intestines, particularly the colon. The same irritation, too, excites the absorbents in common with the other parts of the vascular system, and occasions the more fluid contents of the bowels to be absorbed, leaving the remains hard and dry, and moulded in the cells of the colon. In this manner these scybala are formed, while the materials absorbed vitiate the whole mass and aggravate the character of the disease ; and where the dis- ease proves fatal, the intestines being examined after death, are frequently found contracted, even in some cases, to three-quarters of an inch diameter! — the coats thickened exhibiting ulcers and other evidences of inflammation.* * See Baillie's Morbid Anatomy, pp. 67—71—73. 356 LECTURE XXIX, DYSENTERY. Having noticed some of the symptoms of dysentery, and showed you some of the plates of Dr. Baillie, exhibiting the ulcera- tions and changes which the intestines undergo from the infla- mation attendant upon that disease, I go on to remark, that in most cases of genuine dysentery, the discharge from the intestines appears of a mucous and viscid nature, resembling the scrapings of guts, or those portions of fatty matter which are separated in cleaning the intestines of animals. The thinner parts of the mu- cus, the natural lining of the intestines, are absorbed, and the more viscid remains are forced off by the tenesmus attendant on this disease ; but sometimes the inflammation of the intestines produces, as in other membranes of the body when inflamed, an excretion of matter, which exhibits a membranous appear- ance, and which is . effused on the surface of the inflamed gut. We see this process exemplified in the inflammation of the tra- chea and pleura, the dura mater, and the intestines in enteritis, in strangulated hernia, in the excitement of the uterus, producing the appearance of membranes, and in that of the ovum, leading to the same deception. See Hunter. We see the same in the inflammation attendant upon dysentery. By many, this apparently membranous production, the effect of inflammation, is considered as the villous coat of the intestines thrown off. Not so : this cannot be, except after sphacelus — which sphacelus must be preceded by purulent discharges, the effect of high inflammation. In those cases, ulcers after death, are ob T DYSENTERY. 357 served to have been the attendants upon such separations of the in- testinal coat ; but this apparently membranous matter, which is discharged in dysentery, is frequently thrown off, when no ul- ceration has taken place in the bowels, as has been ascertained by examination of the body after death. This fact is particularly stated by Zimmerman. Dissections too, show the inflammation of the bowels, which ter- minates in ulceration and in sphacelus, are altogether distinct from the former. The inflammation has been sometimes found to extend even to the stomach, which too, partakes of the gangre- nous or dark colour ; the coats of the intestines have been found thickened, the villous coat in some cases entirely consumed, and the vascular in that case is usually found, loaded with distended vessels, and covered with a bloody sanies or slime. The large intestines are more frequently found sphacelated and ulcerated than the small. Why ? Because they are the residence of those more acrid materials which enter into the nature of dysen- tery. Inflammation in that part of the intestinal canal is neces- sarily the consequence. Sometimes too, according to Cleghorn, ulcers are found upon the outside of the intestines as well as internally, thereby show- ing that the whole texture of the bowels is involved in the in- flammation; not only the mucous lining or tissue, but all the tissues inside and outside, muscular and peritoneal, as well as the inner mucous lining. In some, again, small abscesses were formed in the cellular membrane of the peritoneum, contiguous to the colon and rectum. In others, the convolutions of the intestines were found adhering to each other and to the neighbouring parts, as in enteritis. Purulent matter has also been found floating in the cavity of the abdomen, and in two cases related by Dr. Cleg- horn, the omentum was almost wasted by the absorption of its fat ; but in other instances, the omentum has been known to re- main loaded with fat, while the intestines had rapidly run on to gangrene. In some again, small, flat tubercles, like the flat pus- tules of confluent small-pox, are found in the intestines. Pringle, Cleghorn, and Hewson, have all noticed these appearances ; and Linnaeus has also described what he calls scabies of the intes- tines, that he has found in dysentery, and which is probably the same appearance. 31* 358 LECTURE XXIX. Zimmerman too, notices flat aphthae on the intestines, yielding pus like the flat pustules of small-pox ; he also remarks, (see Wil- son, p. 421,) that the mesenteric glands were found swelled, in- flamed, and containing a bad kind of pus. Cleghorn also describes scirrhous tubercles, as found after death, in addition to the inflam- mation and mortification, which are the attendants upon dysen- tery. It is remarked by some writers, that in cases where much blood has been discharged during the disease, upon examining the body after death, it frequently happens that no ulceration is to be perceived, that is, the local inflammation has been removed by such discharge. From this fact, Sir John Pringle and Zimmer- man have concluded, that the discharge of blood is the effect of the typhoid state of the system and the consequent relaxation of the vessels, and not the effect of ulcerations or the mere local constriction of parts. The truth probably is, that both the local and general disease, are concerned in the production of this as well as most of the malignant symptoms of dysentery. The gall bladder has oftentimes been found much distended with bile, and that of a darker colour than is natural, as has been re- marked by Cleghorn. This fact shows the want of fresh bile, the stricture upon this excretion, and the confined and slow state of the bowels, the effect of this diminution of the biliary dis- charge. Pringle has also given an account of the appearances which he met with upon dissection. " Upon opening the body," he ob- serves, " even the day after death, the foetor of the gas extricated from the body, was intolerable ; the intestines were wholly mor- tified, and the stomach partly so ; the very coat of the liver was affected, and abscesses had formed in the substance of the liver itself, containing purulent and ichorous matter." The spleen, he remarks, was likewise found affected by the disease. The thoracic viscera generally escape, but a case is related by Mor- gagni in his 31st Epist, in which the lungs themselves were found very much diseased. Hence then, we see that death is not only occasioned by the general febrile state of the system, but also by the inflammation which affects the intestines. That we may be enabled to form a correct prognosis, let us re- count the favourable and unfavourable symptoms of this disease. The favourable symptoms are, DYSENTERY. 359 1. Natural stools procured — of proper odour and consistency. 2. The fever being diminished, the skin becoming moist and of its natural temperature, the tongue clean. 3. Pain removed, or only returning occasionally. When sud- denly removed, beware of consequences; i. e. if the sudden disap- pearance of pain takes place, attended with cold extremities; not so when the extremities are warm. But it should be remarked that tenesmus sometimes continues from the remaining increased sen- sibility, though the disease itself be chiefly removed ; and indeed sometimes a permanent irritability and even strictures, have been the consequences. Prolapsus ani has also been the result of this disease, when the debility of the system has been great, and the tenesmus more than ordinarily troublesome. The unfavourable symptoms are, 1. Aphthae in the mouth, is a fatal symptom in general ; for it denotes an inflammation of the intestinal coat. 2. Strictures of the intestinal canal throughout. 3. Discharges from the bowels of a bloody water, like the washings of meat, hence called lotura carnium ; not always fatal. 4. Cold extremities, and a livid appearance of the body. 5. Stercoracious vomiting. 6. Tympanites — a fatal symptom ; sometimes vibices. 7. Carbuncles, as in the plague ; black tubercles. Our duty now will not consist merely in procuring the evac- uation of natural fceces, and then giving tone to the system as enjoined in the indications proposed by Dr. Wilson. Nor is our indication that of Dr. Cullen, merely to counteract spasm. For in that case opium, which is our most powferful antispasmo- dic, would be our remedjr ; on the contrary, in the first stage of dysentery, opium is one of the most injurious and dangerous me- dicines that can be prescribed. It reminds me of Dr. Under- wood's prescription of assafoetida in the cure of another dangerous and highly inflammatory disease, the croup. It is a mere pallia- tive of a particular symptom, having no regard to the cause or leading character of the disease. From what we have seen of this disease, as it appears in the whole system and in the bowels, more immediately the seat of its ravages, we are led to believe that the proximate cause of 360 LECTTJUE XXIX. dysentery consists in a febrile irritation of the typhoid type of the whole system, accompanied with inflammation and irritation of the intestinal canal, which inflammation is more especially seated in the colon and rectum. As the proximate cause is of a two- fold character, and as the affection of the intestines is more imme- diately dangerous than the general fever, and the local irritation, than the typhoid state of the system, our indications of cure will also be two-fold, not only to counteract the febrile irritation of the whole system, but our attention will also be especially direct- ed to the removal of the sources of the irritation which exists in the intestines. This irritation consists in inflammation, accom- panied with violent spasmodic constrictions of the intestines, and threatening sphacelus, a frequent consequence of inflamma- tion when seated in organs of great sensibility. This inflammation too, is rendered peculiarly dangerous, from the materials creating it in the bowels, and those aggravating it arising from the state of the whole system. On this account then, let your first attention be directed to the removal of the in- flammatory and other alarming symptoms affecting the bowels. And fortunately, the same means which are calculated to accom- plish this object, are also among the best remedies we can employ to remove the febrile excitement of the whole system ; but you have here occasion, gentlemen, for the best judgment you can form in the treatment of this first stage of the disease. You have a typhoid enteritis to contend with, and it agrees to typhoid peripneumony, or a typhoid inflammation of the throat, or the typhoid puerperal fever. You have enteritis on the one hand, which calls for active re- medies to remove the inflammation ; on the other, the whole sys- tem is threatened with typhus fever, the usual form of fever attendant upon dysentery, in which antiphlogistic remedies are to be employed with the greatest caution. A middle course is therefore to be pursued, especially if called upon in the first days of the disease, before the strength of the system is much reduced. Sydenham and Lieutaud begin the cure of dysentery with venesection. See Parr. Dictionary. Akenside recommends it, but to be done with caution. Dr. D. Monro has also given us a good rule on this sub- ject : "where the pulse is feeble, be sparing of the vital fluid." Where the habit is full — the subject young and athletic, vene- DYSENTERY. 361 section is certainly not only admissible, but called for in dysen- tery; otherwise sphacelus, in such state of body, may be readily induced ; and if possible, this remedy when made use of, should be employed before the third day of the disease, otherwise it will be generally more dangerous than useful. But in a delicate habit of body, depressed by the action of the poison on the system, the pulse small, feeble, and not indicating high inflammatory excite- ment, avoid the lancet, and trust to the other less debilitating means of removing inflammation. Leeches, in such cases, may re- move the local inflammation. After you have reduced the excite- ment by venesection or leeches, when this remedy has been indicated, our next attention should be given to the different se- cretions of the system. The biliary discharges we have observed, are interrupted, and perhaps the gall bladder loaded with a dark acrid bile, at the same time that the secretion of fresh bile is in some degree suspended by the causes which have been enume- rated. Emetics, in such cases, are indicated independent of the general febrifuge operation, which is no less in demand in this state of the system. Wilson says, do nothing to irritate the stomach or bowels ; still he recommends emetics. But although they must be irritating to the stomach and inflamed bowels, yet the irritation is of temporary operation, and they remove that irritation which is more permanent and much more dangerous. Pringle, Cleghorn, D. Monro, Cullen, Zimmerman, Blane, Lind, and most practical writers, all unite in recommending emetics in dysentery. This concurrent testimony too, in favour of emetics, is an additional evidence of the connexion which exists between dysentery and the derangement of the digestive organs. The emetics best calculated for this purpose are anti- mony- and ipecacuanha combined ; not the celebrated vitrum an- timonii cerusum, recommended by Pringle, for this is, in my opinion, an unsafe prescription for general use. Tartar emetic affords us every advantage that antimony can give us ; but I prefer the combination of ipecac, (grs. xv.) and tartarized antimony grs. ij. Sir George Baker gives tartar emetic alone ; Dr. Adair, emet. tart, with calomel; Dr. Saunders, emet. tart, with opium. Ipecacuanha alone is greatly celebrated, first in doses sufficient to excite full vomiting ; (but in my opinion, it is not of itself suf- ficient to dislodge the contents of the biliary organs, which in the sluggish state in which they are usually found in this disease, LECTURE XXIX. becomes indispensably necessary;) and afterwards continued in small nauseating doses, for the purpose of relaxing the surface of the body. Pringle is the great advocate of this medicine. This remedy, I believe, was first introduced in dysentery, by Piso. Another mode of exhibiting ipecacuanha, has lately been re- commended by Dr. Clarke ; (see Observations on the Diseases of the East and West Indies, by Thomas Clarke,) that of administer- ing it in the form of glyster, 3iij. of the root, bruised and boiled in Ibij. of water, to Ifej. ; this to be injected two or three times a-day. I prefer the use of it by the stomach, and it frequently happens that it also operates upon the bowels as a cathartic as well as an emetic, without having recourse to injection. The next object is to cleanse the intestines of their acrid con- tents. This is to be done by those means that operate most effec- tually, but which, at the same time produce the least excitement, either to the bowels or to the whole system. With this view the saline cathartics are preferred by most practitioners ; they operate without creating irritation in the bowels, and relax the system in general, promoting the secretions by the skin and the kidneys, as well as the intestines. Sulphate of soda, is preferred by many for this purpose. Huett's prescription of salts, in combination with manna, is as follows: salts, §i., manna, §ij., water, Ibij., half a pint every half hour, until two or three stools are procured. The practice in the southern states, is doubtless a very good one ; that of giving salts in combination with tartarized antimony : i. e. where an emetic has not been previously administered, JL Glauber salts, §i.; tart. emet. grs. ij. aq. pluv. gviij.; to be given in divided doses ; but where an emetic has been given, salts alone? in gruel, are to be preferred; indeed, I prefer the more sim- ple practice of administering first an emetic, afterwards a ca- thartic. Zimmerman prefers cream of tartar in combination with tama- rinds, as a cathartic in this disease ; but this salt is not suffi- ciently active for the purpose for which a cathartic is now wanted. When the bowels are freely emptied, it will be an excellent feb- rifuge drink, as an auxiliary to more effectual means ; but of itself it is not sufficient. Castor oil is also a very excellent and justly favourite cathartic in this disease. It is expeditious — it is gentle in its operation, yet effectual in unloading the intestines, in doses of a table-spoonful and repeated. DYSENTERY. 363 Let me here caution you against the use of rhubarb. Syden- ham gives rhubarb with senna or tamarinds; Fordyce, the same ; it is valuable in the last stage as a cathartic and tonic. Jalap, aloes, and the other stimulant cathartics, from the excitement and pain which they create, aggravate the inflammation attendant on dysen- tery, and are therefore justly condemned by most practical writers. Senna is no less exceptionable for the same reason, though combined even with manna, as recommended by Wilson. The stimulant additions, frequently combined with cathartics, viz. cinnamon and peppermint waters, and aromatic confection, as recommended by Thomson, are no less to be avoided in the excitement of dysentery. (See his aq. cinn. §ss. combined with salts — aq. menth. pip. giiss. in another prescription, and aromatic confection in a third: p. 278, last edition.) For the same reason avoid tinctures in dysentery; such spirituous compounds aggravate the excitement present in the first stage of this disease. Let me here call your attention to two sources of deception in the use of purgatives. The one is, not to trust the accounts given by nurses of the evacuations which may have been obtained ; the patient may have had twenty stools, and yet not one. Remem- ber, if you have not procured a complete evacuation of the intes- tines, you may be very much surprised to find a great flood of matter evacuated just before the death of your patient, (when all spasmodic constriction of the bowels is taken off,) that ought to have been carried off in the first stage of the disease. This fre- quently happens where dysentery is fatal, and probably neglect in this respect is the great reason of its fatality. Therefore in- spect for yourselves; trust only your own eyes in a disease of so much importance; it is not usually necessary in the practice of me- dicine to inspect the chamber-pot, but in some instances it is indis- pensably necessary, as in dysentery, jaundice, constipation. Inquire if the scybala we have mentioned are discharged; or at least if na- tural faeces, denoting the presence of bile, are evacuated. Do not rest satisfied with merely scanty, watery, or mucous discharges. Another important direction is, not to purge your patient to ex- cess — guided by the offensive smell of his evacuations, which, as I have said before, in typhoid fevers, is frequently increased instead of being diminished by purging, inasmuch as the digest- ive process is impaired, and fermentation of course has an uncon- trolled and exclusive operation upon the contents of the intes- 364 LECTURE XXIX. tines. Avoid, therefore, this source of deception, as well as the former. Another cathartic medicine frequently used in this dis- ease, is necessary, especially in the form of the sub-muriate of quicksilver or calomel. It is doubtless a valuable medicine in this disease: it not only operates very powerfully upon the biliary and other secretions, which take place in the intestinal canal, but in addition to its cathartic effects, its operation upon the secretions of the system in general, render it a valuable medicine in dysen- tery, especially when administered as a sudorific, in combination with small doses of antimony, or James' powder or with ipecacu- anha; but as a cathartic, I prefer the saline cathartics, or castor oil, and afterwards the use of calomel, with small doses of some other sudorific, especially where it is desirable to continue the evacuation hy the intestines; otherwise the ipecacuanha alone, in small doses, is preferable, as prescribed by Sir John Pringle. When in the use of ipecacuanha, your patient may make free use of the vegetable acids in his drinks, but not when in the use of antimony or calomel. But in some cases, even this last medicine, administered alone, may prove too active to the bowels. It may, then, be more ad- vantageously directed in the form of the Dover's powder, where such cathartic effect is prevented, and its operation upon the sur- face secured. Another means of relieving the surface of the body, and of promoting this now desirable determination to the skin, is by the sp. mind., especially in combination with laudanum, gtt. xxx. or xl. to §iij., a table-spoonful every two hours; or the effervescing draught of Riverius may be administered. These combinations not only promote perspiration and counteract fever, but they allay, in an especial manner, the irritation of the bowels; i. e. plentiful evacuations having been previously obtained. With- out a moist skin and a soft pulse, Professor Richter observes, this disease cannot be radically subdued. His remedies are an emetic, laudanum and antimonial wine; and in the advanced stage of the disease, rhubarb; but this last he considers dangerous in the com- mencement of dysentery. But the irritation of the intestines being still continued, (notwithstanding the remedies already di- rected,) and this being evinced by an increase of pain upon slight pressure, a large blister should be immediately applied over the abdomen. Blisters have a double advantage in this disease; they not only remove local inflammation, but they diminish the gene- DYSENTERY. 365 ral fever which attends this disease, and should be resorted to as early as possible after evacuations have been procured. In a less degree of soreness, a warm bath may be advantageously made use of, as advised by Sir George Baker, or fomentations of vinegar and water, or an application of hops, infused in hot vinegar and water, and enclosed in a flannel bag may be laid, of proper tem- perature, to the belly; or in case a blister is laid upon the belly, the fomentations may still be made use of with benefit, and may be applied to the extremities. These last should be frequently renewed, and applied at a moderate temperature. But neither the w r arm bath nor fomentations should be made use of until the first passages have been thoroughly evacuated; for they other- wise aggravate the general fever, and render it more malignant by the resorption of the offensive contents of the belly. But in- stead of a warm bath, or warm applications, Dr. Thomas has ad- vised a cold bath, and cold water to be applied to the belly in this disease! He certainly has never used it, or if he has, I venture to say he has destroyed his patient; for cold bathing, or cold ap- plications are assuredly injurious in diseases attended with local inflammation. In your fomentations to the abdomen, or to the extremities, let me also caution you against the use of spirits, pepper, and other heating applications, as recommended by Wilson! The oil of cloves, the stimulant liniment and spirituous em- brocations prescribed by Thomas, are no less to be dreaded in the dysentery, as they serve to dry the skin instead of unlocking it, and thereby aggravate both the fever and inflammation attend- ant upon this disease. There is an application, however, I ob- serve, much recommended by Dr. Irvine, in this disease, which perhaps, by the great irritation it produces upon the surface, anal- ogous to that of blistering, may be useful; I mean the spirits of turpentine, applied to the belly, and frequently renewed. That author, in his account of the diseases of Sicily, states that he has employed it in many cases with benefit. He, however, I per- ceive, also attaches great value to blisters in the same disease, and they are probably the preferable application on account of the greater inflammation they produce. The excitement of the system, constituting the first stage of the disease, being subdued; the local inflammation being also controlled or counteracted by the remedies which have been 32 $66 LECTURE XXIX. directed, the bowels opened, and the skin relaxed and perspiring, the patient still, perhaps, labours under occasional returns of irritation about the rectum and anus, but unaccompanied by the febrile excitement noticed during the first two or three days of the disease. How is this irritation to be arrested or removed? and is it safe, while the patient continues to discharge blood and mucus, instead of natural evacuations, to arrest them by any means? and what are the most effectual means for this purpose? Injections may now be had recourse to with advan- tage : not stimulant, cathartic enemata, but those which are calculated to soothe and remove irritation. For this purpose, oily and mucilaginous injections, combined with opium or laudanum, are to be preferred. There is a great variety of these in use. Mutton soup, prepared by boiling the sheep's head; and, by the by, many contend, that to be productive of all the advantages in- tended, it should be boiled, wool and all on. Strange as it may appear, there is some reason for this; for the wool of that animal, near the skin, is covered with a mucilaginous, oily matter, called by shepherds the yolk, in which the anti-dysenteric virtues probably, in part, reside. Milk and flaxseed tea is another fashion- able domestic remedy. An opiate poultice to the fundament An opium pill in the rectum. Barley, rice, sago, arrowroot, and starch, are all accordingly employed; and are all, or either of them, useful. Flaxseed and starch, however, are in most general use, §ij. to ^iv. of thin starch, with 3i. or 3iss. of laudanum. Dr. Rutherford's preparation of flour, two or three handsful, boiled six or eight hours, till hard ; grated, made into food, with milk and water, &c. (See Parr. Die.) Great care is necessary in administering it, lest it add to the irri- tation instead of diminishing it. There is no occasion where more depends on the manner in which an enema should be ad- ministered than in dysentery; for if thrown up with violence, the inflamed bowel will instantly reject it. It should be gently ad- ministered, and the pipe as gently withdrawn, that we may awak- en as little sensation in the part as possible. This anodyne in- jection should be repeated every four hours. It will be proper, however, if the least preternatural heat and fever exists, once in every twenty -four, or, at most, thirty-six hours, to procure an evacuation from the bowels, either by a large, oily enema, com- posed of gruel and castor oil, or the ordinary domestic injection, DYSENTERY. 367 or by a repetition of half an ounce of Glauber salts, by the sto- mach, or magnesia calcined. The late Dr. Bayley's favourite prescription, at this stage of the disease, was four grains of rhu- barb, two grains of ipecac, made into a bolus with the Theriac Andromachi. Should the typhoid symptoms still be considera- ble, or the contents of the bowels unusually foetid, and you have reason to apprehend a tendency to sphacelus, an injection of yeast is to be preferred to any other form of enema. I must observe that opium is not to be directed in any form, by the mouth or injection, until the inflammation attendant on this disease, and the general excitement of the system have been subdued, or considerably di- minished; until you are satisfied that the pain present arises more from morbid sensibility than from inflammation, and is out of all proportion to the arterial excitement of the system. In this cau- tion, Lieutaud, Blane, Pringle, Cullen, all concur. In the lan- guage of Zimmerman, " it is always dangerous to give opium be- fore the fuel which feeds the disease be burnt out." The lan- guage of Huxham and Cullen is no less pointed on this subject. The same objections apply to the early use of astringents and tonics. There is, perhaps, no practice so fraught with danger as the premature use of these remedies. But again, when the first stage of the disease is completely passed over, they are not only admissible but indicated. Lime-water and milk,* chamomile tea,f the Peruvian bark, J oak bark, (Quercus robur,) logwood, (haematoxylon eampechianum,) tormentil, (torm. erecta,) marsh rosemary, (statice limonium,) simarouba, as recommended by different physicians, may be in such debilitated state of the system had recourse to ; but remember, when too early prescribed, you may expect every dangerous symptom that has been enumerated and these, again, will be soon succeeded by the death of your pa- tient. They should, therefore, be carefully avoided, while either the febrile or inflammatory symptoms continue; and those reme- dies should be repeated which are calculated to remove every * Dr. Donnald Monro. + Pringle prefers this to lime water. Zimmerman also alleges, that next to opium, chamomile tea allays the pains of dysentery. I Dr. Whytt preferred the bark, especially where aphthce appeared in the mouth, or threatened the alimentary canal. Lime-water and milk is an excellent drink in this case. Magnesia, as a laxative, and borate of soda, to the part affected. Soda-water, as a drink, is also useful in aphthous affections. 368 LECTURE XXIX. source of irritation from the bowels or the blood vessels; i. e. by a continuance of the evacuations from the bowels, and of those means calculated to relax the surface, as in the treatment of typhus fever, and with the same cautions, observing the different grades of excitement. THE DIET. In the diet of your patient, labouring under dysentery, the same attention should be given to the different stages of the dis- ease as in the prescription of medicines. In the first stage the patient should take plentifully of some thin diluents; and these should be taken warm. Toast-water; weak teas, either catnip or common tea; water- gruel; barley-water; or even plain water, Senac, as Pringle tells us, found warm water the best of all drinks. Senac himself, and fourteen of his patients, were the subjects of this practice alone, and continued it five or six days, with the best effects; but he at last preferred the following treatment: jgr* of tart. emet. in a pint of whey or chicken- water, every day throughout the disease; making it both the food and physic of the patient, until he recovered : it acted both as a cathartic and sudo- rific. Baglivi, Huxham, Tissot, Zimmerman and Pringle, all con- cur in the necessity and usefulness of plentiful dilution in dysen- tery, not only for the purpose of washing out the intestines, but indeed the whole system, by the relaxation it produces upon all the emunctories of the body. Vegetable nourishments and fruits, especially in the beginning, may be given. (Cullen.) Grapes, are preferred by Zimmerman. Any fresh fruits are proper. They are not only useful in the cure, but in the prevention of the disease; not only as antiseptics, but from their effect in quickening the bili- ary secretion. Mucilaginous nourishments are also peculiarly pro- per in this disease, not only as nourishments, but as calculated to sheath the intestinal canal from its acrid contents. For this pur- pose sago, cycas revoluta and circinalis, arrowroot, maranta arun- dinacea, salep, orchis mascula, rice, oryza sativa, barley, hordeum distichon, pearl barley, rendered pleasant by raisins $ tapioca, jat- ropha manihot and janipha, cassava or cassada boiled with it; flax-seed tea, linum usitatissimum, are among those to be pre- ferred. All writers on this subject, agree on the bad effects, DYSENTERY. 369 of animal food. They add to the septic state of the bowels, and of the whole system. Baker, Pringle, Zimmerman, D. Monro, are all opposed to it in every shape, even in the form of soups. " Not even chicken soup," says Sir George Baker, "should be allowed in this disease," u nor mutton broth," says Pringle. Akenside, however, to our great surprise, we find recommending animal food, even in a solid form; beef-steaks in a dysentery, animal food in typhus fever! I should rather consult him as a writer on the pleasures of the imagination than follow his directions in dysentery. Another fashionable prescription, much in use, is mutton suet, boiled in milk, with cinnamon and loaf-sugar. This is not admissible in the first stage, but the good women of our city, finding it good in the last stage of dysentery, conclude that they cannot begin too soon, nor have too much of a good thing. In the second stage, let me observe that vegetable nourishments should still be continued; but that they may now be advantageously given with wine; or if the stomach be inclined to acidity, with a moderate quantity of brandy. But recollect, that by giving these articles too early in the disease, you introduce so much fire into the already inflamed intestines. Attention to regimen in this disease is no less important than is our prescription of medicines, or directing the diet of your pa- tients. Inasmuch as dysentery is propagated by means of the excrementitious discharges, there is no rule more important than that these should be instantly removed from the chamber of the sick. Another direction in this case should be that the alvine discharges particularly, should not be thrown in the common privy, but buried ; for privies, it has been observed by all writers, become the principal means of spreading the disease throughout the family or the camp wherever it may occur. With the same view, the clothing of the patient should be frequently changed ; both that which constitutes his bedding as well as his bodily clothing ; and let me add, that flannel worn next the skin consti- tutes the most proper dress of the patient in this disease, as well as the greatest security in guarding those who are well against an attack of it. Dewar, in his observations on dysentery, particu- larly recommends a swathe of flannel to preserve warmth about the abdomen, and to give support to the weakened bowels. There is perhaps, no one direction in the treatment of dysentery to which he attaches more value than to this application, alleging 32* 370 LECTURE XXIX. that he has ever found it attended with the best effects. But not only the clothing, the bed and the bedding should be frequently changed and aired, in this disease ; and the air itself of the apart- ment should also be frequently renewed, and all noxious mate- rials removed as far as ventilation and the disinfecting processes can effect such changes. I need not repeat the processes em- ployed for this purpose, which have been so fully detailed to you. Having removed the inflammation and other sources of irritation from the bowels, and having obviated the general fever, you have now a second indication — to build up the strength of your patient by means of tonic medicines and such system of diet as will be best calculated to counteract the debility that has been induced. The bitter infusion with the addition of the carbonate of potash or soda, and a small quantity of rhubarb will be peculiarly calculated for this purpose — they are among your best tonics. Madeira and Port wines are also now to be allowed the patient, and that freely in proportion to his weakness. Dr. Brocklesby allowed his patients ibiss. to be taken daily if necessary. Dr. D. Monro di- rects brandy and water to be taken, if the use of wine should be followed with acidity or pains in the bowels — an excellent direc- tion. The patient, too, should return gradually to the use of ani- mal food. As there still remains more or less of the typhoid state of the system, he should still continue the use of the vege- table nourishment in part, and when soups are first made use of, let a large proportion of vegetables enter into their composition, as rice, celery, &c ; but if the stomach be especially debilitated and there exists a great tendency to fermentation of its contents, animal food in the solid form is to be preferred, followed with a glass of brandy and water — steadily continuing the use of the bitter infu- sion, or perhaps as recommended by Dr. Whythe, an infusion of bark may be now advantageously administered in conjunction with the Japonic confection 3iij., or the R. of kino, §ss., to Ibi, of the in- fusion. The infusion of bark with lime water is also in some cases preferable. But perhaps your patient has lost a great deal of blood by hemorrhage — his bowels remain in too relaxed a state, or upon falling asleep, such is his debility that he sweats pro- fusely — astringents in such cases are indicated. With this view an infusion or decoction of the bark with the addition of the elixir of vitriol, may be given the patient. Some direct the nitric acid, as in the following prescription, or a combination of the DYSENTERY. 371 nitric and muriatic, viz : gtt. ii. of the nitric, gtt i. of the muriatic, with laudanum, proportioned to the irritation. See Good, vol. ii. p. 470. Nit. acid 5ij., opii. gr. ij., aq. font. ^iij. M.; a tea-spoonful every three or four hours, in any vehicle, say Port wine. By the by, in such cases, pert wine too, or even spiced with cinna- mon, is to be preferred, for the purpose of restraining the ex- cessive discharges to which the patient is yet exposed. And in- deed it may still be necessary to have recourse to an opiate mu- cilaginous enema to allay the local irritation which may remain in the lower bowels — for tenesmus not unfrequently remains af- ter the disease has been subdued and the patient is convalescent. I have occasionally been obliged to have recourse to some means of this kind to quiet the irritations which thus remain. In some instances I have done this by a small quantity of paregoric elixir — by a pill of opium and ipecac, say one-quarter of a grain of opium, and gr. i. of ipecac, or a pill of opium introduced into the intestine as a suppository. But in other cases, instead of ex- cessive discharges there is a tendency to a confined state of the bowels. You should be no less attentive to obviate this state of things either by a mild cathartic injection, or some mild aperient taken by the stomach, with this view. Small doses of rhubarb and magnesia, with mint water, may now be administered in divided doses, for the bowels neglected, a putrid colluvies will soon be formed in the lower intestines, and a renewal of the in- flammation may soon be expected as the consequence. As soon as the patient is enabled to take exercise, and the weather will allow him to leave his chamber, his recovery will be very much hastened by the stimulant effects of the open air. Where ulcera- tions have taken place in dysentery, the turpentine and the bal- sams have been recommended on account of their stimulant effects. It is plain they can only be admissible in the last stages of dysen- tery, and that they can only be useful where you have the evi- dence of such ulceration having taken place, and that more or less purulent discharges are still continued denoting this ulcerated condition. 372 LECTURE XXX. FEVERS.— PLAGUE, OR PESTIS ORIENT ALIS. Under the present system of quarantine laws, which the legis- lature of this state in particular, in their wisdom have adopted, while they continue to be faithfully executed, we shall probably never have occasion to prescribe for the plague. Still it is pos- sible, from the -commercial character of our country, that we may be visited with this form of pestilence, as we have been by the yellow fever and other contagious diseases. The late prevalence of this disease, on the coast of Barbary, with which we hold communication, ought to prepare us to expect a visitation of this nature; and our government, in its quarantine regulations, should ever keep this event in view — for a chest of clothes of a person dead of the plague, introduced into any part of our cities, would infallibly spread the disease as it has done in different parts of Europe; and the utmost vigilance, with respect to that source of it ought, in the increasing intercourse we are cultivating with that quarter of the world, to be exerted by all concerned in the re- sponsible station of guarding against the introduction of foreign diseases. It is important, then, that the physician should become acquainted with this disease, not only because it is a reproach to be ignorant of it, but because it is possible that he may want his knowledge of it at the bedside, should accident so introduce it. It will at least be useful for us to know the peculiar characters of the plague, as it is calculated to reflect light upon those general principles that we have endeavoured to impress upon your minds with regard to the nature and treatment of contagious diseases in general. Dr. Cullen defines the plague to be " typhus maxime conta- giosa cum summa debilitate — incerto morbi die eruptio bubonum PLAGUE. 373 vel anthracum." But Dr. Cullen, on account of these buboes and carbuncles, and perhaps the petechia attendant on this disease, has very improperly placed pestis in his order of eruptive dis- eases. He might, with equal propriety, have placed typhus among his cutaneous diseases. As the plague is attended with general fever, and is naturally allied, in many of its features, to many other forms of fever we have noticed, I have placed it in the class of fevers properly so called. The first source of this disease, like smallpox, syphilis and others, is not yet developed. It is well known, however, that it has long infected the western parts of Asia, from the thirtieth to the forty-second degree of north latitude. The Carthaginians were afflicted with it at least two thousand three hundred years ago. Thucydides has described the plague which wasted the city of Athens two thousand two hundred and eighty years since. Procopius mentions a plague which appeared in the five hundred and fortieth year of the Chris- tian era, and which is stated to have threatened the very destruc- tion of the human race. At that time it was not confined to one spot, nor to one season of the year. It is said to have spread in the winter as well as in the summer, and to have spared no situa- tion, "neither island, cave, or mountain," says the historian, — (Williamson in Med. and Phil. Reg. vol. i. p. 28.) It is, how- ever, remarkable that it did not prevail in Egypt, which many call its birth-place, during the greatest population and splendour of that part of the world, and when it was governed by its native princes; and when, too, it contained larger cities even than Cairo; it was then proverbially a healthy country. Herodotus gives pointed testimony on this subject. He says, " After the Africans, no people are to be compared with the Egyptians, in health and vigorous constitution." And to this advantage he adds, "the climate, which is subject to no variation, may effectually contri- bute." But when the Egyptians came under a foreign yoke, their character changed, their enterprise destroyed, their canals neglected and obstructed, the consequences were, collections of stagnant water, and the air loaded with mephitic vapours; their country, as was to be expected, whether we consider this state of the air to operate as a predisposing or an exciting cause, became the seat of pestilence. In 1346, a plague began in the northern parts of China, spread through Asia, crossed into Europe, by way of Constantinople; 374 LECTURE XXX. from thence it traversed Greece, Italy, Germany, France and England. Indeed, since Marseilles, which is in the forty-third degree of north latitude, began to trade to the coast of Asia, it has been visited at least ten or fifteen times with the plague. England also, since she has engaged in the trade of the Levant, has suffered frequently from that deadly disease. Even the Rus- sians, when at war with the Turks, introduced it into their north- ern climate by means of goods that had been brought from the infected cities of their enemies. It accordingly spread in Mos- cow in 1771, although that city is in the fifty-fifth degree of north latitude! It has, therefore, as you perceive, not been con- fined to the eastern hemisphere; and indeed, in some countries of the east, as Persia and Japan, it was altogether unknown; and I believe they still remain exempt from the visitations of this dis- ease. For a more full history of this disease than my time will allow me to give you, I must refer you to authors — Mead, Sy- denham, the two Russell s, viz. John, the author of the History of Aleppo, and Patrick Russell's History of the Plague; Merten's Plague of Russia, and Samoilowitz, a Russian physician ; Dr. Guthrie, on the same subject; Assalini, on the Plague of Egypt; Volney, Desgenettes's Memoirs; Sir Robert Wilson, Savery, McGregor's Sketches of the Expedition from India to Egypt; Sonnini's Travels into Greece and Turkey, and Dr. Williamson's Observations, contained in the Med. Register, will furnish you with ample materials on this head. Dr. Cullen has called the fever attendant on plague, the typhus form of fever. True, it has many symptoms which would entitle it to that appellation, but it has other symptoms which give it a totally distinct character, and which, in my opinion, constitute it a distinct genus. Besides its general febrile symptoms, it is characterised by the presence of buboes and carbuncles, which are its general attendants, as you will find upon consulting the works before referred to, especially the valuable and elaborate work of Dr. Patrick Russel. "Of 2700," says Dr. Russel, "afflicted with plague, 1841 were affect- ed with inguinal buboes; of the same number, 569 axillary; 231 parotid; 74 spurious; and 490 carbuncles." I ask you, is this typhus fever? Is this bilious remittent? And I ask, will you call him a physician that can confound plague with those diseases; or who can pronounce plague to be the yellow fever? For in yellow fever, none of these characteristic symptoms of plague are PLAGUE. 375 to be found among its usual attendant symptoms. For these rea- sons I have made the plague a distinct disease from every other form of fever; though it must be acknowleged it bears a much greater resemblance to the yellow fever of the tropics than to any other species or genus of fever. The invasion of this disease is like some other contagious dis- eases, frequently sudden and violent. And in some cases, the per- son attacked drops as instantaneously dead as if he had been shot with a musket ball. In many writers on this disease, when it has been epidemic, it is stated that persons have been found dead in the streets — so of yellow fever. In other cases, so violent is its operation on the system, that they perish within twenty-four hours from the time of the attack; but most generally the disease is of several days continuance. In some cases it has continued to the thirteenth, and even to the seventeenth day. Its duration, however, is uncertain, depending upon the character and progress of the local symptoms, which we have observed to characterise it; viz. the buboes and carbuncles. Buboes, in some cases, ap- pear very early, and suppurate early. In such cases, the disease is rendered comparatively mild and of short duration. Where they are late in their appearance, the disease exhibits a more for- midable character, and is at the same time more tedious. Carbun- cles, again, are, for the most part, the attendants upon the ad- vanced stage of plague, and arise from the vitiated state of the system belonging to that period of the disease, in addition to the exhaustion of the vital powers induced by the poison engen- dered by the disease. On both these accounts, then, carbuncles in plague are considered as more alarming and dangerous symp- toms than buboes. Petechia?, too, arising from the same source, appear in this, as in other typhoid forms of fevers. Some physicians, seeing these facts, have been induced to make a divi- sion of the disease into species, according as buboes, carbuncles or petechia?, are predominant symptoms; but such distinction is at least useless, if not absurd; for it is with the plague(see Thomas, p. 234,) as with other febrile diseases. Its character is very much changed by the circumstances of season and situation, as well as the habit of body in which it occurs. Accordingly, in Dr. Rus- sePs practice, you will find many varieties noticed as arising from the operation of these causes; and in Sir J. McGregor's Sketches of the Expedition from India to Egypt, you will also 376 LECTURE XXX. see the character of the disease very much changed by the state of the air, whether it occurs in the crowded hospital or in marshy grounds, or in the cold, rainy months of December and January, assuming the more malignant, remittent and inflammatory charac- ter. The vital functions, in plague as in yellow fever and other diseases arising from contagion, show the deleterious operation of the poison producing the disease. The pulse is sometimes, from the commencement, very small and feeble; in other instances, it is remarkably slow; while again, in other cases, the pulse, as in yellow fever, is very little changed in any stage of the disease; i. e. the poison of the disease fastens on other parts of the sys- tem, and therefore affects the heart and arteries less. Respiration partakes of the same influence. It is frequently attended with great anxiety, despair and depression; and these symptoms, as in yellow fever, are generally considered as fatal symptoms; espe- cially if they appear in the commencement of the disease. The tongue, as in other contagious diseases, is frequently moist and natural throughout the whole progress of the disease; but in other cases it is slightly furred. The thirst, in some cases, is great, but in others it is not remarkable. The skin is usually described as dry and parched, in some cases moist; but when moist, it affords a favourable prognosis. The perspiration has been remarked to be oftentimes foetid to a very great degree in this disease — pro- bably owing to climate as well as the character of the disease itself. The same is observed of the breath of the patient, that it very soon manifests an uncommon fcetor, attended with great nausea, and sometimes a vomiting of dark bilious matter. In some cases an irrestrainable diarrhoea takes place, and soon hurries off the patient. Hemorrhages are also of frequent occurrence in the plague; and, as in other fevers of a typhoid type, they are gene- rally considered at least as dangerous, if not fatal symptoms. They take place from the nose, gums, stomach, liver and bowels, as in yellow fever. But the black vomit, I mean the coffee-ground black vomit, one of the characteristic symptoms of the yellow fever, is scarcely known to occur in the plague. Buboes usually appear on the first, second, and third days — of- tentimes on the first day — and when proceeding early to suppu- ration, they are among the favourable symptoms. They probably direct the excitement of the whole system to a particular part, less dangerous than when the same irritation is expended upon PLAGUE. 377 the other parts of the frame, and especially upon the vital func- tions. Buboes, under any circumstances, are considered by Dr. Guthrie and others, as less alarming and less fatal than carbuncles, and for the reasons we have already assigned. Indeed, carbun- cles and petechias are both unfavourable symptoms in the plague; for carbuncles, when they prove fatal, become gangrenous, as- suming the usual malignant aspect of the anthrax, properly so called. And it is also observed in plague, that petechias and ma- culae, or ecchymoma, frequently turn to carbuncles — so says Sa- moilowitz in his Account of the Plague of Russia in 1771. See- ing this malignant train of symptoms to attend upon the plague, you will be prepared to believe that it is one of the most fatal diseases of mankind. Of the French arm}^ that invaded Egypt, according to the Report of Desgenettes, the chief physician to that army, but little more than one-third of all that took the disease recovered. This leads me to a remark or two relative to the causes of plague. This disease, until very lately, was universally admitted to arise from, and to be propagated by, a peculiar contagion. It is also generally remarked to show itself about four days after ex- posure to persons labouring under it, or after a similar exposure to infected goods. The infection, too, is generally limited to a few feet, and is communicated chiefly by contact, or very near ap- proach to the source of the infection. In this it is unlike other contagious diseases. Warm weather is considered to be favour- able to its progress. Cold, on the contrary, is unfavourable to its increase. Sometimes, however, like typhus fever, it continues throughout the winter. Sometimes, too, it is checked by great heat. In all the plagues of Aleppo, of the last century, it has al- ways ceased in the months of August and September; i. e. dur- ing the greatest degrees of heat. Sonnini (Travels, p. 255,) ob- serves " that the contagion of the plague never failed to cease at once at the summer solstice." It is only during a season of moderate heat that it has ever been observed to prevail exten- sively. In Europe it has invariably raged most violently and fatally in the summer and autumnal months, especially in Sep- tember and October. In the plague of London, of 1665, the deaths from the plague were most numerous in August, 20,046 ; September, 26,230; and in October, 14,373; but ceased altogether with the winter's cold ; for the cold weather of northern climates 33 378 LECTURE XXX. has invariably been observed to check the ravages both of the yellow fever and the plague. On the contrary, however, as I have just remarked, the extreme heat of southern latitudes is equally adverse to the propagation of the contagion, so that the disease is, in fact, unknown in tropical climates. In Egypt and Syria its progress is always suspended during the hottest months of the year. This too, is a strong diagnostic between it and yel- low fever. As in yellow fever, infants are less liable to it than adults; but even those at the breast are not exempt. The poison of plague, also, like that of the fever, is communicated to the fetus in utero, for children are born with the sores of plague on their bodies; and added to this, the plague is generally fatal to pregnant women. That the plague is not known to arise spontaneously any where, but is always to be traced to contagion; and that the distance to which its infection extends through the atmosphere is very small, are established by general agreement. Some particular persons, in a most remarkable manner, escape this disease, as is peculiarly the case with attendants on the sick, the effects of habit, yet we know, in many instances they have no immunity or exemption from its attack. According to Sir. J. McGregor, of thirteen physicians, seven took the disease, and four of the seven died of it; and in the plague of Marseilles, which we have noticed as recorded by Bertrand, confessors, phy- sicians, nurses, all took the infection. (See my paper on Conta- gion. ) This disease, too, as we have already seen, in the cases of Matthias Deggio, as related by Dr. Guthrie, Dr. "White, no- ticed by Sir Robert Wilson, the Russian surgeon by Sonnini, and by Mon. Eusebius Valli, is communicable from one to an- other by means of inoculation, which abundantly demonstrates the fact that the plague, although it is governed by the laws be- longing to my third class of contagious diseases, is still a disease sui generis. But in addition to this cause, viz. contagion, as a mean of propagating the disease, it is also stated, that other agents operate in the production and propagation of it in its native coun- try; viz. putrid animal and vegetable substances; noxious exhala- tions from the slimy deposits of the Nile, crowded and confined dwellings, want of cleanliness, bad diet, either from damaged grain and other provisions, or the excessive use of animal food. A moist state of the atmosphere, according to Sir Robert Wilson, PLAGUE. 379 is also considered among the causes favourable to the production of this disease. He adduces two facts in confirmation of this ob- servation; the first is, that the English and Turkish armies that marched to Cairo escaped the contagion, though they passed through many villages that were infected with it ; while the troops that remained stationary on the shores of Aboukir, ex- posed to a moist air, were severely affected, and lost many men. The second fact is, that a dry air operated to prevent the disease; and indeed, in one instance, it appeared to act as a remedy, after the disease had commenced. He accordingly states, that several men who were ill of the plague in the hospital at Jaffa, escaped into the desert, and endeavoured to reach the army ; but not suc- ceeding, they returned in three days, perfectly recovered! Those too, who were exposed to vicissitudes of heat and cold, w T ere re- marked to be more liable to, and to suffer most from, the plague. Accordingly, bakers, smiths, and cooks, were noticed during the late campaign to Egypt, to suffer most from this disease. Mr. White, although he contends that the plague is never in- troduced by contagion, has the following remark. " None con- tend that the plague is not like all fevers, more or less infectious, according to habit of body and duration in bad air; but that the disease hangs only in the atmosphere, or breath of the immedi- ately affected patient, not to be conveyed by touch on a third per- son." (Expedition to Egypt, p. 253.) He also acknowledges his embarrassment in accounting for the " partial infection of at- mosphere, which at present can only be attributed to the different degrees of fetid matter left on the ground, producing the quan- tity of putrid miasmata." But this difficulty vanishes if we ad- mit the classification we have proposed, and the laws of commu- munication to differ with different classes. No wonder Mr. White remarks, that the problem is arduous, that if the plague be contagious, and not like the small-pox, to be had only once in a life, how, in a country where no care is taken to check the exten- sion, population has not long since become extinct, p. 255. But for the reason that the plague is not small-pox, we should expect it to be governed differently. TREATMENT OF THE PLAGUE, In the treatment of the plague, we shall find that there is no less resemblance to the yellow fever, than we have observed in 380 LECTURE XXX. many of its symptoms. In some cases, according to Dr. Russel, the lancet was found to be very useful ; while, in others, it was a dangerous and fatal practice. In the hands of Dr. White, it proved fatal to all upon whom he employed it ; but Dr. Russel remarks, that when employed early in the disease, a plentiful bleeding is of very great service. Most writers, however, advise this remedy to be cautiously and sparingly employed ; and when employed, that it should be in the invasion of the disease. It is a good rule in this, as in the yellow T fever, " to avoid extremes." Emetics are also, as in many other fevers of the typhoid charac- ter, considered as very useful ; for the stomach is not in plague, as it is in the fever, the seat and throne of the disease ; on the contrary, the patient in the plague not only bears the operation of vomiting, but it is absolutely necessary, for in this disease it fre- quently happens, that there is a very diseased condition of the stomach, biliary organs, and intestinal canal ; this is evident from the nausea and vomiting, and bilious discharges, which appear upon the invasion of the disease. Dissections, too, have disco- vered the gall bladder to be loaded with a dark coloured bile, and attended with an obstruction and enlargement of the liver itself. Cathartics are also indicated, but most writers concur in recom- mending the mildest to be made use of in this disease ; alleging that diarrhoea is always dangerous : — laxatives, injections, and suppositories, are accordingly preferred to active purges ; and when diarrhoea supervenes, the most active astringents with opiates are industriously made use of to restrain it. But of all the means made use of to control the violence of the plague, and to divert its ravages from the vital organs, is sweating. This, whe- ther it takes place spontaneously or is induced by art, is found to be beneficial in this disease. I mean, when induced by those means that do not add to, instead of diminishing the excitement of the system ; for, doubtless, we will all agree with Dr. Falconer, of Bath,* that the sweating regimen as formerly practised by hot drinks, heated rooms, feather beds, and loads of bed-clothing, has been, and must be, a fatal practice, in any fever. Yet it does not follow, as Dr. Falconer has inferred, that because the patient, noticed by Savery, who tied himself on the deck, exposed to the dews and cool night air, recovered from a severe attack of the * Essay on the Plague. PLAGUE. 381 disease; or because the French soldier, recorded by Desgenettes, threw himself into the iMile, and also recovered ; that therefore every patient must do the same, or that Dr. Curries' cold water treatment must, in all cases, be pursued : on the contrary, I be- lieve such practice to be dangerous in the extreme, in any febrile disease, where either the disease itself has been caused by a poi- son, originally introduced, or where the disease, whatever may have been the cause of it, exhibits, in its progress, the vitiated state of the whole system. In either of these cases, as I have very fully stated, the process of perspiration is peculiarly salutary: 1, by diverting the excitement from the vital organs ; 2, by con- veying out heat ; and 3, by carrying off those morbid materials which, in health, are constantly passing off, and which, retained, must necessarily aggravate the already diseased condition of body that attends on fever, especially fevers arising from contagion : and that, therefore, this cold regimen, which restrains or checks this important discharge, must be injurious in the manner recom- mended. It is in confirmation, too, of the benefits that are derived from perspiration in the plague, that the practice of rubbing the body with warm oil has been so universally and so successfully employed in this disease, as stated upon the authority of Mr. Baldwin, the British Consul General in Egypt ; you will also see an account of it in Dr. Duncan's Med. Com. for 1797. In this account you will perceive, that it is not from any virtues con- tained in the oil, but the perspiration induced, that proves so beneficial ; and, indeed, the whole manner in which it is to be made use of is calculated to effect such perspiration. The patient must be in a warm room ; he must be briskly rubbed, and, as stated, for the purpose of producing a profuse sweat, he must take warm sudorific drinks, such as elder flower tea ; he must, too, be exposed to the fumes of juniper berries and sugar to aid it ; and every precaution is employed to prevent cold from checking his perspiration ; his linen must not even be changed, until his per- spiration has subsided, and, indeed, the friction is directed to be repeated ; all these show clearly the manner in which the oil is to operate. The same good effects from this application are noticed by Assalini,who also ascribes its salutary operation to the copious sweating it produces. During the prevalence of plague in West Barbary, in 1799 and 1800, Mr. Jackson, in his account of the Empire of Morocco, states, that it was also very successfully em- ployed. 33* 382 LECTURE XXX. But it is observed that it has a salutary effect in preventing the disease, as well as curing it. The same writers allege, that the dealers in oil, as well as those who are employed in rubbing the sick, escape the disease ; that even the porters and labourers who work in the oil stores are exempt from its attack. I rather sup- pose, that the exercise of these men, by the steady perspiration such labour produces, in part preserves them from the influence of contagion ; for in the great plague of London, it was observed that those who were dealers in pitch, tar, and tobacco, also escaped the contagion ; probably, upon the same principle, but not that those articles furnished any peculiar antidote to the poison of the disease. In like manner, the application of oil has been found serviceable in the yellow fever of the West Indies ; but long be- fore the introduction of the oil as a remedy, the sudorific treat- ment, as recommended by Dr. Warren, was found no less success- ful. The best means of preventing the operation of contagion, if the observation we have already made on this subject be correct, will be cleanliness, ventilation, and purifying the air, by the processes pointed out, by means of the nitric, muriatic, and acetic acid gases. 383 LECTURE XXXI. YELLOW FEVER.* On the yellow fever I have few observations to make to you ; for I have so frequently, in the course of our remarks on fevers in general, had occasion to refer to this subject, that to dwell at this time on this topic, would be to repeat at least much of what has already been said. I shall therefore, in a very summary manner, call your attention to the leading features of this disease, the causes from whence it arises, and that mode of treatment which has been found most successful, especially in the United States. Typhus icterodes cum flavedine cutis, is the definition given of the yellow fever by Dr. Oullen. But this yellowness of the skin combined with typhus, does not alone constitute the characteristic symptoms of the disease when it proves fatal ; for besides this yellowness there is very generally, on or about the third day, not before, more or less disturbance of the stomach or biliary organs, showing itself in the vomiting of black matter. This is indeed so generally attendant on the malignant form of the fever, that the Spaniards thence call it the vomito prieto, or black vomit, from the frequent presence of this symptom, espe- cially when the disease terminates fatally. This appellation of black vomit is therefore quite as appropriate as yellow fever ; for where the disease is early arrested in its progress, and the excre- tions are steadily kept open, such yellowness is frequently pre- * I retain the term yellow fever, for as Dr. Willan observes of scarlet fever, " however offensive the term may be to a classical ear, it cannot well be dis- placed, having found admission into all the systems of nosology." Page 253, Diseases of the skin. 384 LECTURE XXXI. vented. A definition of the yellow fever ought, therefore, to embrace more particulars than Dr. Cullen has included, other- wise we should be at a loss to distinguish it from jaundice, which in some cases proves fatal, and is rendered so by the typhoid symptoms that occasionally attend on that disease, as in the cases already referred to. In like manner we should mistake other diseases of the liver for the fever, that is, judging merely from the colour of the skin. We should also in other cases, confound it with the bilious remittent — whereas, the state of the stomach and biliary organs enables us very readily, for the most part, to separate those two diseases. In the first place I re- mark, that the yellow fever, as far as regards its origin, is a disease peculiar to the tropics, or those climates which experience the heat of the tropics, both in degree and duration. But it is occa- sionally conveyed into higher latitudes, where, like the fruits and other vegetable productions from the tropics, it is preserved and even propagated in the hot seasons of the year, that is, while the heat remains at, or nearly at that temperature which gave it birth. But again, as the tropical fruits are destroyed by the cold of win- ter, so is the yellow fever extinguished by frost. It has accord- ingly appeared at various times in the south of Europe, and in various parts of the United States. But it has invariably, in those cases, been introduced from the tropics, and then usually from the West Indies, or from South America. I shall also then have an opportunity of showing you that the fevers which pre- vailed in the Greek islands, and the dark coloured vomiting, as described by Hippocrates, were totally different from the yellow fever with which they have been confounded by a learned physi- cian of this city, in his report lately published on this subject. I shall also take the same occasion too, to satisfy you that the same writer has been hastily led on to similar errors, when he con- founds the yellow fever with the fever hemitritsea of Baglivi, generated by the marshes of the neighbourhood of the city of Rome. The very direction given by Baglivy, that the patient is not to take a purge until the seventh day of the disease, should alone have prevented him from falling into this error. It has also been engendered on the coast of Africa, as was the case in 1793, during the memorable expedition to Sierra de Leone. On this occasion it first appeared in the ship Hankey, and such was the mortality that it created in the crew of that ship, and those YELLOW FEVER. 385 concerned in that voyage, that it totally defeated the objects of that expedition. The Hankey proceeded to the island of Gre- nada. The disease immediately spread with great mortality, not only in that island, but extended itself to the other islands. It was in that same year, too, introduced into Philadelphia. Dr. Chisholm has given you a record of its ravages, in his very able and instructive work on the pestilential fever as it appeared in Grenada, &c. ; and which you will consult with great pleasure and instruction — pleasure as it regards the manner in which it is written, and instruction from the matter which it embraces. It affords the best evidence of the correctness of Dr. Chisholm's views, that the Board of Health of Great Britain, when they in- vestigated the subject, ordered that ship to be burnt, which was accordingly done. 2. In the tropics, too, the yellow fever is not generally a dis- ease of the natives, but of strangers, and particularly such as arrive from the north, who have been unaccustomed to the in- tense heat of the tropics. It may be called then, a disease of the northern man in the torrid zone, and to which he is especially liable upon his first arrival. 3d. This disease shows itself in various grades, depending on particular circumstances, as upon the state of the air, habit of body, previous modes of life, intemperance in drinking, excesses in eating, bad provisions, particularly the excessive use of salted provisions. In the insulated individual it will exhibit one cha- racter, but in a congregation of soldiers or sailors, it will show another. Hence, too, in the one case the disease terminates with the individual, as was the case with young Roe ; but in the other the impurities of the air add to its malignancy and render it com- municable from man to man in the manner that has already been particularly pointed out. 4th. When thus communicated, like the plague, four or five days usually intervene between exposure to the contagion and the appearance of the disease. For the evidence of the contagious- ness of the yellow fever in this country, let me refer you to the facts and observations published by the College of Physicians of Philadelphia, particularly to the evidence furnished by the late Dr. Kuhn, Dr. Wistar — Wistar's alone is sufficient and unan- swerable — Dr. Samuel Griffitts and others. They have borne testimony on this subject not to be controverted. See also the 386 LECTURE XXXI. Medical and Philosophical Register, which has been chiefly de- voted to that object, and for which, in a great degree, that work was undertaken — and I trust it has not been unsuccessfully de- voted to this important subject, for it contains a body of facts attested by the most respectable evidence, and which I assert, if I know what truth is, is not to be resisted. Read the letters of Dr. Thomas, August, 1816, Sir Gilbert Blane, 1816, do. 1818, in which they express their astonishment at our physicians — "their inverted intellect." The yellow fever of Gibraltar in 1804, recorded by Gilpin, in the 37th No. of the Medical and Surgical Journal of Edinburgh, for January, 1814 — yellow fever of Gibraltar, in 1813, Medical and Physical Journal, No. 181— Burnett on the same subject, No. 184 — Pym's observations on the Bulam fever, as introduced in the West Indies, on the coast of America, Gibraltar, Cadiz and other parts of Spain — Medical and Surgical Journal, July, 1815, will furnish you with the most conclusive proofs of the contagiousness of this disease and of its introduction from the tropics into the other places mentioned. See also reports on its introduction from the Havanna into Barcelona, in 1821 — Walsh's Museum, No. VI. p. 534. 5th. That the yellow fever does not arise from putrid animal matter, the observations by Dr. Chisholm, which is in all your hands, in the appendix to Thomas, abundantly prove. That it is not the product of vegetable decomposition, the testimony of Dr. Stuart also satisfactorily demonstrates. Was it necessary to adduce additional testimony on this subject to show that this dis- ease has not originated from the tilth of your cities, I might re- fer you to the filthy condition of this city, in particular before the revolutionary war, and the offensive state of it during the war, when crowded with British troops, especially after the great fire of 1776, when the cellars of the numerous buildings then destroyed, were made the repositories of filth of every sort. At that time, too, we had nothing like a system of police regulations, yet we enjoyed an almost unexampled state of good health. But again, if we for a moment advert to the offensive state of our ships, our wharves and market places, our cellars, our privies, our tanneries, slaughter-houses, tallow chandleries, manufactories of glue, morocco, and starch, all of which, in the summer season, load the air with the most offensive vapours, and these, too, in YELLOW FEVER. 387 the very heart of our city, without engendering this disease, we shall be compelled to look to some other source to which this disease must be traced — indeed, common sense rejects this doctrine as altogether puerile ; for were filth the parent of this disease, its annual return would be inevitable, both in the city and country. This result is unavoidable. Nay, every stable, farm-yard, or hog-pen, would engender it, if decomposed animal and vegetable matter is to be considered as the source of this form of fever. But remember a foul state of the air has its agency by spreading the disease in the manner already explained, when the poison has been introduced- But on this subject I need say no more; but shall proceed to notice the more prominent symptoms of this disease. Yellow fever, like the plague, frequently comes on by a violent invasion of the nervous system. In many cases, the persons ex- posed to the contagion are sensible of the effects of the poison, by its deleterious operation upon the brain, not by its offensive smell, but a peculiar operation upon the sensibilities of the system. The late Dr. Richard Bayley was conscious of receiving the poison to which he fell a victim, and declared the same at the time he was seized with his fatal illness ; yet that gentleman went to the qua- rantine ground an infidel on this subject : so says his successor, Dr. Joseph Bayley. Dr. Treet, another of our health officers, also died from this disease, contracted on board the Zephyr, the same vessel that introduced the yellow fever into this city in the year 1795. On his way home, after visiting that vessel, he stopped at the house of the Rev. Dr. McKnight, and at Mr. Isaac Clason's, both of whom he informed, and from whom I received my infor- mation, that he believed he had taken the fever, which had been prevalent on board, and which had been very fatal at Port au Prince, from whence she had arrived ; he was immediately con- fined to his bed, and died in a few days with black vomit and all the other characteristic symptoms of this disease. His whole nervous system, at the time of his attack, was violently assailed; he felt great distress at the praecordia, some delirium, and at the house of these his friends, called for a cup of drink to counteract the distressing feelings he there experienced. Dr. Ledyard, an- other of our health officers, also entered upon his office an unbe- liever; but he was converted to the faith by a very short residence at Staten Island. Dr. Joseph Bayley, too, who had entertained 388 LECTURE XXXI. some doubts upon this subject, and who, even at the time he re- ceived the honours of the College, expressed an equivocal belief of the contagious and specific character of the disease, in the Dissertation he published, has now the most unqualified belief of the opinions which I have expressed to you, that this, like the plague, is a disease sui generis. In its attack, like the plague, in some instances, it produces instant death ; in others, mania ; in most it comes on with a very acute distressing pain in the head, particularly across the fore- head, and oftentimes in the eyeballs themselves; in others it affects the brain by stupor ; the pain, too, usually is severe in the course of the back, and extends throughout the limbs, following the spinal marrow and larger nerves. In other cases, again, its force appears to be chiefly vented upon the praecordia, creating great anxiety and depression. This disease, in some instances, comes on with chill, and occa- sionally with rigors; but not so the greater number of cases; they are most generally without the chill attendant on intermittent and remittent fevers. The pulse is usually increased in frequency in the first stage of the disease. In some cases it is but little affected, in others it is soft throughout; in others it is slow and healthy to the last mo- ment of existence. The tongue is moist and clean too in some cases ; but in most slightly furred ; and in others covered with a yellowish sordes, in others a white fur. There is no thirst, or not usually trouble- some. The skin is flushed and hot, but sometimes so little affected that the patient is not usually considered to be very ill. The respiration is quickened and frequently very anxious, with much sighing and hysteria. The belly is costive. On the second and beginning of the third day, if not relieved by evacuations and by perspiration, with attention to the different excretions, a yellowness of the adnata of the eyes, of the neck, breast, and upper part of the arms, supervenes, and gradually ex- tends itself over the whole body. This symptom is probably occasioned by a change produced in the blood, and is not to be attributed to the absorption of bile, as many bave supposed. In- deed the biliary organs do not show any peculiar derangement in the commencement or at the early stage of the disease ; whereas the stomach is especially acted upon ; for it is, as expressed by YELLOW FEVER. 389 Dr. Warren, the very seat and throne of the disease ; indeed, after death, it is found that in yellow fever there is rather a diminished secretion of bile, and very little found in the gall bladder. The disease too frequently occurs in the inflammatory, not the bilious, habit of body. It is otherwise in the bilious remittent; in that the biliary organs are at first affected, and show the effects of their derangement in every part of the system, in a yellow skin, yel- low eyes, yellow sordes upon the tongue, a bitter taste in the mouth, yellow turbid urine, &c. Nor is the yellowness which supervenes upon the third day of yellow fever, of the golden yel- low of bile, but of a different hue, partaking of the colour of the orange, mixed with the reddish hue of copper. The explanation given of it by Dr. Warren, of Barbadoes, that the serum derives its change from the decomposition of the blood, as is produced by the operation of poisons upon the system, or analagous to the changes produced in blood that is extravasated and has lost its vital principle, is, in my opinion, much more satisfactory; for a total decomposition, or death, very generally soon succeeds to this change of colour, and is attended with all the symptoms which, in fevers, announce dissolution, as hemorrhages, petechias, &c. About the same period that this yellowness displays itself upon the surface of the body, great irritation shows itself in the stomach ; a sense of heat and burning now takes place, attended with hiccup, and occasional gulping or disposition to return the drinks that may have been swallowed. At length they are rejected as fast as they are swallowed, and with some force ; and when drinks are not taken, the stomach still acts, spirting out portions of its contents analagous to the violent ejection of the contents of the stomach in the inflammation of that viscus, or in the inflam- mation of the oesophagus. Now succeeds a discharge of a dirty brown water, with a suffi- ciency of bloody turbid matter to give it that dark tinge, and at length a black matter is thrown off with the fluid ejected, and which sometimes falls to the bottom of the vessel; in other cases it floats on the surface of the fluid. This matter I have observed to exhibit itself in different forms. 1st. In flakes, like tinder, floating on the fluid discharged ; this I believe to be the effect o a sphacelus of the villous coat of the stomach, and which I have remarked is invariably fatal. 2d. It appears to be discharged in the form of blood and mucus which gradually subsides. But 34 390 LECTURE XXXI. the more common evacuation is that of the 3d, the coffee-ground discharge, and which immediately falls to the bottom of the ves- sel, precisely resembling the appearance of coffee-grounds, and which appears to be made up of broken or dissolved blood. After death, this has been traced to the coats of the stomach ; in other instances it has been followed into the gall bladder and biliary vessels, and is supposed to be discharged from the liver through the biliary vessels themselves, as if, to use the expression of Dr. Saunders, (see his Treatise on the Liver) it was blood hurried through the liver before it has time to undergo the changes necessary to be formed into bile ; in this manner 1 have seen it discharged in quarts ; in some instances, too, of diseased liver, I have seen such discharges, precisely like the black vomit of yellow fever. Another proof that the black vomit chiefly consists of blood is, that the strength rapidly and manifestly declines with every discharge from the stomach, the powers of life are sensibly wasted by each successive evacuation, as we ascertain by the loss of pulse, and the coldness of the extremities. Hemorrhages, too, now frequently take place from the bowels, gums, lips, tongue, nose, ears, and blistered surfaces. The proximate cause of this form of fever I consider to be an inordinate irritation of the system, the effect of the tro- pical heat acting upon the northern man, or of contagion, which has a definite or specific operation upon the body. When the disease proceeds from the first of these sources, and assumes more especially the character of the ardent fever, or causos, as it does in the insulated individual, and is not derived from conta- gion, our indication is, in that form of fever, to reduce the violent excitement of the system by the means of depletion already pointed out in cases of simple excitement ; but when it proceeds from the second source mentioned, from contagion, as is frequently the case during war, when a great number of soldiers and sailors are suddenly transported to the tropics, and the air is rendered impure by their crowded condition, and thence a septic state of system is induced, the indication is to moderate the action of this poison upon the system ; in other words, to place the body, like the ship exposed to a hurricane, in a condition to sustain its action and violence, with as little injury as possible to the vital organs, for you cannot annihilate the poison, but, like opium or arsenic, it will continue to operate until it wears itself out. Our object, TELLOW FEVER. 391 then, is to prevent it from wearing out the system at the same time. For this purpose, then, open all the excretions, and keep them so until the enemy shall have disappeared ; not that you evacuate the morbid material, as some have supposed, though you do more or less of this, too, in all probability, but because in this open state of the excretory organs, and division of the excitement, the poison operating does less injury, because there is less fever, and fewer sources of irritation to augment the fever constituting the disease ; for the retention of faeces in the bowels, and of the perspirable matter from the suppression of the discharge by the skin, cannot fail to increase the violence and to add to the malig- nancy of the disease, inasmuch as these sources of excitement, of themselves, are frequently the causes of fever. But in the means we employ for this purpose of obviating febrile action, and in the evacuations we make use of, let us not conspire with the enemy in producing a destruction of the vital powers. Venesection, there- fore, when advisable, as is the case even in cases of fever from contagion, as we have seen, must be done early, cautiously, and judiciously, both as to quantity and repetition. We are not, how- ever, as Dr. Rush has recommended, to run the body under bare poles. To continue his figure, we should always keep enough sail to enable us to la}^-to during a gale, but not to be altogether at its mercy, or we assuredly shall be overwhelmed; for blood-letting has certainly been a fatal practice; death has very generally fol- lowed in the footsteps of the physician that has adopted it. As I have said before, upon another occasion, the indiscriminate use of the lancet in the yellow fever, as it has been pursued and recom- mended by some writers and practitioners, is adding the sword to the pestilence — it is putting arms in the hands of the enemy for our destruction. Most generally, the lancet may be dispensed with. In this country, as well as in Spain, particularly in Barce- lona, venesection was a fatal practice ; it was found otherwise by one of our navy surgeons, Dr. Cooke, in one of our armed ships. The best and most successful practice, in my opinion, consisted of mild cathartics, such as Glauber salts and castor oil, aided by lax- ative injections ; it is improper to wait for a slow cathartic. You, doubtless, recollect my statement of the success which attended the practice of Richardson Underhill, of this city, and of Thomas Penrose, John Vaughan, and William Clifton, of Philadelphia, in the epidemics of the two cities; and that these good Samaritans 392 LECTURE XXXI. cured a much greater number of the sick by their castor oil, their catnip tea, their eupatorium, and their sage, than the graduated doctors of Europe or of this country, that directed what were de- nominated your Herculean remedies, the lancet, and their 10 and 10, their jalap, and their calomel. Emetics, in this disease, are universally proscribed by all who have been particularly conversant with it, as a fatal practice, and in some instances ending in an unceasing vomiting. At this we are not surprised when we look at the cause of the disease, its violent action upon the nervous system, and the plentiful supply of ner- vous influence bestowed upon that organ, and the connexions it holds with the coeliac plexus and ganglions, and with the other parts of our frame. The practice found most beneficial after cathartic medicines have operated, is to relax the surface by sudorifics. These, when the bowels have been opened, are among the most beneficial means we can employ. This was the practice intro- duced by Dr. Warren, of Barbacloes; he learned it from a sailor. The same was pursued by Dr. John Bard, by Dr. Samuel Bard, and myself, in the endemics of our city. This consists, first, of washing the body with vinegar and water, applied cold or warm, according to existing circumstances ; cold, if the skin be hot and dry ; tepid washing and fomentations, if the body be moist but too much heated. Now the sp. minder, and laudanum, or the draught of Riverius may be advantageously administered, and re- peated every two hours : repeating also the cold washing as cir- cumstances may call for it; and giving frequently a cup of toast- water, or some diaphoretic drink. It is necessary to observe caution in the continuance of the sudorific mixtures when a free discharge by the skin is obtained, and not to continue them be- yond the first or second day, lest the stomach be too much debi- litated. Antimony is used by some, but this is hazardous in its operation. Mercury is bad for the same reason, in part. In warm climates, it is said to be a beneficial practice. This may be so where hepatic affections so extensively abound; but not so in our climate; with us it has been a fatal practice.* In like manner, it has been found injurious in Spain. Blisters to the region of the stomach should be early applied, * See my letter to Dr. Currie, of Philadelphia, in the Transactions of the Col- lege of Physicians of Philadelphia. TELLOW FEVER. 393 to prevent the disturbance of that organ, and to counteract the in- flammation with which it is apt to be affected in that disease. If the yellow fever should again visit us, it will be one of my earli- est applications. It is useful, too, in allaying the irritations of that viscus, such as hiccup or black vomit. They are also ser- viceable applied to the limbs for the purpose of removing fever, and diverting the irritations of the system to a part. They are useful when applied behind the ears, and between the shoulders, to relieve the brain when congested or greatly disturbed. When black vomiting has been induced, have we any means of relieving that deadly symptom? As I have already observed, there are various anti-emetics. The most effectual of these is the mixture of lime-water and milk. My first application of it was in 1798. I was led to the use of it in that disease, by the bene- ficial effects I had derived from it in dyspepsia — it succeeded ad- mirably, aided by spirituous fomentations. There was a public re- commendation of it by Dr. Samuel Bard and Dr. Charlton: it was then communicated to Dr. Rush, who also, in his works, testified to its success. (See my letter to Dr. Currie.) Lime-water and porter may be used; or brandy and water, and spirituous foment- ations. Cayenne pepper also is good. It is Dr. Wright's pre- scription. Ice has also very happy effects. Spiced wine, with cinnamon, and blisters to the extremities may be advantageously resorted to. Let your patient's drink be cold water, toast-water, soda-water, mild teas of different kinds, as mint, catnip, snake- root, or boneset. Let his diet be altogether vegetable. With these observations I conclude our view of the first class of diseases, in which we have had a very varied and circuitous course to pursue, and one attended with much embarrassment and difficulty. In the next class, the plegmasiae, our path is more plainly marked. We may therefore, in allusion to the winding course in the one, and the clearly marked channel of the other, emphatically say — u Farewell to Thames, all hail to Tyber's stream," 34* 394 LECTURE XXXIL PHLEGMASIA— INFLAMMATION. The term phlegmasia is derived from the verb $%£vfiatva, or %eyn 9 uro.) Galen has well denned it in his work De Tumoribus Prseter Naturam, Lib. i. cap. 2. " Hoc phlegmones nomen Grsecis dici consuevit, de carnosis partibus; majorem in molem, cum tensione, renixu, dolore pulsatorio, calore et rubore, extuberentibus." He should have added to this enumeration the usual termination of inflammation thus seated ; viz. by suppura- tion or abscess. This inflammation, too, is generally of longer duration; the parts being less sensible, its termination will not be so rapid. It is also on the same account less painful than some other inflammations to be noticed. The external parietes, at the boundary of the tumor, being inflamed, form an union of many of its fibres by cohesive inflammation, making a kind of wall; but in this the inflammation is less violent than that in the centre of the tumor. In the centre, where the inflammation is most active, effusion at length takes place of purulent matter; a viscid secretion of considerable consistence, corresponding with the en- larged dimensions of the vessels, and this is sometimes mixed with blood. This matter, acting as a foreign body, excites the absorbents. The skin adjoining the matter is rendered thin; it points and finds an exit in that direction where there is least re- sistance; not that it finds the surface by an instinctive operation, as Dr. Good supposes. Instinct does not always direct it to the surface: instinct is generally unerring. The other parts of the cavity show similar changes. If in the lungs or liver, consider- able removals of their substance takes place, leaving large cavi- ties. I have seen a case of this kind in Bridewell, another in the New York Hospital, and a third in Cherry street. The two first recovered, the third died. I examined him after death. The liver, diaphragm, and lungs were all consolidated; there was a large aperture, sufficient to permit my arm to pass through. In this last case, too, the inflammation was so insidious that a very emi- nent and experienced physician did not detect the real state and nature of the disease, but treated it as a case of hypochondriasis by gum pills, and the decoction of the woods. Diseases of the liver were then not as well understood as at this day. In another instance I have seen a large portion of the rectus muscle carried away by absorption, the effect of the stimulus of an encysted tu- mor, acting upon it as a foreign body. This tumor was removed, and disclosed the ravages it had created upon the neighbouring rectus muscle. I have seen another case of the gastrocnemius . PHLEGMASIA. INFLAMMATION. 401 nearly excavated by an abscess. Upon examining the interior of an abscess this is not all; the cellular membrane which first made the seat of the tumour, is also in a great degree removed, and pus found in its place, mixed with some remaining fibres, probably of vessels. This little mass of vessels which remain, is vulgarly called the core of such abscess; i. e. a mass of the vessels which were perhaps the first seat of the inflammation. This core is kept in its place by a few of the fibres or remaining vessels still ad- hering to particles of the abscess. Hence time is required to remove this core from its connexions. It is important, too, to remember that inflammation, when thus located in cellular sub- stances, is less painful, and of course more insidious, as in the liver, lungs, and brain. The pulse, too, manifests it less than when seated in the mucous, the dense or serous membranes; and still less than in the more sensible organs that have been enume- rated; as the skin, the stomach, uterus, &c, the whole symptoms of general irritation are less. Indeed we may observe, that phleg- monoid inflammation scarcely ever appears but in the cellular membrane, or in those organs abounding in it, as the brain, lungs, liver, kidneys, muscles, as the psose, producing the psoas abscess. Their loose texture, in a particular manner, admits of this extra- ordinary distension — this tumor, the pulsation, and secretion or effusion of a fluid of the consistency of pus, having globules nearly resembling in their size the globules of blood. I believe such purulent effusion rarely appears otherwise. I say rarely, for I have seen, in some instances, a purulent secretion from the surface of the intestines, floating over the surface after enteritis. We also sometimes find an analogous enlargement of the vessels upon the surface of the lungs, and a purulent fluid dis- charged from the surface, and proving fatal, exhibiting all the symptoms of phthisis; and yet upon examining the lungs after death, no abscess, no vomicae, no phlegmonous collections are to be found, not even the least appearance of ulcer. The next form of inflammation is that which is seated in the secreting membranes, especially those pouring out mucus, and which have an outlet from the system. Those membranes are more soft or spongy, less dense than the internal membranes, and they have a villous surface supplied with numerous follicles pouring out fluids ; these, being of a mucous nature, defend those surfaces from any acrid materials that may flow over them. We have examples of these secreting 35 402 LECTURE XXXII. membranes in the lining of the nares, fauces, bladder, urethra, and uterus. The effect of inflammation, when seated in those membranes, is an increased thickness of them ; the villous surface becomes red and spongy, with great heat and soreness ; it is attended with but little acute pain, except such as arises from the acrid fluids pouring over their inflamed surface. The fluid itself, which such membrane secretes, becomes changed ; instead of being ropy and adhesive, it becomes thin and acrid, losing its tenacity, and excoriating the neighbouring parts ; now at length it becomes somewhat purulent, and then soon returns to its original consistency and qualities. As there is not much acute pain, there is, therefore, comparatively little fever, except when the inflammation becomes deeper seated, reach- ing other organs beneath the part primarily affected. Fever is not generally produced to a great extent by the inflammation of mu- cous membranes, (for the inflammation to a degree at least appears to be moderated or diminished by the discharge,) though fever produces ^inflammation in them. When terminating favourably, the discharge, from being first thin and acrid, becomes purulent; afterwards it recovers the properties of a bland mucus, with all its tenacity and transparency. But when the inflammation is greater, it ulcerates the membrane itself, and sometimes even extends to the parts deeper seated, producing abscess or phlegmonoid inflam- mation ; even sometimes ending in gangrene, as in the bladder, intestines, womb, &c, but this is not the usual termination of inflammation seated in the mucous membranes. This inflammation of mucous surfaces is also oftentimes chronic, while the preceding, and those which are to follow, are acute ; with some exceptions, as when dense membranes, or even the cellular, are the seat of scrofula or of lues, even the dense membranes, as well as the cellular membrane of glands, then become affected with chronic inflammation, depending then, however, more upon the nature of the cause than the structure of the part, the seat of . the inflam- mation. In the inflammation of mucous surfaces, sponginess, red- ness, and great sensibility remain in the parts affected ; the fluid secreted remaining sharp and corrosive. The third sort of inflammation is that which is seated in dense membranes, which are internal, having no external outlet for the matter they secrete, and the matter secreted is thin and serous ; from their dense structure, Haller thought them insensible, and incapable of inflammation; he even thought a pleurisy to be seat- PHLEGMASIA INFLAMMATION. 403 ed in the intercostal muscles, and not in the pleura. Haller was a much better anatomist and physiologist and poet, than physician. It is now ascertained that those membranes, as of the brain, lungs, peritoneum, &c, when inflamed, are exquisitely alive to impres- sion ; the sufferings of a periostitis are inexpressible. In the membranes of the joints, the same sensibility is manifested when inflamed, especially upon the admission of air to the cavity of the joint; this being a stimulus to which they are unaccustomed. I have seen a very violent degree of inflammation induced in the cavity of the knee joint, by discharging a large collection of water from it. The operation was performed by Mr. Bennett and John Bell. Although it was performed in such a manner as to make the least possible wound, and with a valvular opening allow- ing the water to flow off, and as far as possible to exclude the air; a most violent inflammation ensued, and ultimately proved fatal. Mr. Bell then declared that this event had so frequently taken place, that he would open no more joints. The symptoms of in- flammation in dense membranes, are violent pain and irritation. Why more so in these than other membranes ? Because of the firm unyielding texture, resisting the distention that takes place in other parts, from the quantity of fluids loading the inflamed ves- sels. Great fever is of course to be expected as the consequence of such irritation ; the membrane itself is thickened and becomes opaque ; an excretion of a matter like lymph is poured out upon its surface, sometimes a turbid serum, and in other instances, bear- ing a resemblance to very thin fluid pus. An adhesion to the adjoining inflamed parts also frequently takes place ; in some cases I have known the parts to slough, as in the case of an in- flamed testicle, in which case the coats of the testis were peeled off in succession, like the coats of an onion. In a pleurisy, the patient suffers a severe pungent pain, with a short and painful cough, the pleura becomes thickened, and often a gelatinous effu- sion and adhesions are the result. In some few cases, such pleu- ritic inflammation ends in serous effusion or hydrothorax, while, in still fewer, I have known it to end in sphacelus. So, in like manner, peritoneal inflammation is attended with intense pain, fol- lowed by gelatinous exudation, adhesion, serous effusion, and sphacelus. In inflammation of dense or serous membranes, as Bichat calls them, the pulse is quick, hard, and small; the fever too attending it, is greater, as we see in inflammation of the mem- 404 LECIXTRE XXXII. \ branes of the brain, periostium, &c. Inflammation is also peculiar in parts highly organized by nerves, and thence possessing great sensibility, as in inflammation of the skin, the mouth, fauces, sto- mach, intestines, bladder, vagina, uterus. Inflammation in either of those organs is painful, from the irritation applied, in conse- quence of the great sensibility of the parts. Excitement is then reproduced throughout the whole system ; it is rapid of course in its termination, for the vital powers of those parts are soon worn out, and sphacelus, the common consequence, is produced. We see examples of this sort in the skin ; as sphacelus from blisters, especially in children, or in fevers where, from their long applica- tion, the vital principle is already impaired, also, sphacelus from erysipelas ; hence, too, the fatality of burns, especially in the sen- sitive systems of children. In the fauces, in like manner, inflam- mation rapidly ends in gangrene. The inflammation of the intes- tines in dysentery, as we have seen, is in some instances rapidly fatal in this manner, by terminating in sphacelus ; in the inflam- mation, too, of puerperal fever, the same result is not uncommon. Beware how you deceive yourselves by cold extremities, a pale face, or a small pulse ; do not by them be deterred in the begin- ning from an active antiphlogistic treatment; on the contrary, remember the cause and seat of these phenomena, and let them teach you that they are the very reasons for your greater activity in the use of those means that are indicated ; and remember, too, that the first six hours are your time of action,' and of securing your patient's safety. It is important, therefore, to know these facts, not only as it regards their symptoms, but your cure. The natural termination of those various inflammations leads to impor- tant conclusions, in this respect: they teach us, if we cannot rea- dily obtain resolution by active and early measures, to guard against adhesion, and especially gangrene and sphacelus, for we have seen, 1. That when inflammation is seated in the cellular mem- branes, the tendency to suppuration is scarcely to be counteracted. 2. That when seated in mucous membranes, the inflammation is less severe and more manageable. 3. That in dense membranes adhesion is to be expected. 4. That, seated in parts highly organized, there is no time to be lost, or it will end in gangrene or in sphacelus, as in the treat- ment of the inflamed part locked up in the stricture of hernia. 405 LECTURE XXXIII. PHLEGMASIA.— INFLAMMATION. Inflammation not only varies in its nature and consequences, according to the structure and sensibility of the parts in which it may be seated, but it also varies in its character, depending on its remote or exciting causes. Ophthalmia, for instance, may proceed from cold; it may proceed from scrofula, or it may be the effect of syphilis. According as it proceeds from any of these causes it exhibits a different train of symptoms; is of long or short du- ration; and requires a different mode of treatment. In that from cold, it is attended with fever; in that from scrofula or syphilis, it is most generally without fever, or it is comparatively mild. That from cold is of short duration; while that from the other two causes is tedious, and does not yield to the same treatment. In that from cold, the antiphlogistic treatment is called for, and alone affords relief; while in the other, the lancet and other means of depletion are of little avail, and the disease is only to be re- moved by the antidotes to the peculiar vice with which the sys- tem may be affected. For the most part, the physician, by atten- tion, will readily know the one from the other, by the more active form of the one, and the less violent symptoms of the other. But unless we advert to the cause we shall be unsuccessful in our treatment of this disease. Inflammation of the throat may in like manner arise from cold. 2. Contagion, as in cynanche ma- lig. 3. Syphilis. 4. Or even from mercury. The two first and the last, i. e. from cold, contagion, and mercury, are attended with fever. That form of syphilis is most usually without fever : but the latter calls for peculiar treatment. Mercury alone is the remedy. But if mercury is the source, other means must be directed. 35* 406 LECTURE XXXIII. Again, glandular affections, as obstructions of the lymphatic glands of the neck, may proceed from, 1. Cold; or from, 2. Teeth- ing; 3. From scrofula; 4. Or from syphilis; 5. From porrigo — scald head. The two first are attended with more or less of fever; the other none, except what the humours themselves may create. In- flammation of the joints may also arise in like manner from cold r from gout, from scrofula, or from syphilis, Mr. Pott's skill be- came celebrated for detecting the last mentioned cause in two eases which fell under his care, of disease of the joints. We see the same illustrated in an inflammation of the skin, that it exhibits different phenomena, is more or less dangerous, and has different terminations, according to the causes which produce it ; and con- sequently that it demands, according to the nature of the causes producing it, a different mode of treatment. We see erysipelas from cold, also from heat, from intemperance; we see it from gout; i. e. from an inflammatory habit of body, or from plethora; we see it in the form of of an erythema, the effect of mercury ; and we see it the effect of a general septic state of the fluids. To prescribe successfully, these causes must severally be kept in view in our prescriptions. Celsus has very justly said, " Eum recte curaturum quern prima origo causae non fefellerit." That he will readily cure diseases who is not deceived with regard to the causes of them. Such are the phenomena of inflammation; and by these circumstances they are influenced; viz. by the struc- ture of the part in which it occurs, and the nature of the cause producing it. Let us next briefly inquire, what are the several remote causes of inflammation. They divide themselves into the predisposing and exciting causes. The predisposing causes are, 1. Certain temperaments of body are more susceptible of in- flammatory diseases than others; as the sanguine and nervous temperament. 2d. Debility, by producing great sensibility, predisposes to in- flammatory diseases. Hence we see the same person more liable to a second attack, and of the same disease ; i. e. this debility shows itself in the part as well as the whole system. 3d. Climate has its influence, as a predisposing cause. A climate in which many vicissitudes of weather occur, or a very hot lati- tude produces inflammatory diseases, as we see illustrated in our own climate, to which the character given of that of Pennsylva- PHLEGMASIA. INFLAMMATION. 407 nia may with great truth be applied. Dr. Rush observes of it, that it is uniformly variable. 4th. Certain seasons of the year, for the same reason, as spring and autumn, predispose to diseases of an inflammatory character. 5th. Manner of life: a full habit of body, our beefeaters, and five-bottle men, are the candidates for gout, as well as other dis- eases of plethora and inflammation. They not only act by the fulness they create, but by the indirect debility which they induce. 6th. Females are more liable to inflammatory diseases than males, both from their natural delicacy and sensibility of frame, as well as that sensibility which is the effect of confinement and sedentary habit of living. Cynanche tonsillaris, pneumonia, end- ing in phthisis and hemorrhage from the lungs, come from the same cause. Rheumatisms are of much more frequent occurrence in the female sex than in ours. 7th. Time of life has its agency in this respect. Infancy and childhood, in an especial manner, predispose the body to certain inflammatory diseases. It is the preternatural sensibility of in- fancy that renders them so liable to anginas, to croup in particu- lar, and to pneumonia; especially those inflammatory diseases which are seated in the mucous membranes, are the predominant diseases of that period of life. 8th. A plethoric habit of body predisposes to the same class of diseases ; for the secretions in such being more abundant, they are also, by the application of cold, or other exciting causes, more easily checked; and in such habits of body the inflammation in- duced is more violent. The exciting causes may be said to embrace every means of quickening the circulating system. 1st. Mechanical injury, as (1) wounds inflicted by instruments; the wounds from a ball; from splinters; even friction of the thighs by riding or walking, proves an exciting cause of inflam- mation. (2) The irritation arising from calculi, as in the gall-blad- der ; biliary ducts; kidneys; ureters, or urinary bladder; or de- posited in other parts, as the lungs. 2d. Cold partially or suddenly applied. 3d. Heat, either from the direct rays of the sun, or by fire. 4th. The alternate operation of heat or cold, as in the changes of atmosphere. 408 LECTURE XXXIII. 5th. Animal stimulants, as the stings of various insects. 6th. Vegetable stimulants, as turpentine, the effluvia of the cashew nut, anacardium occidentale; the foetid liquor exuding from the urtica urens. 7th. Chemical, or metallic stimulants, as the oxydes of arsenic, mercury; the mineral acids, as the nitric, muriatic, and sulphuric acids, caustic alkali, quicklime. 8th. The peculiar acrimony of diseases, as syphilis, scrofula, and especially, 9th. The diseases of contagion, of which there is a great va- riety, as measles, catarrh, small-pox, scarlatina, &c. 10th. The irritation of fevers, and especially synocha; and, 11th. Obstructions of vessels; that is, partial determinations taking place, as in fevers, to particular organs, as to the brain, lungs, &c, especially when they have before been the seat of irri- tation. These local inflammations supervene as the attendants on fever. Thus, too, we see glandular swellings in the advanced state of fevers, and other diseases, as from syphilis, scrofula, typhus fever, plague, or yellow fever. But obstructions are also, in many cases, the causes, as well as the consequences of inflam- mation as in the mammse, when obstructed sometimes. Such ob- struction creates inflammation, and that, too, whether it be a re- cent obstruction from milk, or it may have been an old scirrhus. In either case it may be the cause of active inflammation. In this way the former may end in abscess; the latter in cancer; i. e. ulceration, the effect of inflammation in the obstructed part. Again, we see collections of blood in the hemorrhoidal vessels not only painful in themselves, but such is the irritation excited that a phlegmon, and that terminating in fistula in ano, are the con- sequences. In like manner, accumulation of blood in the uterine vessels, the effect of suppression of the menses by cold, or a sud- den check of the lochia, not only creates great distress and sore- ness, but puerperal fever; i. e. uterine and peritoneal inflamma- tion. In some cases, scirrhus and cancer uteri are the consequences of the natural cessation of the menses; and such inflammation, like that affecting the liver and lungs, is frequently insidious in its approach; or, as I have said before, speaking of the inflamma- tion in mucous membranes, it is perhaps, partially relieved by a degree of fluor albus, that is frequently the attendant upon such uterine obstructions. An analogous suppression of accustomed excretions from the surface of the body, from the intestines, from PHLEGMASIA. INFLAMMATION. 409 the biliary canal, or from the urinary organs, by creating a new stimulus to the parts, and indeed to the whole system, also produces inflammation and its consequences. Even sphacelus is in this way not unfrequently the effect of the suppression of urine. Thus, too, we see the check given to the excretions from the throat, trachea, lungs, nose, lachrymal glands, produces inflam- mation of those organs. Even the glandulse meibomii obstructed produces psoropthalmy, or perhaps the hordeolem, or common stye. Indeed, all such obstructions become the immediate causes of irritation, by creating a fulness of the vessels of the parts, and thence extending that irritation more or less to the whole sys- tem, depending upon the extent of the connexions which such part may hold with the general system. Having taken this view of the phenomena and remote causes of inflammation, we are prepared to inquire into, and to appre- ciate the different opinions relative to the nature of that diseased condition, and I trust, too, to perceive their insufficiency, as that of Dr. Hoffman, after him adopted by Dr. Cullen. They supposed the proximate cause to consist not only in increased action of the blood vessels, but also a spasmodic stricture of their extremities. This spasm, as in fevers, may be the consequence, but not the cause — it may be an aggravating circumstance, but it is not essential to inflammation. The distended vessels may be spasmodically affected, or they may not be. Therefore, such spasm is not essential to the inflammation any more than it is essential to fever; or that spasmodic action in the trachea is essen- tial to the inflammation of the membrane lining that tube, yet it is a common consequence in all. But let us not confound causes and effects ; let us not identify causes with consequences. Ac- cording to Dr. Boerhaave's view of this subject, inflammation consists in what he denominates an error loci ; that is, that the small vessels containing blood, which vessels did not before con- tain it, are the seat of, and constitute inflammation. This doc- trine is certainly a near approach to the truth, as corresponding with the phenomena we have seen ; but alone it does not consti- tute the whole truth. Effusion of blood frequently takes place in the loose texture of the eye-lid, nay, in the very adnata of the eye ; yet no inflammation attends or follows such effusion. There is then, something more wanting, namely, an impacted state, a forcible entry of such blood vessels, so as to create 410 LECTURE XXXIII. pain and irritation, is necessary ; and frequently there is no er- ror loci in inflammation, except in as far as a disproportionate quantity of blood may exist in the very vessels in which it cir- culated before. Vacca, preceded in this theory in 1766. Mr. Latta's opinion is also somewhat original on this subject. He believes there is a deficiency of action in the part, and a para- lysis of the vessels instead of spasm. These, too, are doubtless the effects, but not the causes of inflammation. The capillaries being overloaded, more or less of obstruction necessarily follows, and hence effusion is the consequence. Diminished action, how- ever, although it may exist, is not the cause but the effect of such inflammation ; for it appears in the greatest degree when the in- flammation is at an end, as illustrated in the experiments of Wil- son : like Dr. Cullen's debility, it comes too late to be a cause ; it is only in time to be the consequence. Again, this paralytic state which Mr. Latta supposes to exist, is certainly very inconsistent with the local irritations attendant upon inflammation. It is alto- gether inconsistent with the pain, the heat, the redness, and the tumour attending the part. Paralysis of the part, like paralysis of the whole system, may be the consequence of plethora and ob- struction, and probably is so. In like manner, too, the debility of the capillaries of the part, is not essential, as stated by Wilson. He, too, has the cart before the horse. The preternatural disten- tion doubtless exists, but the other does not necessarily follow, from the facts he has adduced, any further than as a consequence of the distention ; but this debility has nothing to do with it as a cause of the inflammation, any more than debility is the cause of fever. It may be a predisposing cause in both cases ; but in this respect it is not essential to fever, nor to constitute inflammation. It necessarily, however, follows great distention and excessive action, but does not necessarily beget either or precede either. Another opinion has been lately advanced from that hot bed of speculation, Edinburgh. I refer to the view taken of this subject by Dr. Thompson, the Professor of Military Surgery, as con- tained in his volume of Lectures on Inflammation. That is, that in some cases the vessels acted upon, are readily distended by the exciting cause, constituting the passive inflammation ; in others they are not previously debilitated, and therefore resist the im- pulse a longer time, constituting the active form of inflammation. These are certainly facts not to be questioned — they, however, PHLEGMASIA INFLAMMATION. 411 merely show, as I have said before, that debility predisposes the part to be more easily acted upon, but that it is not essential to constitute the proximate cause of inflammation. Let us next inquire for ourselves, and deduce such inferences as the phenomena we have seen will justify. We have seen an irritating cause applied to the part, producing inflammation ; and that part, too, we have seen in some cases more susceptible of impression from the debility occasioned by a former attack; but this is not essential, as inflammation is produced without such preparatory condition of the part. As a child gets the croup, although it takes the disease more readily a second time, yet it has a first attack without any very peculiar sensibility of the part affected, with that alone which is peculiar to that early period of life. We have seen the phenomena of irritation or ex- citement in the part, the consequence of this irritating cause — we have seen redness, tumour, heat, pain, throbbing, vessels carrying red blood that never carried it before ; and those which before were scarcely perceived to convey red blood, now very much distended with it, and carrying more than the ordinary quantity of red blood, as in the vessels of the adnata, and those which were the subject of Dr. Wilson's experiments. We have seen these evidences of irritation not confined to the part, but extending to the vicinity and even to the whole system; but this is not all, we have seen again the whole system reacting in the part diseased — loading it with blood, carrying to it a quantity altogether dispro- portionate to the size of its small vessels ; and we have seen these small vessels under this extraordinary pressure, showing different terminations, according to the structure and functions of the part affected, the resistance it makes, and the cause keeping up the impulse. We have seen these inflamed vessels pouring out some- times blood — serum — pus — a gelatinous effusion becoming the medium of adhesion between the part originally inflamed and the neighbouring parts ; and we have seen the more sensible parts of the body ending in sphacelus. From all these facts we are authorised to conclude that the proximate cause of inflammation is a preternatural accumulation of blood in the part affected, ex- citing local or general irritation, according to the structure and sensibility of the parts and the nature of the remote causes and the time of their application. Observe, every temporary accumu- lation is not the proximate cause of inflammation; but kept up, it 412 LECTURE XXXIII. will become so. General exercise quickens the circulation — par- tial exercise or the irritation of the part — mere friction from a flesh brush will increase for the time the quantity of blood in such irritated part ; but even that partial excitement will, if continued, excite inflammation. Scratching, friction, will excite inflamma- tion. General exercise will create general inflammatory fever; that is, inflammation of the whole system or synocha. Such is the best view I am enabled to take of the subject. It is the only one which in my opinion will explain the phenomena we have seen, and I believe it is the only one which will lead us to rational indications of cure, and the most effectual means of fulfilling those indications.* * I perceive Dr. Good has come to nearly the same result. " Inflammation," he observes, " consists in an increased impetus and accumulation of blood in the vessels affected, accompanied with a proportionate swelling and sense of heat." (See Study of Med. vol. ii. p. 228.) This I consider as a strong confirmation of the views and doctrines which I have taught in this College from its first esta- blishment, implying an increased momentum ; that is, an increase of quantity or weight multiplied into its velocity. 413 LECTURE XXXIV. TREATMENT OF INFLAMMATION. From the view which has been taken of the proximate cause of inflammation, seeing that it consists in an inordinate quantity of blood, and the increased velocit)^ with which it flows into the part, the seat of the disease, creating both local and general irri- tation, the following indications may be derived: 1st. To dimi- nish the quantity of blood circulating in or obstructing the part affected ; and, 2dly, thereby to prevent the debility, the effusion, whether of blood, serum, or coagulable lymph, the adhesion of parts, or the sphacelus, which such obstruction has a tendency to create. But it is to be remarked that there are two stages of in- flammation, viz. the acute and the chronic, the active and passive, tonic and atonic, and that the means of fulfilling the indications of cure will accordingly differ in those two stages, at least they will differ as it regards the extent to which the remedies indicated are to be employed. The means of fulfilling the first indication, that of diminishing the quantity of blood circulated upon the part affected, and consequently of lessening the momentum with which it is circulated, are the following : 1. The removal or avoidance, as far as possible, of the remote causes, whether predisposing or ex- citing, if they are still present and operating upon the system, or upon the part, the seat of irritation, as in ophthalmia, the foreign body must be removed, the syphilitic matter must be counter- acted. 2. By bloodletting, general or local, which both lessens the quantity of blood, and the force or impetus with which it flows ; for the momentum and quantity are generally in proportion one to the other ; or, to speak more accurately, the momentum con- 36 414 LECTURE XXXIVo sists of the quantity multiplied into the velocity. This evacuation, too, is especially important, when the inflammation is seated in parts of the body possessing great sensibility, or in parts intimately connected with life, for the reason already assigned, because more violent, and thence more rapidly exhausting the vital principle. But, in the use of this evacuation, we must observe some caution, regarding, not only climate, season, constitution, time of life, stage of the disease, &c, but the character of the disease itself, as in the local inflammation sometimes attendant upon typhus fever. But in recent injuries, the system, being under no other influence than pure synochal fever, or a purely local injury, bloodletting may be used with the utmost freedom, local and general, by open- ing a vein, or the division of an artery, or by the various modes of local bloodletting, by leeches, scarification, and cupping. In such cases, remember, "A little bleeding is a dang'rous thing, Eleed free, or open not the vital spring." 3d. Other evacuations are indicated, not only with the same intention as bloodletting, but for the purpose of transferring ex- citement, and changing the determination or current of the fluids from the part affected to the exhalent surfaces, upon which those remedies are to operate. Active cathartics, such as the saline, or calomel and jalap, have a double operation in this respect. They not only act as so many lancets, or trocars, drawing off the fluids of the system, but they create new and strong impressions, new places of rendezvous ; they divert the enemy from the part they are ravaging, and attract them to other and new objects of atten- tion; we thereby, too, create new determinations upon parts where such irritation is relatively safe. This is an important idea to be kept before us, especially when the disease is seated in parts of great sensibility, either naturally so, or when acquired by dis- ease, as in a pleurisy or an inflammation of the brain. Boyer, in cases of this nature, to our great surprise, trusts to the "lave- mens," instead of active cathartics ; the advantage of cathartics in this respect is very apparent. 4. Upon the same principle, we employ sudorifics, i. e. such of them as at the same time that they effect this evacuation, do it without adding to the general excite- ment of the system ; on the contrary, which operate by relaxing the body, by unlocking the secretions, and, at the same time, re- tarding the circulation. Antimonial preparations, either in the TREATMENT OF INFLAMMATION. 415 form of emetics, producing full vomiting, or in nauseating doses of that metal, are here indicated. Boyer objects to vomiting, yet he approves of venesection, because it relaxes ; but, I ask, is not relaxation the principal effect we expect from antimonial medi- cines ? Emetics are in many instances adviseable, particularly after other evacuations by venesection and cathartic medicines have been premised, as in cynanche trachealis, maligna and ton- sillaris, but not in phrenitis, gastritis, or enteritis ; of these here- after. In the latter cases, antimonial preparations in nauseating doses are to be preferred, as James's powder, the antimonial solu- tion, the union of tartarised antimony and the super tartrite of potash, (viz. 3ij cream of tartar, and tartar emetic gr.ij M., divide in pulv. viii. one every two hours. ) Some prefer the combination of the antimonial powders with calomel, but if the latter be im- proper in inflammation, the combination certainly will not justify the use of it, except only as a cathartic. The sp. minder, with a small quantity of laudanum, is an excellent sudorific, or the citrate of potash, or the Dover's powder may be employed ; opium, not- withstanding its supposed stimulant effect, you will find particu- larly proper after evacuations by the lancet, for the purpose of diminishing the pain and excitement attendant upon inflammation. Professor Reichter, of Gottingen, is a warm advocate of opium, for the purpose of subduing irritation in all inflammatory diseases ; for even pain becomes an additional and aggravating source of ex- citement in such diseases. Ware, too, in ophthalmia, pursued the same practice. Dr. Post also, in his own person, frequently divert- ed inflammation from his lungs by the use of opium. 5. Blisters are also adviseable, by translating irritation from important parts, the seat of inflammation, and are useful by the new excitement they create upon the surface ; with this view they are among the most valuable remedies to be employed. Sinapisms are also sometimes advantageously applied, upon the same principle. 6. Diuretics are in some eases prescribed with benefit, especially such as sensibly diminish the excitement of the system, as the nitrate of potash gr. x. or xv. every two or three hours, and per- haps digitalis, if this plant be ever safe or useful. But this poison, on account of its deleterious effects upon the brain, is to be admi- nistered with great caution ; indeed, it may be dispensed with altogether, for you have abundant means of diminishing arterial action, without producing the deleterious and narcotic effects 416 LECTURE XXXIV. which this medicine creates upon the brain, by which it effects the object of retarding the circulation ; its sedative operation is doubted by Orfila, which induces me to doubt the correctness of his observations in general, not only upon this, but other subjects. 7. Local applications, which are calculated to lessen the activity of the circulation, are also to be permitted. In cases of violent local injury, in which a rupture of vessels takes place, and an effu- sion in the cellular membrane is the result, it is a good practice to empty the part by the lancet. I mean where the extravasation is very considerable, and more than- the absorbents can readily take away. I know a case in which the blood was discharged with great benefit ; whereas, when such blood is permitted to remain, it becomes coagulated, and afterwards undergoes a great change in its properties, and produces disease of the parts beneath, analo- gous to the retained menses behind the hymen. (See Smellie.) I have seen two cases in which an injury was sustained by persons rupturing a blood vessel on the anterior part of the leg, by striking it violently against the sharp edge of a carriage stone; they were neglected ; the result was, the blood effused, acting as a foreign body created a good deal of disease and ulceration in the parts on which it lodged. I dilated them very freely with the bistoury, and dressed them as common ulcers. In another instance, where the tumor was very extensive, I introduced a seton, which had a similar effect in discharging the contents of the tumor, and in restoring the parts to a healthy state. To prevent these consequences therefore, it is a good rule im- mediately to open such tumour and to discharge its contents as soon after the accident as possible, then applying a compress with lead water, a cure is readily effected. Upon the same principle the application of leeches, scarification, and cupping, are also to be used where a particular part is surcharged with blood in a less degree, especially accumulations about the brain, the eye, the mammae, the testis. In the former, cupping is to be preferred, in the latter, leeches are the most effectual application. Lead water, that is, the solution of the acetate of lead, or Goulard's extract, is frequently had recourse to. In cases of recent inflammation it is certainly an excellent application, that is if applied at a moderate temperature ; but applied as it usually is, cold, it is in many in- stances objectionable, by producing pain, especially in inflamma- tion of secreting surfaces, or secreting organs, as the eyes, the TREATMENT OF INFLAMMATION. 417 urethra, the joints, testicles. Cold water, vinegar and water, or salt and vinegar applied cold after recent injuries, I have ever ob- served to add to the distress of the patient under such circum- stances, and especially in strains of the joints to which they are usually directed by most practitioners, they are peculiarly inju- rious ; for they assuredly by their stimulant operation, add to the pain and to the stiffness of the parts to which they are so applied. Tepid applications, on the contrary, in the form of fomentations, are in my opinion, infinitely preferable, and are the remedies I usually direct ; they soothe the parts and allay the existing irrita- tion, and thereby diminish the flow of blood to the part affected, and are among the best means of effecting resolution of the exist- ing inflammation. But when the inflammation is removed and the parts remain debilitated, in that case cold applications, cold water and other stimulants to restore the tone, are indicated ; for cold water applied suddenly, as before remarked, is among the most powerful stimulants and restoratives to debilitated parts that we can direct. During the first stage of active inflammation, atten- tion should also be paid to the diet of the patient, and which, as ill synocha, should be very simple, and the least stimulating, Abstinence from animal food, from wine, and other stimuli, should be rigidly attended to; even in the quantity of bread and water, great moderation is to be observed — while lessening our fluids with one hand, let us not increase them with the other. Upon the same principle, too, we should enjoin the avoidance of all stimuli which are calculated to excite the system — as light* heat, noise, exercise of mind or body, should all be carefully guarded against. But, secondly, when inflammation is very far advanced, and considerable obstruction or congestion has been produced, espe- cially when seated in the yielding cellular and muscular fibre, the indication will be to promote effusion from the distended vessels; for it is now ascertained that the means already employed are in- sufficient, or perhaps we are called upon at that advanced degree of inflammation, that it is too late to expect benefit from their use. To promote such effusion or secretion of pus, from the congested vessels, we must have recourse to warmth and moisture combined, such as fomentations by means of flannels wrung out of vinegar and water, or an infusion of hops. The application of a warm poultice of bread and milk, or of ground flaxseed mixed with it, 36* 418 LECTURE XXXIV. or of the white lily roots, (the lilium candidum,) remarkable for their mucilaginous properties, and which, therefore, have proba- bly been so long in use — or a poultice prepared of the slippery elm bark, (the ulmus fulva, called also Americana, by Dr. Dyck- man, in his excellent Dispensatory,) or other American species — the seeds of the quince, (the Pyrus cydonia,) also make an excel- lent poultice — the pith of the Laurus sassafras also. Even to the inflamed eye, a poultice prepared of some of these emollient ma- terials, is one of the best applications that can be made to the part — it should be boiled to a jelly. Tepid drinks, taken frequently, are also calculated to aid such effusion, and indeed in some cases if these means be early made use of, they prevent a purulent dis- charge, by removing inflammation and effecting resolution. But great care is to be taken not to reduce the tone of the system too much, or you prevent the secretion of pus, as you would impair the secretory power of any other vessels of the body; for both the whole system and the part itself, are sometimes so relaxed and debilitated that the parts remain stationary, neither tending to resolution nor proceeding to suppuration. In such cases both general and local stimuli so far from being injurious, are advanta- geously directed. In such cases of torpor or inactivity, bark, wine, and a better diet are to be prescribed. In like manner the stimulant gums, different stimulating plasters, stimulant poultices composed of onions, or garlic, honey, spirituous fomentations, and various other substances are had recourse to for the purpose of exciting the parts to suppuration; but be cautions that you do not employ them in active as well as in passive inflammation — this is a common error. Spirituous fomentations and the infusion of stimulant and bitter herbs are oftentimes improperly employed in the first as well as in the second stage of inflammation. When abscess is produced, that is, the effusion or secretion of matter has actually taken place, the matter is to be discharged without delay, by means of a lancet or the knife. Opening by caustic is too tedious, and leaves a ragged ulcer behind it, which by the use of the lancet or scalpel, is to be avoided. Such collection, too, should be discharged before a great excavation may have taken place; for the absorption arising- from the stimulus of the foreign body, remember, is not confined to the parts nearest the surface, but as I have already told you, extends to every part of the parietes or walls of the tumour. TREATMENT OF INFLAMMATION. 419 Again, it should be evacuated early, to prevent that debility, that laxity which follows long distension of such parts, and espe- cially those which are naturally of a loose and relaxed texture, as about the anus. In like manner, when seated near parts of great importance, it should be discharged as early as possible, lest such parts become involved in the disease, as abscesses situated near the larger joints, as the shoulder, or hip, or knee joint. In like manner, such discharges, too, will both be facilitated by continu- ing the poultice perhaps a day, or even two; and which will at the same time lessen the irritation occasioned by the wound made to evacuate the matter. But of all things avoid the irritation of the part occasioned by the common practice of pressing it after opening, and indeed, as most strangely advised by Dr. Thomas. This becomes totally unnecessary when the part has been properly and freely opened. When the contents of the tumour are com- pletely discharged, the next, the third indication will be to give tone to the debilitated parts, and to the whole system, where it also partakes of the debility that may now be produced. This is not only necessary for the purpose of preserving a healthy action, but to enable the parts to reproduce those materials which have been removed or destroyed, by the secretion or generation of new parts to supply such loss, and to fill the cavity created. For this purpose, tonics and stimulants are indicated, both general and local, bark, wine, porter, ale, milk punch, the most stimulant nour- ishments are the most effective means of building up the strength of the whole system, while stimulant washes, viz: soap and water with rum, or some other spirituous addition, or with the sulphate of lime, or stimulant ointments, aided by bandage or compress, are advantageously directed. Setons, too, to excite the surfaces of such collections as cannot be completely or safely laid open by the knife, may be employed. Stimulant injections may be substi- tuted, and are among the means of exciting the parts themselves to healthy action. The principles upon which this treatment of the different stages of inflammation is founded, are no less applica- ble to phthisis pulmonalis and other inflammatory diseases, than they are to the simple phlegmon seated in other parts of the body. Even in the secondary stage of inflammation, constituting cancer, the same doctrine is our guide. Hence we now find extraordinary virtues ascribed to the carbonate of iron and other medicines, as if they contained a specific antidote to that disease. In this disease 420 LECTURE XXXIV. be careful to avoid the relaxing effects of long continued poultices, as you would do in other ulcerations — you would otherwise render the part an issue — as I have known to happen in the N. Y. Hospi- tal. I knew a case of a young mulatto woman that had a tumour of the breast for months — cured by the stimulant or alterative ef- fects of mercury, at the same time that mercurial ointment and a mercurial plaster, by its stimulant effect on the breast, totally removed the obstruction of the part affected — the mode of treat- ment lately introduced by Samuel Young, by means of pressure, partly by plasters, and in part by compresses of sheet lead, no doubt is founded upon the same principle. (See Thomas' Pract. p. 609.) A fourth termination of inflammation, viz: by the serous effusion of fluids, as in the cavity of the joints, deserves our notice. A dropsy of the part is produced by the large effusion which follows inflammation when seated in these secreting cavities. In this case we have oftentimes both increased exhalation and dimi- nished absorption combined ; a great determination to the part, and an inability in the absorbing and circulating vessels of the part to convey off the matter effused. Stimulating plasters, such as the composition heracleum gummiferum, the gum ammoniac, dissolved in the vinegar of squills, the stimulating ointment com- posed of tartarized antimony may be used. The same ingredients applied in the form of a wash ; viz. Z'\. tart, antimony; gss. sp. camphor; ifei. water, are well calculated to produce an active excitement upon the surface, and thereby to divert the tumor from the part within, and perhaps to excite the absorbents of the joint to an increased action. This last application was first made use of in angina pectoris. (See Lond. Med. and Phil. Journal.) It is now employed in the treatment of white swellings, rheuma- tism, &c. i 2d. The repeated application of blisters to the part, has been attended with no less beneficial effects. In the case of a lad, threat- ening white swelling, the tumor was removed by blisters, follow- ed afterwards by the use of tonics, general and local. Another remarkable case also occurred of a respectable merchant of this city, who was relieved of similar dropsical affections of the joints, particularly of the knees and wrists, by the application of blisters. No less than twelve in succession were applied; but in that case he had been a cripple for three years. He now walks as upright- ly as one of us. Another stimulating application which I have TREATMENT OF INFLAMMATION. 421 prescribed with good effect, especially in those chronic enlarge- ments of the joints, is the saturated solution of the muriate of am- monia in vinegar, as recommended by Benjamin Bell. In cases of inflammation, the ordinary gangrene, he particularly recom- mends this combination: his prescription is as follows: — Zi. of the sal ammoniac: ^ij. of vinegar; ^vi. of water. The following is preferred by many: gss. mur. ammo.; Ibi. vinegar or alcohol. But in the chronic cases I have referred to, the application should be stronger; viz. the saturated solution of the salt. But when the active inflammation is removed, i. e. all pain, heat, and tender- ness to the touch, and mere enlargement and relaxation remain, great advantage may be obtained by the application of cold water, or the application of rum or brandy, and the parts sustained by the flannel bandage. The same division of the stages of inflam- mation and its consequences, with the different treatment indicat- ed in each, is no less applicable in other inflammatory affections than in those of the joints, to which I have called your attention. But, fifthly. In case of sphacelus, after inflammation has sub- sided, as occasionally occurs after blisters have been too long applied, what is to be our treatment? 1st. Remove the dead matter that may loosely cover the parts affected. This done, apply a stimulant .poultice of bark and yeast, or bark and spirits, to the parts, and let them be applied mode- rately warm: occasionally also, cleanse and excite the surface of the part by washing it with a strong solution of soap and water, with the addition of yeast or spirits; or make use of the sulphate of zinc or of copper ; or apply the acetate of copper, in the form of an ointment, to the blisters when sphacelated. In like man- ner, it is useful to burns, asuming that character. From gr. ij. to gr. iv. to §i. of simple ointment. In the Infirmary of Edinburgh, the rectified sp. of wine is generally made use of as the most use- ful application to mortified parts, and is preferred to the bark, as a local application. Dr. Kuhn made an experiment in the Penn- sylvania Hospital, upon a person, both of whose legs were mor- tified: to one he applied the spirits of wine, the other he covered with the powdered bark. The first was the best application. In a short time, if the system be supported by proper nourishments, and by the use of bark, bitters, and other tonics, a healthy secre- tion will soon take place, and throw off the sphacelated parts. The carbon poultice, viz. gij. of charcoal, finely pulverized, and mixed with the common poultice, is also useful for correcting the 422 LECTURE XXXIV. foeter, and changing the character of such ulcer. The carrot poul- tice is made use of for the same purpose. The fermenting poul- tice is also an useful and active application; i. e. a poultice com- posed of meal, either Indian or oatmeal, or other meal, with a proportion of ground flaxseed meal, mixed with the infusion of malt, with the addition of fresh yeast to it, at the time of the ap- plication. Fermentation soon follows. This application, by its heat and moisture, and stimulant materials composing it, is among the most effectual means of preserving the tone of the parts, of exciting a healthy action, and thereby of separating the dead matter usually attendant upon sphacelated parts. When such separation may be effected, afterwards, as before directed, support the tone of the parts by bandages and other local stimulants. But if inflammation still continues to accompany this appearance of gangrene or sphacelus, the simple poultice should be renewed until such inflammation shall have subsided, and the line of sepa- ration between the living and dead parts become apparent. The gastric liquor of graminiverous animals has also been used by Dr. Harness with success, in arresting mortification, in separating the diseased parts, and in promoting healthy granulations. (See 2d vol. of the Trans, of the Society for promoting Med. and Chir. Knowledge.) Dr. White, of Manchester, has recommend- ed, in cases of this sort, the use of musk and ammonia, to remove the irritation, the subsultus tendinum, and other distressing symp- toms, frequently attendant on the local organs and producing high inflammation and sphacelus, as the effect of punctures. His pre- scription consists of musk and ammonia, gr. x., each in bolus. Another means recommended by a late writer in the Med. and Phys. Journal, for the purpose of arresting mortification, is by sprinkling the parts twice a-day with the nitrate of potash, finely pulverised. Mr. Pott has also written a paper in praise of opi- um in mortification, especially that which attacks the toes ; i. e. that opium is useful in arresting the irritation and pain which continue the inflammation when seated in parts of so much sen- sibility as the toes, and which irritation probably continues the inflammation until it ends in the total destruction of those parts. In cases of this sort it is doubtless indicated for the purpose of removing the sufferings of the patient, at the same time that it exerts its salutary effects by the general relaxation and diminished circulation that ensue from its use. But it is certainly a good ge- neral rule, that opium is not to be employed until the force of the TREATMENT OP INFLAMMATION, 423 circulation has been subdued by venesection, and other depleting means, and only where the inflammation is seated in parts of great sensibility, and thence producing an inordinate degree of pain. Hence you do not find Mr. Pott's prescriptions of opium made use of in other cases of inflammation and sphecalus, but when thus seated in highly organized parts. In violent inflammation of the eyes it has also been found serviceable. — Case of Mr. Hartshorn, subject to ophthalmia, in which he informs me he has arrested the disease in its forming state by taking a large dose of opium and camphor: op, gr. vi., camph. gr. iv. There is another form of mortification, denominated dry mortification, arising from the ossification and obstruction of the arteries of the toes, in which opium is of little use, and which is only to be removed by early amputation. In such cases, Dr. Mott states he has sometimes found this practice useful. Dupuytren, on the contrary, is op- posed to amputation, under such condition of the system, believ- ing that the whole system labours under some general affection that produces such obstruction of the arteries. A very question- able practice has been recommended by the late Dr. Peiffer, and adopted by Dr. Physic; that of blistering mortified parts. This practice has more the air of novelty than real usefulness to re- commend it. They can certainly be of no other use than as sti- muli to the parts, or to the whole system. But these effects we derive from the antiseptic and tonic applications of yeast, bark, spirits, and the fermenting poultice; and we may add, the pyro- ligneous acid. May not the pyroligneous acid be advantageously employed as an external wash in typhoid fevers, as well as the acetous acid? Whereas, you have not only the stimulant opera- tion of the cantharides, but a new inflammation, which, like the first, may add to, instead of diminishing the evil. For the same reason that scarifications, in such cases, have been laid aside because of the fresh inflammation they create, I should question the propriety of applying blisters. Dupuytren uses the actual cautery to excite the surface of sphacelating parts. Astley Cooper employs the wash of the nitrous acid and water, 3i. to a quart. But the most formidable state of gangrene and sphacelus in the form of carbuncle, and that, too, under the most unfavoura- ble circumstances, yield to the treatment I have recommended, and as such I shall continue to employ it; together with the free use of bark, wine, and other stimulants and tonics, while the de- bility of the whole system, or of the part, may continue, 424 LECTURE XXXV. PHLOGOSIS. Phlogosis, Dr. Cullen defines to be pyrenia, partis externa^ rubor, calor et tensio dolens. This genus he divides into two species: 1. Phlegmone; 2. Erythema, in which he includes the ery- sipelas of authors. But Dr. Cullen is not satisfied with this arrange- ment ; he not only includes erysipelas here as a species of phlogo- sis, but in his order of exanthemata he again makes erysipelas a genus, besides including it under the species of phlogosis, viz : erythema. Rather let us make them, as they should be, three dis- tinct species of phlogosis: 1. phlegmone, 2. erysipelas, 3. anthrax. 1st. Phlegmone, which Dr. Cullen defines thus: rubore vivido ; tumore circumscripto ; in fastigium plerumque elevato, saspe in apostema abeunte ; dolore saepe pulsatili. Yet he strangely believes all distinctions of inflammation founded on the structure of the parts, the seat of inflammation, to be altogether visionary ; absolute folly ; inepta ! 2d species, erythema, the erysipelas of authors, he thus defines : phlogosis, colore rubicundo, pressione evanescente, ambitu inaequali serpente, tumore vix evidente, incuticulae squamu- las, in phlyctsenas vel vesiculas abeunte ; dolore urente. Here, again, according to Dr. "Cullen, such distinctions are visionary. A man must indeed have a singular abhorrence to correct reasoning that can thus violate his own principles in almost every page. Un- der this head of erysipelas, or erythema, he includes anthrax or car- buncle, as the more violent form of erysipelas, the erythema gan- grenosum of Sauvages. But there are so many peculiarities, as we shall see, in the carbuncle or anthrax, that I am inclined to sepa- rate it both from the phlegmone and erysipelas ; more especially PHLOGOSIS. 425 too, as requiring a particular and distinct treatment, and different in some degree from either. Phlegmone we shall find to be. seated more immediately in the cellular membrane ; erysipelas in the skin, rarely extending to the cellular substance ; but anthrax includes both as its seat, at the same time that it most usually in- volves even the fasciae of particular parts of the body, as those on the back of the neck, on the loins, and on some parts of the extremities. So far, then, they differ in their seat: but erysipelas we shall find to extend over the whole or any part of the body, but affecting the skin alone, while anthrax is local; though in its course, and in the fever which attends it, it involves the whole sys- tem, yet it has, where it terminates favourably, the suppuration of phlegmone, but like erysipelas it has great tendency to sphacelus. Hence it may be considered as a compound both of phlegmone and erysipelas, but having characters sufficiently peculiar to constitute it a distinct species. Dr. Cullen notices, but very unnecessarily, the various terminations of phlogosis, or local inflammation, under different heads; viz. 1. Suppuration or apostema, (read these in his Nosology,) " post phlogosin, remittentibus dolore et pulsatione, tumor albescens, mollis, fluctuens, pruriens." 2. Gangrene, the part livid, soft, little sensibility, and vesicles pouring out ichor; " post phlogosin, pars livens, mollis, parum sensibilis, saepe cumvesiculis ichorosis." 3. Sphacelus, the part black, flaccid, easily torn, with loss of sense or heat, and with the fcetor of putrid flesh, the cor- ruption or destruction spreading rapidly; "pars nigricans, flaccida, facile lacerabilis, sine sensu vel calore,et cum foetore carnis putridae, vitio celeriter serpente." These two last are mere grades of death in the part, and the whole of these terminations are but the symp- toms of phlogosis, and should make a part of its history, but do not call for the distinct notices bestowed upon them separately in Dr. Cullen's Nosology. Phlegmon, the first of these species, falls first under our atten- tion. This species of phlogosis, as I remarked, is seated in the cellular membrane, and exhibits a train of symptoms similar to those already noticed when speaking of inflammation in general. Phlegmon we may define to be a tumor, circumscribed, painful, red, and elevated, for the most part, to a point or top, terminating sometimes in resolution, most frequently in suppuration, and oc- casionally in sphacelus; depending upon the seat of it, and the nature of the cause producing it. Its causes have also been em- 37 426 LECTURE XXXV. braced in our view of inflammation in general. Our indication in phlegmon is, in the first or forming stage, to effect the resolution of it, if possible, and especially if it be seated in very important parts ; this is to be attempted by the means already pointed out, viz: 1. by evacuations, venesection, leeches, cathartics, antimonials; 2. by blisters; 3. local sedatives, as the lead water poultice, lead water and laudanum, (excepting when such inflammation is seated in secreting surfaces.) In all cases these applications should be employed of a moderate degree of warmth, not cold, as recom- mended by Thomas, and indeed by most writers. Fomentations of vinegar and water are also among the best applications for effect- ing the dispersion of such tumors, especially in the mammae and testis. But, secondly, if the tumor be so far advanced as to give you no reason to expect its dispersion, you are next to promote the formation of matter in the manner already pointed out, and to dis- charge it as soon as possible by the lancet or scalpel. Do not leave it to discharge itself, for, as already remarked, you will have a tedious ulcer, and one in some cases attended with great inconve- nience, as in the inflamed breast, and in other cases attended with real danger, as when seated near an important joint. Should the tumor be large, and so seated that you are in danger of dividing important vessels, nerves or tendons, if by pressure or stimulant compresses you cannot excite the parts to healthy action, and destroy the fistulous state of the parts within, or stimlant injec- tions fail, make use of the seton ; this not only effects a complete discharge, but it also stimulates the diseased surface, and thereby promotes the healing process. The matter being thus freely discharged, the second stage having arrived, in which all inflam- mation is removed, the next object is to restore the tone of the part, and of the whole system ; not only for the purpose of filling up the cavity created, by the generation of new flesh, but so to invigorate the whole system as to diminish that sensibility to fever, which is, otherwise, at the time likely to ensue, from the absorption of pus. I mean hectic fever, and which I contend never arises from any other source, but that analagous to fevers from irri- tation, the effects of acrid matter in the blood vessels, as in the typhus, scarlatina, and various other eruptive diseases, so this is caused by and contined by the presence of pus, whether the pro- duce of an ulcer or the soft parts of the core. Hence Dr. Cul- len considered it as always symptomatic, and did not give it a ERYSIPELAS. 427 place under fevers properly so called. We find the matter of the different contagious diseases to produce fevers of a peculiar cha- racter: so purulent matter begets its peculiarites, producing gene- rally two paroxysms in the twenty -four hours, about mid-day and midnight; and accordingly you perceive that when such matter is freely discharged, hectic fever is readily removed. But even where absorption of pus takes place, fever is frequently pre- vented or diminished by the use of tonics and stimulants, viz: bark, elix. vit, bitters, &c, and sometimes by opiates, as Dover's powders, with a nutritious diet, such as animal food, the liberal use of porter, ale, wine, &c These remedies I remark are fre- quently too long neglected, not only to the waste of the whole system, but that in some instances the sphacelus of the part is also the consequence of the general debility induced. Hence, there- fore, when matter has been formed and discharged, we cannot too industriously make use of both local and general stimulants and tonics, to bring about the healing process in the part as well as to improve the state of the whole habit ; both the local and general means of accomplishing these objects have already been particu- larly enumerated. In case of gangrene or sphacelus occurring, as we know by the blister appearing on the part, the remedies have also already been noticed, viz: bark, wine, the yeast poultice, the fermenting poultice, the infusion of malt with yeast and oatmeal, or strong beer mixed up with these last materials. The second species of the genus phlogosis, in the arrangement we have adopted, is erysipelas. The word comes from sqvcj, to draw, and 7te%a$, adjoining, because it involves the neighbouring parts. Dr. Cullen places this disease among his exanthemata; but he also notices the same when entirely local, and confined to the skin, without an affection of the whole system, under the head of erj^thema, making it a species of phlogosis, while that more formidable shape of the same disease, in which the whole system is affected, he places among his exanthemata or eruptive diseases. This distinction is certainly not well founded ; and indeed you will find, under his erythema, the most malignant form of erysi- pelas described by authors ; nay, under the head of the milder ery- thema he also includes among his synonyms the still more malig- nant affection, both of the skin and of the whole system, called carbuncle or anthrax. This, surely, is inconsistent with correct arrangement Although I have retained the arrangement of 428 LECTURE XXXV. eruptive diseases as adopted by Dr. Willan, and you find erysi- pelas among them, that I might not violate the integrity of his order, certainly the most proper place for erysipelas, which is not to be considered an eruptive disease, but is rather a pure inflammatory disease of the skin, is among the phlegmasia^. I have accordingly made it, as you will recollect, the second species of phlogosis, for the purpose of distinguishing it from its fellow members of the same family, phlegmone and anthrax. The first of which is seated in the cellular membrane — the last in the skin and cellular membrane combined, while erysipelas chiefly confines itself to the skin alone; and they all occasionally, however, like other inflammatory diseases, transgress their seve- ral limits; that is, phlegmon runs into erysipelas, and erysipelas into anthrax. But when erysipelas extends beyond its ordinary limits into the cellular and adipose membrane, in that case the inflamma- tion beneath is the effect — the effect too, of bad management. But it is not an essential part of the disease; on the contrary, so far it is a departure from the original character of the complaint, and which erysipelas derives from the pecular organization of the skin, viz: its- dense texture beset with small sebaceous glands and exhalents, which appear in a peculiar manner to be the seat of the disease. Dr. Cullen defines erysipelas to be an inflammatory fe- ver of two or three days; in general with drowsiness, often with delirium, affecting some part of the skin with an inflammatory erythema, but most frequently the face. Synocha duorum vel trium dierum, plerumque cum somnolentia, saepe cum delirio, in aliqua cutis parte, ssepius in facie, phlogosis erythema. Observe, in shingles oftentimes there is little or no fever, and very rarely, if ever, delirium. He divides it only into two species, the vesicu- losum, ending in large blisters, including rosa, that is, erysipelas of the extremeties, and sideratio, as it appears on the head and face ; and the second species, phlyctasnodes, which consists not of large, but many small pimples or spots, and which end also in small blisters or vesicles, and are for the most part confined to the trunk of the body. Under this species he describes the shingles, being a corruption of the French term, ceingle, a belt or girdle, or zona ignea of Hoffman and others — so called because it sur- rounds the waist like a belt; the eruption in some instances reach- ing entirely round the body. But Dr. Cullen has great doubts whether this species, the phlyctsenodes, is at all different from ERYSIPELAS. 429 the first, the vesiculosum. Dr. Cullen also suggests the possi- bility of there being an inflammatory and a putrid erysipelas; but that of this he is not satisfied to say whether these two species should be formed; he very justly observes that as in hot climates the putrid diathesis exists, and in the cooler climates that the in- flammatory diathesis prevails; so in like manner the same disease may accordingly have different tendencies to the one or the other depending on these circumstances. There is doubtless some foundation for this distinction as far as a septic tendency will aggravate the symptoms of erysipelas. Accordingly it happens that in an impure atmosphere, as on board of ships crowded with men, and in hospitals, there is not only a great tendency to ery- sipelatous inflammation from the slightest wound, but erysipelas also readily assumes the typhoid character; and hence, too, it has been said to be occasionally in hot climates, a contagious disease. Thomas, in St. George's Hospital, Dr. Parr, also see Good, vol. ii. p. 646—7. Willan, Dr. Wells, Pitcairne, Baillie. In the Guer- riere it has been observed, in her late voyage to the Meditera- nean, that notwithstanding the free use of fruits and vegetables, such was the habit of body induced, that in every person on board who received the slightest wound or fever, it assumed immedi- ately a malignant character. But from the very texture of the skin itself, even in temperate or cold latitudes, there is a great tendency to sphacelus and the typhus type of its fever; and Dr. Cullen very properly, himself, remarks in the same note, that erysipelas oftentimes carries with it somewhat of a gangrenous nature, ("hie tamen notandum est erysipelas ssepe aiiquid putridae et gangrenosa^ indolis cum se ferre.") I divide this disease into four varieties. 1st. Sideratio as it appears upon the head and face, and which is the most troublesome, the most tedious, and the most danger- ous; for in this eruptive disease, as we see in small pox, not only the eruption is greatest about the head, but such is the deter- mination to the head, that not only all the external parts become highly loaded with blood, and all the features swelled or dis- torted, but the brain itself becomes severely affected, either by stupor or delirium; and sometimes hydrocephalus is produced, for the carotids cannot carry an inordinate quantity of blood to the scalp, without also conveying a disproportionate quantity to the brain, being both branches of the same trunk. An important in- 37* 430 LECTURE XXXV. ference from this is, that in affections of the brain, as phrenitis, hy- drocephalus, apoplexy, our blisters will be more properly applied to the distant parts of the body, or between the shoulders, than to the head itself. 2d. Zona, or belt, or shingles, which appears upon the trunk of the body, and chiefly about the waist, and like herpes, gradually multiplies itself to such an extent as to reach entirely around the body, which among the vulgar it is supposed to be attended with great danger. According to Dr. Darwin, this form of the disease frequently denotes an obstruction in the liver or some other of the viscera — this is not always true — for it frequently arises from a check of the perspiration alone; hence, it is common in the autumn, especially in plethoric habits. 3d. Rosa — the erysipelas of the extremities, and which we most usually see, as connected with the gouty diathesis and old age. A fourth variety is the symptomatic, that is, attendant upon other diseases, as fevers, as miliary and typhus fever. It is frequently symptomatic, too, of affections of the stomach and bowels from indigestion, symptomatic of teething, and of ob- structed perspiration, especially in the heat of summer, or after violent exercise. This form shows itself in different parts of the body, and frequently in patches or weals. These also appear sud- denly, and are as suddenly removed ; whereas the varieties before mentioned, are of longer duration. The symptoms of erysipelas or St. Anthony's fire, more especially as it appears in the more formidable shape of sideratio, are : 1st. The symptoms of inflammatory fever, viz: chills, suc- ceeded by general excitement of the system, a quick, hard pulse, hurried respiration, tongue white, much thirst, the skin unusually red, and attended with a sense of itching and sometimes burning; the surface, too, is remarkably dry as well as hot, and perspi- ration is not easily induced, resembling in this particular, the locked state of the excretory vessels that we meet with in scarlet fever. The whole system being powerfully excited, in a short time an elevation of the parts of the surface most affected is per- ceived, and an increased secretion from that part of a thin sharp acrid humour is now very apparent; fresh inflammation is ex- cited as well as an increase of the first; small vesicles are pro- duced, and in some cases a considerable discharge of a thin watery humour is manifest to the eye; but in some instances this is not PHLOGOSIS. 431 perceptible, except by means of glasses; yet an irregularly spread- ing inflammation takes place wherever the fluid extends, and pro- bably beyond. It is however true that if wet or greasy applica- tions be made use of,, the inflammation is still more exten- sively diffused. A fatal angina in some cases ensues, when seated upon the neck and throat; or if in the head, such is the great flow to the brain that all the features become swelled and disfigured; the eyes in some instances are closed; but the irritation is not only external, the brain becomes oppressed by stupor; in some cases absolute phrenitis is induced. The disease thus continues for eight, ten, twelve, or fourteen days; if it is not gradually removed by evacuation, and resolution effected, it terminates either in vesica- tions, foul ulcers, or gangrene, or it breaks down the system by effusion upon the brain, or ends in typhus, and thus proves fatal. Hence it has been observed that inflammation of the brain and its consequences have been found upon dissection after death in this disease. This inflammation never ends in suppuration, or it ceases to be erysipelas. Suppuration, says Pearson,* is never seen in genuine erysipelas; but it has a constant tendency to gan- grene and sphacelus. Erysipelas, as I remarked before, derives its peculiar character from the very highly organised and dense texture of the skin, and of the infinitely numerous glands with which it is supplied independent of its excretory vessels, the func- tions of all of which are probably diseased in erysipelas. In conse- quence then of its great sensibility, and its numerous nerves, we are not surprised at the tendency of this disease to gangrene. But suppuration sometimes attends it when it involves the parts beneath, as in anthrax. I have seen a case of cedematous effusion in the cellular membrane beneath, enlarging the neck and dis- tending every feature of the face. The predisposing causes of erysipelas, are: 1st. Certain temperaments, and especially the sanguineous and the nervous. Females are more liable than males; and children than adults, owing partly to their greater sensibility of habit. Hence, too, it appears more in certain families. Capt. G d's family, of the sanguine temperament, are subject to it, father, son, and daughters, and most usually every autumn. The same sensibility too, that is occasioned by one attack, predisposes to a second, &c. * Principles of Surgery. 432 LECTURE XXXV. 2d. A plethoric state of body predisposes to erysipelas; hence it frequently attends upon pregnancy — hence, too, it follows a sudden suppression of the menses, or is the consequence of their natural cessation. Women giving suck whose menses are sup- pressed, are frequently the subjects of erysipelas, especially upon being heated by exercise. 3d. A vitiated state of the fluids, this was the opinion of Hip- pocrates and Galen. Tissot, too, ascribes erysipelas to the state of the blood, and to the want of due discharges by perspiration, in like manner it is frequently the attendant on chronic rheuma- tism. And it is the effect of old age, in which case both the ple- thora of age and the vitiation from the diminished excretions usual in advanced life, are probably combined. The exciting causes of erysipelas are, 1st. Cold, suddenly applied, especially when the body has been previously heated; a cold bath made use of when the body is in a state of perspiration, is a frequent exciting cause of this disease. Hence, too, erysipelas is the disease of autumn. 2d. The suppression of the natural excretions by the skin, bowels, or the menses, from whatever cause such suppression may proceed, is another common cause of erysipelas. 3d. Fever is another exciting cause of this disease; not only by means of the stricture upon the excretions which takes place in fevers, but also by the inordinate excitement of the blood vessels, such determination to the surface is both produced and aggravated. 4th. The irritation attendant upon indigestion frequently ex- cites an erysipelatous inflammation on the surface, Lobsters, crabs, and other articles difficult of digestion, are fruitful sources of that disease. The effects of vinegar show the intimate connexion be- tween the state of the stomach and the surface of the body. From the connexion between this disease and the disturbance of the digestive organs, some writers, ancient and modern, have consi- dered this disease in some cases to be of a bilious nature, and have made a species of it, which they so denominated. Galen, among the ancients ; Desault, Richter, and Richerand, among the moderns. They therefore attach much value to emetics. (See Cooper's Surgery.) 5th. The irritation of teething produces not only sore ears, or a strophulous on the cheek, but in some instances a general eruption and erysipelas, with a febrile state of the whole system, are the consequence. PHLOGOSIS. 433 6th. Irritation of the skin itself, as by blisters, wounds, &c. is a frequent exciting cause. Blisters I have known to excite an erysipelas, which diffused itself over the whole chest. Sulphur, mercury, arsenic, the euphorbium, the fumes of the cashew nut, (anacardium occidentale.) Insects may also be in- cluded among the exciting causes of erysipelas. 7th. Wounds, as gun-shot wounds; wounds, especially on the head, and scarifications employed in dropsy of the extremities, and especially the large incisions made by the lancet instead of slight punctures. 8th. The distension of parts, as in dropsy, is sometimes fol- lowed by erysipelas, in the form of rosa; i. e. in the extremities; and that, too, not unfrequently ends in sphacelus, and proves fatal. 9th. Heat, as the direct rays of the sun, not only in the trop- ics, but even in our temperate climate. Burns, and scalds. 10th. Intemperance in the use of spirituous liquors. The phenomena which we have noticed to characterise this dis- ease ; viz. the white tongue, the frequent and tense pulse, the hot and dry skin, and great thirst, all announce it to be, especially in the first stage, a pure inflammatory disease. The causes, too, both predisposing and exciting, lead to the same conclusion; and that it demands the treatment which we have observed is indicated in such condition of the system: guided, however, by the habit of body, the peculiar cause from whence it has proceeded, the part more immediately the seat of the disease, time of life, dura- tion of the disease. Venesection is called for where the disease occurs in a full, athletic habit of body, and has been occasioned by cold, or suppression of the natural evacuations, as of the men- ses, or in pregnancy. Venesection then is to be employed libe- rally, especially when the disease appears upon the head and chest. In like manner, the species called zona, when induced by change of season, is most effectually removed by the same reme- dy, inasmuch as it usually occurs in the full habit of body. To my great surprise, I perceive Dr. Good is not the friend of vene- section in this disease. He remarks: " Venesection was formerly recommended, and has been so, of late, by a few writers, but upon mistaken principles." "I can conceive," he adds, " very few cases in which it has a chance of being serviceable. " He then recommends gentle laxatives, and instantly after tonics, bark, &c. 434 LECTURE XXXV. 2d. Cathartics are, for the same reason, to be employed, as the saline cathartics. Dr. Friend appears to depend principally upon cathartics, even in the most violent forms of this disease. In a gouty habit of body, where the stomach is generally irritable, the preparation of rhubarb, magnesia, and mint-water may be prefer- able. In the erysipelas occasioned by teething cathartics are also indicated, especially magnesia. This, on account of the acidity which is predominant in the stomachs of children, at this period of life, is peculiarly advisable. I am also, on account of the febrile symptoms, much in the habit of directing the combination of small doses of ipecac, and rhubarb, aa. gr. i.; or gr. ij. M.: these are my favourite febrifuge, which I denominate my tooth-powders, or rather my teething powders. 3d. In some cases of erysipelas, as that from the sudden check of perspiration, or from indigestible food, emetics are the most effectual means of removing the disease, and will be found useful in this disease in most cases, except where it arises from plethora or in a gouty habit of body. But remember, where a fulness of the vessels exists, and perhaps a determination to the brain, that emetics, by the mechanical effects of vomiting, in retarding the return of blood from the brain, are in such cases peculiarly dan- gerous. In old age they should on these accounts be avoided. 4th. Antimonial and other diaphoretics are generally indicated in this disease; but, 5th. What shall we apply to the parts affected? The best applications, in my opinion, are such as will not only defend the parts from the air, but which at the same time are cal- culated to absorb the acrid, watery fluid which is poured out from the inflamed glands and excretories of the skin, and thereby to prevent the disease from extending. Any moist application or ointment, I observed, is calculated to spread the inflammation; therefore let all such be carefully avoided. Chalk, starch, very fine wheat flour, or rye or oat meal, and hair powder, dried over the fire, are in my opinion the safest and the best applications for this purpose, and should be frequently renewed by means of a puff, removing at each application of the farina, such portions as may have been rendered wet by the discharge, which, in some cases, is very profuse. In this way powder the parts fifty times a day; a very good powder is half starch, half calamine. (See Good vol. ii. p. 616.) Blisters have lately been recommended by Dr. PHLOGOSIS. 435 Dorsey and Physic, upon the authority of the late Dr. Pfeiffer, of Philadelphia, who is said to have introduced that practice; and which, both Physic and Dorsey advocate as the best mode of healing erysipelas. Dupuytren applies them in the erratic ery- sipelas; also the actual cautery! Delpech also states that he has frequently prevented suppuration or sphacelus by the early appli- cation of blisters. Where the brain is much affected by stupor or delirium, they will no doubt be found useful. Where sphacelus is approaching they may also be found beneficial; but I have ne- ver employed them. In some cases the farinaceous applications are said to be of but little benefit. In these cases, Dr. Thomas states that cooling lotions, as recommended by Cooper, (see his Dictionary of Surgery, and his First lines,) he has found of great benefit; and that, for this purpose, he has made use of the liquor ammonias acetatis and water, equal parts ; or muriated ammonia dissolved in water, with the addition of a little vinegar and cam- phorated spirit, with great relief to the feelings of the patient, when the farinaceous powders seemed rather to aggravate than soothe the sufferings attendant on this complaint. But where this is the case, I am fearful the vis a tergo has not been taken off by by the lancet and other means of depletion. But perhaps by the severity of the disease, or by the neglect of the depleting means recommended, you are called upon to prescribe for the parts alrea- dy arrived at the state of gangrene or sphacelus. Farina now will be of little use ; in such case, treat them by the same means which we have already recommended in sphacelus and gangrene from other causes, viz: by the yeast poultice, bark and yeast, bark and spirits, and the liberal use of bark internally. If the patient be young, he may still perhaps be preserved, but if in the decline of life, you have little to expect. Dr. Fordyce gave it in doses of 3i. every hour ; he tried it for twenty years, and with growing confidence, says Dr. Good ; but he adds, (i when there is an even- ing exacerbation, some diaphoretic, as James's powder, is called for, or the sp. mind, with the spirit of sulph. aether ; or which is in my opinion preferable, the nitrous aether. Where the habit is much vitiated, as is frequently the case in old age, and in per- sons who have suffered much from chronic complaints, as gout or rheumatism, you will find great benefit in the ordinary erysipela- tous eruptions of such habits by the use of the decoction of the woods, composed of guaiac and sarsaparilla, i. e. after the use of 436 LECTURE XXXV. some mild aperient. Lead water has been recommended, by Dr. Dorsey and others, as an external application which has been em- ployed with benefit in this disease. Dr. Thomas, in my opinion, very justly remarks that no solution of lead, copper, or alum, should be employed in erysipelas ; but if it be of service in re- moving the inflammation of erysipelas, it can only be so after the various means of depletion which have been enumerated have been previously employed; it will otherwise be a hazardous pre- scription; for even if we succeed in repelling such inflammation without previous evacuations, and the first cause of the disease be still operating upon the system,we only translate irritation from one part of the system to another, and perhaps to the brain, or some other organ intimately connected with life ; apoplexy or convulsions are, I believe, frequently thus produced. If eruptions or local irritation ever prove critical in fevers, so may the repel- ling of such eruption be the means of renewing fever, or of ex- citing some other irritation in the system; hence, then, the danger of suddenly suppressing local irritations, when they appear ; and especially when they may have been of some duration, and the system has become habituated to them. Two or three facts on this subject will at least teach us caution in the use of this remedy. In a case of an eruption behind the ears, from teething, I over- looked the cause; directed some mild aperient and lead water to the eruption; the inflamation was suddenly suppressed, fever was renewed with convulsions, which terminated in death. An habitual ulcer and irritation in the forehead, operating like an issue to the system, was removed in the same manner; but apoplexy soon ensued, and proved fatal. But in a case of erysipelas on the arm and chest, in an old gentleman, of this city, of full habit, where venesection was omitted, and wet applications of this nature were employed in the first stage, instead of the farinaceous wheat or rye; sphacelus en- sued and proved fatal. Look at erysipelas, therefore, as a disease of the whole system, and remember the great tendency to sphacelus, which inflammation manifests when seated in parts too highly organised. Nevertheless, there are cases in which, after the excitement of the system has been removed, the local irritation of the skin will continue ; in that case, lead water has in some cases been very advantageously directed. Magnesia, too, used in the place of lead water, is beneficially ap- ERYSIPELAS. 437 plied without; a translation of the inflammation. The diet and regimen of the patient should also constitute a part of }*our pre- scription, and should be directed according to the stage of the disease. In the first stage it should be simple and plain, and chiefly composed of vegetable nourishments and acid fruits; the frequent use of diluents, to promote the secretions, should also be enjoined, especially the sub-acid drinks, as tamarind water, lemonade, cur- rant jelly and water, barley water, &c. But in the second stage, especially where gangrene is to be apprehended, the diet of the patient should be stimulant and cordial, with the liberal use of wine and porter, sago, arrow root, &c. The dress of the patient, air of the room, temperature of his drinks, should also be attend- ed to as in the treatment of inflammation in general. But should the typhoid termination of the disease, the erysipelas gangreno- sum of Willan, show itself instead of the inflammatory character with which it usually appears in this climate, you will, in that case, have recourse to the means we have so fully recommended, viz: bark, snakeroot, the mineral acids, and especially vegetable nourishments and the plentiful use of wine. There is another form of erysipelas noticed by authors, I mean the erysipelas in- fantum of new born infants. (See Underwood. ) One form Brom- field has described ; another form of it, as attended with varia- tions, and tending to gangrene. In it the external use of bark and spirituous fomentations are the chief remedies. Lead water was found by Dr. Garthshore injurious, by inducing sphacelus. Blis- ters also are injurious. (See Willan. See Thomas and Underwood.) But the spirituous applications have been more successful: both have been tried in the British Lying-in Hospital. Bark also has been given by injections. A third form called by Drs. Ham- ilton and Underwood, skin-bound, and by the French "endurcis- sement du chair, 7 ' is also occasionally met with, but I believe never cured. 38 43S LECTURE XXXVI. ANTHRAX, OR CARBUNCLE— THE THIRD SPECIES OF PHLOGOSIS\ Anthrax is a Greek word signifying a burning coal. Carbuncle comes from carbo, charbon the French call it. This disease, as I re- marked before, when dividing the genus phlogosis into its three species, appears to partake both of phlegmon and of erysipelas in many of its symptoms; k divides itself into two species. 1st. Idio- pathic anthrax, and 2d. symptomatic anthrax. It is symptomatic when it occurs in plague, in typhus, in yellow fever, or in other dis- eases. This subject has very early attracted the attention of physi- cians. Galen, in his work, De tumoribus, Celsus and Fabricius have all shown tkeir knowledge of this malignant form of inflammation, and by modern writers it has also been very minutely described; particularly by Wiseman, Bromfiejd, Kirkland, David, in the Academy of Surgery, by Pouteau, Pearson, William Fordyce, and by Willan and John Hunter. In the Medical Comm., vol. ii. pp. 34, 37, you will also find that it has received notice. But notwithstanding the attention that has been bestowed upon it, both by the ancients and moderns, there appears to be a great diversity of opinion relative to the mode of treatment which ought to be pursued in this disease. Having seen several cases of this tumor, some of which have ended fatally, and others have been treated with success, I shall now submit to you such obser- vations as I have been enabled to make on this interesting subject. Anthrax I define a hard circumscribed tumor, seated both in the skin and cellular membrane, accompanied w T ith a sense of burning and pain, (not the pulsation of ordinary phlegmon, nor is it con- fined to the skin as erysipelas,) of a livid purple hue, and early exhibiting the symptoms of approaching sphacelus, for such is its ANTHRAX. 439 general tendency unless relieved by art. 1. It begins like a com- mon boil, having the circumscribed character of phlegmon; in the beginning too it has redness, great pain, with burning heat, but not the pulsation of phlegmon; sometimes a violent itching exists in the part. 2. In a day or two, for the inflammatory or active stage is comparatively of short duration, the tumor manifests a dark crimson red colour, particularly in the centre, but paler to- wards the circumference. 3. It soon shows a small pimple or pustule on the top, and at first view you may be inclined to think that the tumor is about to discharge itself at this point, and thus terminate. Not so : for the top being broken off, it is not well formed pus that is discharged, as in simple phlegmon, but a sharp, thin, brown liquor, a sort of bloody water, or sanies, and that without the least relief of its symptoms. 4. The swelling does not become very much elevated above the surface, but re- mains for a long time, say several days, hard and deep seated, attended with great stiffness in the neighbouring parts, and severe pain, especially on motion, and exquisite sensibility to the iouch. Like erysipelas, too, it has the burning heat of skin ; shows the skin to be much affected, and that too very early; manifesting throughout a dark reddish brown, or even a crimson, or a purple colour, and attended with great sensibility; like erysipelas too it exhibits a diseased and febrile condition of the whole system ; like erysipelas it is not inclined to end in pus as its natural termi- nation, as is the case with phlegmon ; like erysipelas too it is pro- tracted beyond the usual period of phlegmon, and much inclined to gangrene ; and like gangrenous erysipelas, says Dr. Willan, (p. 497,) the swelling exhibits a dark red inclining to a livid hue. It shows, as I remarked, a febrile state of the whole system, and this fever, I should add, has a great tendency to the character of ty- phus. The pulse, very early in the disease, is weak and low, but frequent ; for the operation of the disease upon the system is severe, and the subjects of its attack are usually the aged and the feeble, and whose general health is more or less impaired by pre- vious disease, particularly eruptive diseases. An exception is mentioned by Tournefort, who states, in his Travels through the Levant, that it attacks feeble infants in warm climates, and proves quickly fatal ; he also describes it as endemic, in his day, among the islands of the Archipelago. The tongue is sometimes white, but frequently it is moist, and in some cases of a deep red colour, 440 LECTURE XXX7I, as in the advanced state of typhus fever; the patient is usually languid, showing great prostration of strength, and that, too, ap- pears early in the disease ; and such is the depression of the vital powers, that it is frequently difficult to excite the system, even by wine and cordials ; such, too, is the impression made upon the nervous system by this disease, that the patient very early mani- fests it ; sometimes it shows itself in great restlessness ; a general irritation and sense of itching over the whole surface of the body, and eruptions too are commonly attendants upon this excitement of the surface ; the patient also complains of frequent chills, and at the same time the skin is dry and hot. In other cases, instead of restlessness, I have known the patient to be remarkably drowsy, yet unable to sleep, owing to the pain and irritations of the system, and, in some instances, delirium appears within the first days of the disease. The nervous system also manifests the depression at- tending this disease, by palpitation of the heart, and a tendency to delirium. The appetite is bad, attended with great nausea and sometimes vomiting. These symptoms also are doubtless ascriba- ble to the intimate connexion which exists between the stomach and other sensible parts of the body; for any violent pain or irri- tation, as we have seen, especially when seated in organs of great sensibility, is readily communicated to the stomach ; this is no less expected when the skin is the seat of the disease, as in erysi- pelas, in eruptive diseases in general, and especially in the painful tumor now under consideration. The bowels are for the most part costive; but sometimes I have seen it succeeded by diarrhoea, and that in a very short time proceeding to a dangerous degree ; for the system, as I said before, is readily exhausted under the sufferings of anthrax. The tumor also, when the disease is about to terminate unfavourably, assumes in a few days a very dark colour; a black slough forms in the centre, and a sharp bloody humor is effused from that part of the tumor; vesications also show themselves on other parts of the swelling, indicating the general sphacelus of the part, that is about to ensue. But if the patient be well treated, or has strength of constitu- tion to give a favourable termination to the disease, the tumor, instead of the dark livid hue, the bloody sanies and vesications, denoting gangrene or sphacelus, exhibits a different character. It breaks out in many small holes, or little cells, through which pus of good quality flows. The tumor appears like a morass, or ANTHRAX. 441 quagmire, of a spongy honey-comb structure, not altogether un- like the convex surface of a placenta, and upon pressing it you find it full of matter beneath and of considerable extent. Fre- quently, says Pearson, (Principles of Surgery, p. 308,) there are in this cellular texture little caverns, and intercurrent sinuses; and he adds, "that considerable sloughs are thrown off in masses;" i. e. I suppose he means, where sphacelus has been the consequence, for where a healthy pus is discharged, the fleshy substance of the part is not detached as where its texture is de- stroyed by gangrene. On the contrary, the whole mass becomes gradually condensed, as the parts beneath are filled up. The disease too at this time shows that it is not confined to the skin, but is connected with the cellular membrane and the subjacent parts. Indeed they appear united, and so intimately that each cell appears to find its exit by a corresponding aperture in the skin. The size of the tumor sometimes extends to six, eight, ten, or twelve inches diameter. It is also of long duration, say from three weeks to three months; very much, however, depend- ing on the manner of its termination. Where the destruction of parts does not take place by sphacelus, but a healthy pus is poured out, it usually heals in three or four weeks; not so where a large excavation is made by mortification of the part, and where for the most part the disease proves fatal. This leads me to notice the ravages of this dangerous disease. This disease is very generally traceable to a vitiated habit of body, especially of a scorbutic sort. The same idea is expressed by Bromfield, for he makes two kinds of anthrax, that from a great quantity of blood highly inflamed, and that the effect of a putrid and malignant fever; and speaking of these, he adds, " a bad habit of body from the vitiated state of the circulating fluids, which, producing fever of the most malignant kind, must always be attended with the utmost danger." (p. 120.) My observation has been that simple phlegmons, ending in large abscesses are the more common consequences of plethora when unattended by the vitiation of the habit before men- tioned. These, indeed, are not unfrequent from that fulness of the vessels alone, though in some instances they too are as- cribed to the supposed peculiar gouty humor floating in the sys- tem. But the anthrax we have described is not merely the effect of such fulness alone, but generally arises from an additional 38* 442 LECTtfRE XXXVI. vitiation of the system. In the first place, I observe, it usually appears in old age, when such change of the state of the system is most apt to occur. The greater number of cases which I have seen have appeared in advanced life; and where it occurred in women, it has been after the cessation of the menses, and in those too of a plethoric make and who have lived a sedentary life, and whose secretions had become more or less impaired; but in habits of this description you will also see it at any age. 2. I have observed that in all I have attended, they were more or less subject to eruptive diseases, especially to erysipelatous inflamma- tions. In the case of Mr. H — — -e the disease was preceded by, accompanied with, and followed by eruptions, and those of a very obstinate character. This too is an observation made even by Galen, that vesicular eruptions generally precede carbuncles. Galen De Tumoribus Prset. Nat. See Assalini, Neale's transla- tion, p. 54. The same idea is expressed by Willan, (that anth- rax like erysipelas, is attended with an extraordinary heat, creep- ing and pricking under the skin.) TREATMENT OF THE DISEASE. After what has been said of the time of life, and the vitiated state of the system in which this disease usually occurs, and the great prostration of the vital powers which appears to characterise it in its progress, you will be induced to believe that venesection is rarely indicated; indeed the circumstances which have been mentioned generally, forbid the use of the lancet, yet there are doubtless cases of great fulness, where it will not only be justi- fied, but may be absolutely necessary in the forming stage of this disease; but it must be done with due reference to the state of the system, as in other diseases in which local inflammation is conjoined with a vitiated habit of body, as in dysentery, typhus, cynanche maligna and puerperal fever, &c. Indeed we may denominate this tumor a typhoid phlegmon. In general, how- ever, you will trust to evacuations from the bowels and attention to the skin, particularly the latter ; and as the strength of the patient is early impaired in this disease, and the stomach irritable, the purgatives you employ should be such as are least offensive and least debilitating ; such as rhubarb and magnesia, an infusion ANTHRAX. 443 of senna and manna, or castor oil, if they can take it; but let me recommend to you, with the view to the state of the whole system, as early as possible to induce perspiration, and to preserve the skin in this condition, for by such diaphoresis you both lessen the local irritation and counteract that general condition of the habit that appears to constitute an essential part of this disease. This should be accomplished by the use of warm bathing ; bathing the feet and legs in tepid vinegar and water, and by the ordinary warm drinks that have been directed in febrile diseases. If the stomach be not much disturbed, an ounce dose of the spiritus mind, and laudanum may be given, or the saline draught of Rive- rius, with advantage, during the first days of the disease; but in a short time you will have occasion to keep up such diaphoresis by wine whey or an infusion of the Virginia snake root, for as the tumor advances, its malignant character shows itself with a gene- ral typhoid tendency in the whole system. The applications which you will make to the tumor itself in the first or inflam- matory stage with most advantage, will be a soft light bread and milk poultice, fomentations of vinegar and water; a light vinegar poultice; cloths wet with the sp. mind, and laudanum; but lead water should be carefully avoided. Dorsey recommends blisters to the part as preferable to every other local remedy ; and after- wards the parts to be dressed with basilicon ointment, and if poul- tices are applied they are to be light, he observes, and frequently changed. But of blisters I have had no experience, but if useful, they doubtless must be so in the early forming stage of anthrax; in such case I believe they may be useful as in other tumors, but not in the last stage. The second stage of the disease having arrived, your object will be to obtain suppuration, that is, a heal- thy action of the vessels of the part. This can only be done at this time by stimulants and tonics, and these both generally and locally applied. It is most strange that writers should talk of an anthrax healing without suppuration, yet such is the language of Wiseman, of John Pearson, and countenanced by the Edinburgh system of practice in this disease. The best tonics to effect this object both of supporting the general strength and of causing a healthy action in the part, are the Peruvian bark, bitters, snake- root, and the mineral acids. The bark is to be preferred, and in substance, if the patient can receive it. William Fordyce recom- mends it to be taken in drachm doses, in conjunction with a few 444 LECTURE XXXVI. drops of mineral acids every hour; this, for reasons advanced, when speaking of t) T phus fever, must be proper. The diet should correspond with the medicine prescribed; it should be both the most nutritious and the most stimulant; wine should be given ad libitum, and in every form, consulting the taste of the patient. Wine alone, wine whey, in the form of caudle or panada, or with sago, &c; brandy milk-punch is also, in some cases, preferable, being most acceptable to the patient. Soups, if the patient has an appetite for them, (but usually they have no appetite; on the con- trary they generally manifest the greatest disgust to animal food in every form in which it can be presented,) may also be given, especially strong beef tea. In some cases I have even given my patient eggs and oysters, where they have called for them, that is, when the patient is free from fever. Opium you will find in- dispensably necessary both to allay pain and to procure sleep. It is quite as useful here, as in mortification of the toes, as recom- mended by Mr. Pott, and for the same reason; for great pain and irritation is doubtless a means of increasing inflammation whenever it is seated in any highly organised and sensible parts of the system, and in which of course there is a great tendency to sphacelus. In this disease, accordingly I have found opium of infinite use, both administered through the day in small doses, and at night to procure sleep. The nitrous aether, or Hoffman's anodyne, or the tincture of hops in severe irritations may suffice to allay the sufferings of the. patient, or at least they will prove valuable auxiliaries for this purpose. The local applications in this stage of the disease should also consist of the most powerful stimulants, such as bark with spirits or yeast, or yeast alone, or spirituous washes and applications, or the yeast poultice, &c. as already noticed in the treatment of sphacelus, and when healed the part should be washed with rum to remove any remaining morbid sensibility. The decoction of the woods is also an ex- cellent drink to correct the general state of the habit. The occa- sional use of the warm bath, and attention to diet, will also very much contribute to the same end. From the cases I have treated I have come to the following inferences. 1st. That the treat- ment by lead water and the ordinary relaxing poultices and oint- ments made use of in simple inflammatory phlegmon, are injurious in anthrax and should be avoided, excepting in the first two or three days of the disease. 2d. That the stimulating and antiseptic ap- ANTHRAX. 445 plications are called for and are found peculiarly beneficial. Ac- cordingly too, the cases which have ended successfully in this city have been treated by the last mentioned means, while those which have ended fatally have been treated by the anti- phlogistic system. Dr. Rush mentions another case cured by the same means. Extirpation has been proposed, and by others, as by Kirkland, Cooper, and the Edinburgh practice, it is recom- mended that the parts be freely dilated and discharged, as in phlegmon; but this practice, in most cases, becomes at least un- necessary, and as the parts have a great disposition to bleed and to sphacelate it must be certainly improper, or done with much caution. A case where the knife was so employed was followed by a fatal sphacelus. Another application that has been recom- mended is to cover the centre of the tumor with lime, and the edges with lint moistened with chalybeate wine, (see Edinburgh Practice,) but in my opinion bark and yeast are to be preferred. In the time of Galen the Falernian wine was made use of as a local application in wounds and in tumors of this description. It was no bad application. Rum is better. Arsenic recommended as early as by Agricola, and has been used in the form of orpiment and Plunket's caustic. Ledran preferred corosive sublimate; Riverius caustics; Pouteau the actual cautery. But Mr. Good, (vol. ii. p. 290,) justly observes that radical success must, after all, depend upon supporting and giving strength to the system by cordials and tonics, for if this cannot be accomplished, it is perfectly clear that the predisposition will be neither subdued nor subside spon- taneously; that the ulcerations will not heal, and the system must gradually sink under their constant discharge and irritation." I should have added that in case of sphacelus actually taking place, the carrot poultice, or the poultice of carbon, or the ferment- ing yeast poultice may be applied to correct the fcetor and to re- new a healthy action in the parts affected. 446 LECTURE XXXVII PHRENITIS, OR INFLAMMATION OF THE BRAIN. The term Phrenitis is derived from- the Greek word $wv, the mind, supposed to be seated in the brain. Dr. Cullen gives the following definition of this disease : " Pyrexia vehemens; dolor capitis; rubor faciei et oculorum; lucisetsoni intolerantia; |fervi- gilium: delirium ferox vel typhomania:" meaning by this last term, what the Greeks usually associated with it, a degree of coma, or heavy stupor, with delirium, lethargy, and madness. These are the characteristic symptoms. Dr. Cullen acknowledges that he added typhomania to his definition, to designate the coma attendant upon that form of the disease, which appears to reside in the brain itself, as distinct from the membranes ; but he adds that, upon further reflection, he finds no foundation for this ; and that the symptoms he has included, always mark the acute inflammation, i. e. of the membranes; while the other of the parenchymatous exhibits a more chronic affection. This chronic character is his only mark of the latter form of the disease, without pointing out its' insidious character. Dr. Cullen divides phrenitis into idiopathic and symptomatic. At the first view of the symp- toms already related, we should be inclined to consider it always symptomatic of fevers of great excitement, in which we generally observe more or less of affection of the brain and nervous system. It is symptomatic also of typhus, worms, erup- tions, as erysipelas, hydrophobia, injuries of the brain, and strong passions, particularly severe grief. But dissection has shown it to be an idiopathic as well as a symptomatic disease, and that although attended with general symptoms of synocha, it is still a true idio- PHRENITIS- 447 pathic inflammation of the brain or its membranes. Sauvages, Linneus, and Sagar divide it into inflammation of the brain and its membranes; i. e. into phrenitis, denoting the inflammation to be seated in the membranes, and cephalitis or sphacelismus, as seated in the larger vessels, or in the substance of the brain itself. This distinction, you will perceive, I have adopted for the reason that it furnishes an important practical distinction in the sick room. Dr. Cullen says that he admits the full force of the dis- tinction between inflammation seated in the membranous parts, and that which is seated in the parenchyma of the viscera, (yet in his Nosology, as you have seen, he can pronounce all such distinc- tions visionary;) but he considers it very difficult to make such distinction in the present case of inflammation of the brain. Wil- lis, Langrish, Huxham and Pringle have all related cases of ab- scesses being actually formed in the substance of the brain, when the symptoms of inflammation have been inconsiderable, or not at all to be observed ; therefore such inflammation must have pre- viously existed in the brain, but not in the membranes, and con- sequently should have been designated by Dr. Cullen ; indeed Dr. Baillie (see Morb. Anat. ch. 25.) observes, that the most usual termination of inflammation of the substance of the brain is in ab- scess. Dr. Fordyce has observed that when seated in the mem- branes the pain is acute ; but when seated in the substance of the brain that it is obtuse and less sensble ; so in hydrocephalus, the pain is at first not acute, yet certainly, judging from the effects, inflammation exists previously to the effusion of water. Dr. Parr remarks, if in any part of the body, this distinction between mem- branous and parenchymatous inflammation be called for, it is in inflammation of the brain. We may observe that when inflamma- tion is seated in the brain itself, all the symptoms of inflammation are comparatively mild ; i. e. almost all the symptoms of mem- branous inflammation of the brain are present, but that they exist in an inferior degree ; see my Nosology — read the distinction of species. Dr. Good, I perceive, has adopted the same distinction. Cephalitis comes on with a slight head-ache, increased heat of the head, a disinclination to motion or business ; if a child, it is gene- rally found reclining its head upon its mother's lap, upon a chair, or against some substance near which it may be sitting ; the pulse in the first instance is quickened, but it is comparatively full ; at least, it is not corded as in membranous inflammation; but as the 448 LECTURE XXXVII. disease advances, the pulse becomes more slow, and more full, attended with coma. The pain too is deep seated, and considera- ble stupor follows, occasionally interrupted with sharp shooting pains ; the pain, however, is not constant. Cephalitis ending in hydrocephalus, generally attacks those of irritable and nervous temperaments ; not so much the full habit ; hence it has been ge- nerally remarked, that feeble and sickly children are most usually the subjects of it ; and hence too the erroneous and absurd infer- ence, that dropsy of the brain is a disease of debility, and the still more absurd negative practice arising from this error, instead of the antiphlogistic treatment, which alone can snatch the little pa- tient from the danger that awaits it. To Dr. Rush again we are indebted for a correct view of the pathology of this disease, and for pointing out its inflammatory character. Dr. Cheyne, who wrote in 180S, also is entitled to much credit for inculcating the same doctrine in Great Britain. The disease now is even deno- minated, in consequence of this association, phrenitis infantum, or phrenitis hydrocephalica. (See an early description of this disease by Wm. Paisley, Ed. Ess. vol. iii. by Dr. Whytt, in 1768.) The symptoms, as they affect the head, are more like those of conges- tion in the last stage of fever, or as in apoplexy. Cases of this sort occurred in two young ladies whom I attended, one of this city, and the other of Baltimore. They had all the characteristic symptoms of hydrocephalus internus; while labouring under this disease, they frequently awoke in the night with very acute dis- tress in the head. " Oh, my head ! oh, my head V- was their frequent cry, and then again they would collapse into the stupor at- tendant on such congestion. But besides the quickened circulation and the distress it created in the brain, this disease is indicated by the white furred tongue, the dry skin, great heat of head, ful- ness of its vessels, high coloured urine, a costive state of the belly, the loaded and heavy eye ; in the first stage, the preternaturally contracted pupil, frequently too expressing the distress of the head by habits of frowning, and in the more advanced stage of the dis- ease, squinting, or the turned up eye; both the effect of an irregular action of the external muscles of the eye. These are pathogno- monic of this disease. But as the disease advances, the pupil dilates in proportion to the congestion that is produced; in a word all the symptoms of inflammation of the membranes are to be discerned, but in an inferior degree. PHRENITIS. 449 But the symptoms of phrenitis where located in the mem- branes are generally considered as most important to be known. I think otherwise, for those which attend upon membranous in- flammation cannot be mistaken, while those of the inflammation seated in the parenchyma, and which constitute the first stage of hydrocephalus, are generally very obscure, compared with those of the membranous inflammation, and are accordingly apt to be overlooked not only by the family and friends, but also by the physician. But in many instances, it is to be observed, that the inflammation is not exclusively confined to the membranes, or to the substance of the brain, but that both partake in whichsoever of the two the disease may have commenced. On this account, probably, Dr. Cullen was led to the remark that these two species are not to be distinguished, and hence has given no species or division of his genus, but even includes many of the genera of Sauvages, Linnaeus, and Sagar, under one head. In membranous inflammation the pain of the head is very acute and unceasing, at- tended with shooting from one part of the brain to the other, and occasionally with corresponding transient flashes of light affecting the optic nerves and retina; these are attended too with a throb- bing of the carotid and temporal arteries. Sometimes the pain is most severe in the forehead, at other times in the occiput, but more frequently on the top of the head, with a sense of burning, conveying the sensation of burning coals on the top of the head, or, as the patient expresses it, he feels as if his very brain were on fire. The pain frequently too extends to the very surface of the scalp. At this we are not surprised, after seeing the com- munication of inflammation to the brain from the surface in erysipelas. Case of Dr. Bayley's patient on board ship, in which the soreness of the scalp pointed out the seat of injury in the brain, and led to the successful use of the trephine. The eyes also denote the great irritation which exists. They are inflamed; the vessels of the tunica adnata are loaded as in idiopathic oph- thalmia; the eyes are also painful, and very sensible to light; frequently too, flashes of light pass across them ; they exhibit fierceness of look, which is very manifest to the ordinary obser- ver. In some a wild acute stare, and a remarkable quickness in the motion of the eyes are very characteristic of the impulse that is within. The hearing too is affected ; at first it is quickened, but afterwards deafness ensues. This, however, takes place, 39 450 LECTURE XXXVII. most commonly, at the close of the disease, and is the attendant upon the form which is among the consequences of the preceding excitement or inflammation, and of the effusion which follows it. The countenance is flushed, not only pointing out the general ex- citement of the system, but evidently marking an extraordinary impetus in the vessels of the brain, and a great determination to the head. The manner of the patient also shows great agitation of the whole nervous system; he is hurried, agitated, anxious, impetuous; both mind and body partake of the irritation. The pulse too is frequently hurried like the whole system, hard cord- ed or incompressible. Respiration corresponds with the circula- tion ; it is also quickened, and as is to be expected when the ner- vous system is violently invaded, it is anxious, analogous to what we see in the yellow fever; indeed there is some resemblance in the operation upon the brain and nervous system in these two diseases. There is also more or less too of irritation about the prascordia, showing itself in frequent sighing. The skin is hot and dry, and about the face and neck particularly flushed: (not so in inflammations in other parts of the body.) The tongue is fur- red and covered with a white paste, attended with great and inor- dinate thirst. The urine is high coloured, almost bloody, but in the advanced stage of the disease it is sensibly diminished in quantity, that is, when the current of fluids becomes great to the brain, analogous to the scarcity of urine in dropsy : when it be- comes dark coloured in the last stage, it is considered by Dr. Lobb, (see his Practice of Physic, &c.,) as an unfavourable symp- tom, being, as he expresses it, partly hemorrhagic; that is, the thinner or serous parts of the blood are chiefly directed to the part diseased. The bowels are costive; the secretion of bile is, in some cases, increased in the beginning, and is attended with bilious vomitings, hence has arisen the mistake of some physi- cians, confounding phrenitis and yellow fever, forsooth because the stomach is a good deal affected as symptomatic of nervous irritation. As phrenitis advances in its progress the flow of blood deter- mining to the brain increasing, the secretion of bile is dimi- nished. The fceces lose the yellow colour ; they become white ; this too, according to Dr. Lobb, is a fatal symptom in this dis- ease, the pathology of which is, that it denotes a very inordinate determination to the brain, and hence a diminished circulation to PHRENITIS. 451 the liver. The brain and nerves continue, as the disease ad- vances, to manifest a still more unfavourable train of symptoms. Delirium in two or three days shows itself; the first evidence of it is incoherence in conversation, and a false imagination. He supposes his friends, and those immediately about his person, to be his greatest enemies, and constantly meditating evil against him. He becomes jealous of every thing passing. He becomes very irascible, is easily excited into violent passion, even at his favourite connexions and servants, resisting the directions that may be given. He is, for the most part, unable to sleep, and when he for the moment may forget himself, dreams of a very distressing nature agitate him, but he has no recollection of them when awake; he is totally unconscious of what has passed; and when awake he is alive to every impression; such is his suscep- tibility, that even a whisper takes his attention. In a case related by Dr. Good, a similar sensibility in the organs of vision and hearing took place : " insomuch," says he, " that the slightest light and sound, even the humming of a fly, were insupportable." (Vol. iii. p. 329.) True delirium ferox follows. He picks at the bed-clothes, catches at flies; the muscse volitantes are be- fore him; he gets out of bed, manifests great strength and even violence; he requires force to confine him; he swallows his food and drinks with great hurry, and that with a convulsive effort, and sometimes hiccups, for the nerves of the diaphragm participate in the disease; in a word, it becomes perfect mania of the acute sort. Stoll relates an extraordinary instance of the chronic inflammation of the brain that ended in mania, but not till it had been of nine weeks continuance. Rat. Med. sect. iii. p. 175. Delirium is one of the characteristics of this inflamma- tion, though not of the phlegmasia^ in general, except synochal fever. In the phlegmasise the general excitement too, is fre- quently as great as in a general fever without local inflammation, yet frequently no delirium takes place ; but in this disease, phre- nitis, delirium appears among its earliest symptoms, not only be- cause the disease is seated in parts, which inflamed, possess great sensibility, but particularly because it at the same time involves the seat and source of all excitement, the brain itself, to which the inflammation usually extends; whereas, in the other phleg- masia, seated in other distant parts of the body, the excitement of the brain is taken off; the current has a different direction, with 452 LECTURE XXXVII. the exception of ophthalmia, and that variety of erysipelas we have noticed called sideratio, and as we shall find also to be the case in obstruction of the lungs as in paripneumony. In those cases delirium is induced and easily accounted for : in the two former by a direct flow of blood to the brain, and in peripneu- mony by the resistance which such injection of the lungs makes to the circulation through the chest, and thereby to the return- ing blood from the brain. I might have added another of the phlegmasia?, in which delirium is a common attendant symptom; diaphragmitis, in which this disturbance of the brain proceeds from the irritations of the important nerves distributed upon that muscle. Such are the symptoms from the third to the sixth or seventh days of the disease. A different train now succeeds, de- noting the termination of the inflammation, either by coma, the effect of effusion in the brain from the inflamed vessels, or we see a livid countenance, with coldness of extremities, involuntary discharges of the foeces and urine. In some instances this sur- charged and excited state of the vascular system is followed by hemorrhages from different parts of the body, as from the nose, mouth, stomach, bowels, kidneys, attended with some symptoms of a general typhoid state of body, but these are of short duration when compared with the preceding excitement. The following are among the unfavourable symptoms which now succeed, and which indicate a fatal result : 1. Coma with deafness. 2. Grinding the teeth. 3. Hiccup. 4. An irregular pulse and small. 5. The stools becoming white, or clay coloured, or 6. Hemorrhages from the bowels, colouring the stools. 7. Dark coloured urine, or urine mixed and coloured. 8. Retention of urine from the loss of sensibility in the bladder. 9. Cold sweats and coldness of the extremities. 10. The invol- untary discharge of the foeces and urine. 11. Convulsions; these occurring at an advanced period of the disease, are invaria- bly fatal. But to aid. you in your prognosis, let me also recount some of the symptoms which announce a favourable termination of this formidable disease. 1. Early hemorrhage, especially from the nose. 2. Spontaneous and copious sweating, or sweating easily induced. 3. Diarrhoea in the first stage of the disease. 4. A plentiful flow of urine. 5. The pulse losing its corded cha- racter, becoming full and soft. 6. Disposition to natural sleep, not comatose or attended with dreams, and the remembrance of PHRENITIS. 453 his dreams, if he has any, but it is preferable he should have none. When the disease may have ended fatally, upon exami- ning the brain after death, the effects of the inflammation are manifested in some instances by the effusion of blood that has been extravasated. In some cases the vessels and sinuses of the dura mater are all loaded and distended with blood, while in other cases where the brain itself is the original seat of the disease, or subsequently involved, we see the effusion of pus. If the inflam- mation be located exclusively in the membranes, an adhesion is oftentimes found of the dura mater to the skull, and the mem- branes themselves thickened. (See Boerhaave and Van Svvieten, Aph. 775.) In some cases the dura mater is covered with a gela- tinous matter, an additional membrane; in some few cases it has been known to end in gangrene. Sometimes too, ossification has been found in some of the membranes, even of the pia mater, the effect of the plethora and inflammatory action, as in the cases of the deposit of earthy matter in the kidney, which I have before related. The vessels, as I remarked, are not only all loaded with blood, but the ventricles also are frequently found distended with serum constituting hydrocephalus interims; and in some cases the serum is found diffused between the mem- branes as well as within the ventricles, so that we find both forms of hydrocephalus, the externus, as well as that within the ventricles. But how shall we distinguish phrenitis from those diseases which we have enumerated, to which it bears a close resemblance ? How shall we distinguish it from mania — from synocha — from typhus ? From acute mania it is not distinguishable; on the contrary, it is identified with it; I mean where mania proceeds from bodily causes, as intemperance, fever, violence, &c. From chronic mania it is easily separated; this stage of madness being without fever. From synocha, phrenitis differs in the pulse. In phrenitis the pulse is more corded — in synocha less so — in phrenitis the stomach is more disturbed — less in synocha — the organs of sense are less affected in synocha, as the sight and hearing — the delirium is much more violent, and comes on earlier than in synocha — the faculties of the mind are less impaired in synocha — the head being relieved in phrenitis, the disease is soon ended — but in synocha the fever frequently continues — the duration of phrenitis is usually con- fined to six or seven days, and when fatal it proves so generally 39* 455 LECTURE XXXVII. in that time. Whereas, synocha, says Eller, is frequently of longer duration, and then ends in typhus. Between phrenitis and typhus the diagnostics are, 1. That the typhoid symptoms of phrenitis are of short duration, and compared with the preceding excitement, are relatively mild. It exhibits less vitiation too, of the general state of the system. 2. In phrenitis the hemorrha- ges are more violent, and they are the chief evidence of a broken up state of the system, the effect of violent action; the fluids being less affected, as it regards their quality, than they are in a pro- tracted synocha or typhus. 3. The eyes, too, differ; in phrenitis they are inflamed and sparkling; but in typhus they are also loaded with blood, but they are glassy and dull. CAUSES. The predisposing causes of phrenitis, are, first: 1. Temperament, especially the sanguine and choleric. 2. Plethora — hence those who indulge in spirituous and fer- mented liquors, not unfrequently become the subjects of this dis- ease. Hence, too, young persons are the subjects of this disease; and if we include hydrocephalus, we may also say that in child- hood there is a strong predisposition to such inflammatory dis- eases; for at that early period of life, say from the second to the fourteenth year, a much greater proportion of blood circu- lates upon the brain, for which reason it is that hydrocephalus is the effect of other febrile diseases. Indeed Dr. Gregory of London, considers it as so identified with the febrile diseases of children, that he even says it is usually known by the name of the " infantile remittent fever." 3. Having once had the disease, the brain becomes afterwards liable to returns of it, as we see to apoplexy and mania; even so of hydrocephalus. (See Van Swieten.) 4. A hot climate, and the hot seasons of temperate climates — hence coup de soleil, or stroke of the sun, which is inflammation of the brain ; but in temperate climates phrenitis is compartively a rare disease, except as symptomatic of fever. The exciting causes are 1. Mechanical violence, as a blow on the head. I have known a case of an Irish woman, who, throwing a pail of water out of the window, threw herself along with it — phrenitis was the con- sequence. PHRENITIS. 455 2. The sudden suppression of accustomed discharges, as the sudden suppression of milk, of the menses, or of accustomed hemorrhoidal discharges, is in some cases the cause of phrenitis. Suppression of eruptive diseases, the plethora in like manner of gout, sudden check of the lochia has induced the mania — the plethora of pregnancy: and especially the circulation called into increased action by the irritation of parturition, has thus induced phrenitis, as well as the more common effect upon the brain, con- vulsions. In some in pregnancy the mind is peculiarly affected; the moral principle disturbed, showing a propensity to swear, to steal, in those too, who are very abhorrent at those things in a perfectly healthy state of body. 3d. Excessive exercise of body, especially in a hot climate, and in the hot seasons of temperate climates. 4th. The heat of the sun — coup de soliel ; easily renewed, and frequently assumes the general symptoms of synocha, or the fever with which phrenitis has frequently been confounded by some of our physicians. 5th. Spirituous liquors are a prolific parent of this disease. Most of the cases of acute mania in our asylum, are, I believe, occasioned by this cause. 6th. An exciting cause is excessive exercise of the mind, either intense application alone, or intense thought, with great anxiety of mind, or the indulgence of strong passions. Love, and reli- gious fanaticism have, in this way, been the cause of phrenitis or acute mania. Intense application of the mind to business, and anxiety, induced this disease in the late Mr. Cheetham. 7th. Want of sleep is also an exciting cause of phrenitis. In other words, this may resolve itself into the former; i. e. ex- cessive exercise of mind, the effect of watchfulness. Sth. Excessive venery has produced this disease. 9th. Poisons; viz. copper, mercury, and arsenic. Case of phrenitis, induced by eating fish, caught on the copper banks. Dr. Bayley. Cases of hydrocephalus from mercury — - and learn a caution as to the repeated use of this metal for sup- posed worms, or in fevers in young children, lest you create this most formidable and fatal of all the diseases. (See Bedingfield on hydrocephalus internus: p. 27.) In the first stage of this dis- ease, I apprehend that mercury is very injurious — that it only serves to increase the febrile symptoms. (See also, p. 16, 21.) — 4 56 LECTURE XXXVII. read Blackall too, on dropsies — Parry also. Such are the sources of idiopathic phrenitis. Symptomatic phrenitis is most generally the effect of synocha; infantile remittents ; pestis; yellow fever, or typhus in its various forms. But in some cases, it is the at- tendant of smallpox, measles, and other inflammatory diseases — then the effect of suppressed eruption. In some cases, it is the attendant upon the first stage of fevers ; in others, it supervenes upon the last stage of febrile diseases, and is the effect of local congestions. Phrenitis being a symptomatic, as well as an idio- pathic disease, we hence can readily account for the epidemic phrenitis which has been described by Saalman, in the 32d vol. of the Leipsic Trans, called " Acta Erudita." In some cases, he states the phrenitis he describes to be intermittent, either return- ing daily, or every second day. The blood drawn in it, too, he observes, has not always the buffy coat; (but which is to be ex- pected in most continued fevers.) Bedingfield made the same observation. The delirium, too, in his phrenitis does not come on until the fifth, sixth, or seventh clays. A very accommodat- ing species of phrenitis truly — almost as much so as Beglivy's yellow fever, noticed by Dr. Miller, in which it was not proper to give a purge till the seventh day. Saalman also re- marks, that the epidemic phrenitis he describes frequentty terminated in pneumonia. It therefore surely must have been general fever, but not phrenitis. He observes, too, that it attacked the old as well as the young; and that it was most fatal to those above forty years of age; and that the hypochondriac and melan- cholic temperaments were most subject to it. That they should readily take fevers to which their fears alone would predispose them, is not improbable; but that they should be most liable to attacks of phrenitis is indeed most extraordinary, and is contra- dicted by all experience. The treatment of idiopathic phrenitis demands our chief attention; but we may remark of symptom- atic inflammation of the brain, that our remedies should always be prescribed with great caution, paying due regard to the pecu- liar cause; the character of the fever indicating it, and the stage of the disease, as well as the habit and strength of the patient. In the first stage of the disease, if it be synocha, yellow fever, or typhus, as we have already remarked, the use of venesection, active purges, or bisters is indicated; but in the last stage, a more cautious, and, sometimes, a very contrary treatment may be PHRENITIS. 457 called for. In the treatment of idiopathic phrenitis, general vene- section, repeated even to syncope, says McBride, is a good prac- tice — until a state resembling apparent death, says Dawson, (p. 71.) No regard should be paid to the quantity drawn. An abate- ment in the violence of the affection of the brain should alone determine the frequency of bloodletting, or the quantity drawn. Indeed, I would remark, that bloodletting oftentimes fails in the removal of active inflammatory diseases, by the common practice of physicians, directing the limited number of ounces to be drawn, instead of urging it to be continued and repeated until a mitigation of the disease is perceptible. Twenty or thirty ounces drawn in the forming, or early stage of phrenitis, will do more than three times that quantity drawn at different times. In these inflammatory diseases, too, the patient bears the loss of blood without the same deliquium or sense of exhaustion that he would experience under other circumstances. The man who in health would faint at the loss of a pint of blood, under the excitement produced by phrenitis or gastritis, enteritis, or other inflamma- tory disease, seated in sensible parts of the body, will bear the loss of two or three pounds without the least inconvenience; and at the moment of drawing it will perhaps not exhibit the least evidence of the change and depression which will in a short time be perceived from it. Venesection, too, in the foot may per- haps be more useful than from the arm, upon the principle of re- vulsion. Burserius is favourable to this principle. (See also Med. Recorder: paper on blood-letting, by Dr. Ducachet: vol. iii. p. 461: also vol. v. p. 1S7.) Local blood-letting by leeches, cupping, division of the temporal artery. Opening of the jugular vein is recommended by Hoffman, Cullen, Ellis, Dawson. These last are unnecessary, and sometimes attended with difficulty, and in- deed danger in delirium. They are also improper on account of the tight bandaging of the head and neck, to close the divided arteries and veins. Purging. — Saline purges are preferable; or, calomel and jalap. These should be frequently repeated. It is also usual with most writers to advise blisters to the head, which should be inva- riably shaved; but, query, would it not be preferable to apply them successively to the wrists and ankles — to the arms and thighs? And do not blisters, applied to the head, like the in- flammation of erysipelas, rather invite an increased quantity 458 LECTURE XXXVII. of blood to the brain, as well as to the outside of the head? I am of this opinion, and am confirmed in it by the so com- mon failure of them in hydrocephalus. Diaphoretics, antimony and crem. tart., or antimony and calomel blended; or sp. mind, and laud. Camphor is very generally recommended by prac- tical writers, as beneficial in this disease of excitement; and, by the by, this is an indirect evidence that it is not the powerful stimulant that it is represented; and if this medicine be proper in phrenitis, it is assuredly a poison in the typhoid state of fever, in which also it has been recommended. If perspiration be de- sirable in phrenitis, encourage the use of the diaphoretics by tepid drinks. For the same reason, too, the warm bath and the pedi- luvium are indicated, to aid in relaxing the surface. And for the same reason, cold applications to the head, cold water, cold vine- gar and water, cloths wet with sether, the spirituous applications recommended by Mr. Bedingfield, (see his Compendium, p. 37, first, ed. ) and the clay cap recommended by most practitioners, Cullen, and Thomas, and Good among the rest, should be totally prohibited. Perspiration, with the aid of blisters, will do infi- nitely more good in diminishing the determination to the brain; and if the irritation of blisters, or the discharge by perspiration, be useful in lessening the excitement within, how is it possible that cold affusions can be proper or justified upon any principle whatever? On the contrary, do they not, by diminishing the quantity of blood in the external vessels, increase the fulness of those within? And do they not, by diminishing perspiration, add to the fulness of the vessels of the brain? They did so in the very case related by Good, (p. 330.) He had nearly lost his pa- tient, but he was saved by Dover's powder and diaphoresis. (Ibid,) Diuretics are also useful medicines in this disease; i. e. such as do not operate by exciting the system. The nitrate of potash is among the best of this class of medicines: gr. x. or gr. xv- may be given every two or three hours in drink, or in com- bination with the diaphoretic medicine with advantage, in this disease. Digitalis may also be prescribed with advantage in phre- nitis. If it ever be useful, it will be so in this case. But it is not to take the place of any of the remedies that have been mention- ed. It may be employed as an auxiliary, but is not to be trusted alone. Belladonna, stramonium, hyosciamus, have been used by Baron Storck and others. When this disease, as is sometimes the PHRENITIS. 459 case, proceeds from suppressed menses, we are told always to attend to this habitual discharge, and to see that the menses are restored. This is not always practicable, and indeed it is unim- portant, if other vicarious evacuations be substituted; for we know that the state of that function is intimately connected with the general plethora of the system, and not on local ful- ness, or congestion alone, as contended for by some writers. Diet. — Bread and water, or at most, sago, arrow-root, gruel, or barley-water. Sub-acid drinks: crem. tart, and tamarinds. Regimen. — The position of the head and shoulders should be elevated, for the purpose of diminishing the flow of blood to the brain — this is essentially important. Avoid light, heat, noise, business, conversation. Have as few attendants as possible; none but those neeessary for the purpose of administering to the pa- tient should be present — more disturb him. In a word, let the most rigid antiphlogistic, or sedative treatment be in every re- spect strictly pursued, as it regards medicine, diet, and regimen. And when the patient has become convalescent from this inva- sion of the brain, remember that inflammation may be easily re- newed in this organ, the seat and source of all sensation. Let him, therefore, return very cautiously to his accustomed diet, and particularly to the use of animal food, wine, and other stimuli, composing his diet in a state of health. And let him still more cautiously return to his ordinary pursuits, especially if of a pro- fessional sort, as they in a particular manner occupy the mind. 460 LECTURE XXXVIII. OPHTHALMIA. The eye is at all times an organ of exquisite sensibility to im- pressions, but when it becomes the seat of inflammation the suf- ferings connected with it are peculiarly severe and dangerous, not only to the organ itself, but so numerous are its nerves, and so immediately connected with other important senses, and with the brain itself, that such inflammation is frequently transferred even to the brain, and thence involves the whole system in dis- ease. In this manner I have seen ophthalmia a fatal disease. It is at all times important, and calls for active treatment on the part of the physician. Recollect that the eye has several pairs of nerves bestowed upon it, besides several branches of other pairs not immediately belonging to it. 1. The optic. 2. The ophthalmic branch of the fifth pair, the trigemini, and which holds extensive connections by means of its other two branches, the superior and inferior maxillary. 3. The motores oculorum, which are distributed upon the straight muscles of the eye. 4. The trochleatores, or pathetici, which are spread upon the oblique muscles. 5. The abductores, or abducentes, the sixth pair of nerves proceeding to the abductor muscles ; and 6. A branch of the seventh pair, auditory, that is, coming from the portio dura of that pair. Seeing then that the eye holds such extensive communications, we are taught the importance of active treatment whenever it becomes the seat of inflammation, for such is the determination to parts thus highly organised that they readily become overwhelmed. The characteristic symptoms of ophthalmia, according to the definition given of it by Dr. Cullen, OPHTHALMIA. 461 are great redness and pain ; intolerance of light ; attended for the most part with an increased flow of tears. (Rubor et dolor; lucis intolerantia ; plerumque cum lacrymatione.) Dr. Culien divides it first into idiopathic and symptomatic ophthalmia. The idio- pathic he again subdivides into the opthalmia membranarum, that is, as seated in the adnata and its subjacent membranes, and the ophthalmia tarsi, or the inflammation seated in the lids, more especially in the sebaceous glands, or glandulae meibomU which beset them. These when inflamed are swelled, followed by more or less erosion and a glutinous exudation, which occa- sions them readily to adhere after being kept in contact, as is the case in sleep. But you cannot readily have one of these parts inflamed without the other, that is, when seated originally in the membranes; the tarsus is, in that case, soon involved, and vice versa, the tarsus being the primary seat of the disease the inflam- mation is soon extended to its membranes. Mr. Ware, indeed, who has seen more ophthalmia than almost any other man living, expresses the opinion that the greater part of the cases of ophthal- mia which occur, originate in the lids, and from thence com- municate to the eye itself; and that very few cases occur that spontaneously originate in the membranes. The symptomatic inflammation of the eye, Dr. Culien also divides under two heads, 1st. As symptomatic of some other disease of the eye itself, as trichiasis, or entropium, that is, the hairs of the lids turned in upon the eyes. 2d. As symptomatic of diseases of other parts of the body, or of the whole system, as, scrofula, syphilis, measles, scarlatina, fever, or phrenitis. When the disease is seated in the membranes, or eye-lids, the whole eye soon manifests the pre- sence of an unusual flow of blood to the part; small serous vessels now carry red blood that before were not at all or scarcely per- ceptible, In some instances, the eye becomes blood-shot by the effusion of blood from some of the vessels that may have been ruptured by the new determination that takes place. The patient at first has the sensation of some foreign body in the eye, and is not easily convinced that this is not really the case, arising merely from the turgescence of its vessels. This sensation is soon succeeded by acute pain, and frequent flashes of light pass- ing before the eye; a great flow of tears now takes place; these too are not only increased in quantity from the whole surface of the eye, and from the lachrymal glands, but the discharge itself is 40 462 LECTURE XXXVIII changed in its qualities, and is rendered very acrid. They are in such quantity that they pass over the lids, and in some instances? scald the cheek as they flow, producing even an erysipelatous in- flammation of the face; and those which pass by the natural chan- nel into the nostrils inflame that passage also, and in connection with the inflammation extending from the eye, have induced fistula lachrymalis by the inflammation induced in the ductus ad nasum; but the inflammation not only changes the secretion from the surface of the eye and that of the lachrymal gland, but the secretion of the eye-lids is also affected by it; the secretion by the nose also partakes of it. These organs, indeed, mutually act one on the other. If originally seated in the lids, as Mr. Ware ob- serves, the membranes become affected, and if in the membranes, the lids, in their turn, frequently show it. Hence it happens, that we see the lids adhering in most cases of ophthalmia, whether ori- ginating in the lids or in the membranes. But the inflammatory action of this disease is not confined to the eye itself, the whole system frequently manifests it by the general febrile symptoms attending it, and which are those of synocha, showing itself in the circulation, respiration, the various secretions, and excretions, and, indeed, more or less in all the functions of the system; for the most part, however, such is the determination to the head, that the pa- tient complains much of headache as well as pain of the eye, great sensibility to the light, throbbing of the carotid and temporal ar- teries, and of flashes of light frequently passing through the eye ? as in phrenitis. In some instances, as already intimated, the brain itself becomes the seat of inflammation, and renders it a fatal disease. Ophthalmia has various terminations : in some instances, as in other inflammations of secreting surfaces, it is removed, 1st. by resolution; or, 2d. it ends in an increased secretion, and by pu- rulent secretion from the external surface; and when such dis- charge takes place externally, it affords relief analogous to the re- lief afforded by purulent discharges from other inflamed surfaces, as the nose, throat, or surface of the lungs; and, indeed, this is another example of a purulent secretion, without actual ulceration or destruction of parts but from a mere change in the state of the exhaling vessels, as in gonorrhoea, phthisis, &c. &c. 3dly. In other cases ophthalmia terminates by an effusion of pus inter- nally, behind the cornea, constituting hypopion, (so called from OPHTHALMIA. 463 v*oj, under, and jtvov, pus,) or in a less degree, in which a very partial or inconsiderable discharge takes place behind the cornea, when it is called, from a resemblance to the circle on the nail, onyx, from owl, a nail. 4th. Inflammation of the eye in some cases ends in a thickening of the membranes, the seat of the dis- ease; the whole scelerotic coat becomes thickened; in other in- stances the cornea is rendered opaque, and is totally lost in the general disease of the eye; and as ossification was found in phre- nitis, so in ophthalmia it has been known to be attended with an ossification of the coats of the eye, and indeed may have had some agency as a cause of the inflammation. 5th. Ophthalmia in some cases produces a disease of the crystalline lens, either obstructing the lens itself, or the capsule investing it; in either case ealigo, or cataract, is the consequence ; inflammation is not always the fore- runner of cataract; it is sometimes the effect of congestion from age. 6th. Inflammation of the eye is, in some instances, succeeded by amaurosis, or a paralytic state of the retina, the extension of the op- tic nerve upon the posterior part of the eye. (See Trucke'sHistoria Ophthalmias ) 7th. Ophthalmia produces a new growth of ves- sels upon the adnata constituting membrana, or film. This re- ceives the name of pterygium, from Hts^vt^ a wing, bearing some resemblance in its shape to a bird's wing. 8th. In other in- stances, it ends in a large effusion, within the eye, of water, or pus, constituting a dropsy of the eye, producing in either case, a great distension and overgrowth of the eye, which occasions it to protrude from its socket far beyond the lids, insomuch that the lids can no longer cover but a small portion of the tumor thus produced. This hernia, or displacement of the eye, is now de- nominated staphyloma, from some supposed resemblance to a grape. It looks, however, in many cases, much more like a blood peach than it does like a grape. In this state of things it is not unusual for the action of the muscles compressing the eye to produce a rupture of the e)^e itself. 9th. It frequently ends in sphacelus and death. These being the consequences of inflammation of this important organ, it necessarily calls for all your attention ; and let me entreat you, in every case to which you may be called when you may enter into practice, to keep these terminations before you as a possible event, if you should omit the use of those means which are indicated in a dis- ease seated in an organ of so much sensibility. 464 LECTURE XXXVIIL CAUSES OF OPHTHALMIA. Predisposing — 1. The sanguine temperament. 2. A plethoric habit of body, especially kept up by intemperance; sensibility induced by — 3. A former attack. 4. Change of climate from a cold to a hot one, or from a clouded atmosphere and short days, to a clear atmosphere and a long day. These changes induced ophthalmia in the British troops in Egypt. 5. Debility and con- sequent increased sensibility. The effect of disease predisposes to ophthalmia, as after fever and the confinement it produces. In like manner women after the confinement of parturition and the debility attendant upon it, are liable to this disease. 6. A dis- eased state of the constitution, as scrofula or syphilis predisposes to ophthalmia. The exciting causes of ophthalmia all resolve themselves into irritation applied to the eye itself, as— 1. By mechanical injury; a blow and a black eye we know to be very generally associated; but the red or inflamed eye usually pre- cedes the black. 2. Inversion of the eye-lids or trichiasis. A case is related by Dawson, (nosology, p. 57,) in which this disease had been of forty years duration — the effects of hairs which were re- moved as fast as they reappeared. For the first seven years they reappeared — they were conquered at last. 3. Sand or lime is a frequent exciting cause of inflammation. The sands of Egypt are a productive source of ophthalmia, independently of other causes in that climate and country. The sands of America pro- duce the same disease as those of Egypt. During Lewis and Clarke's travels up the White Earth river, the party were tor- mented with sore eyes occasioned by sand which was driven from the sand bars in such clouds as often to hide from them the view of the opposite bank. The particles of this sand are so fine and light that it floats for miles in the air like a column of thick smoke, and penetrates every thing. " We were compelled, " says the writer, "to eat, drink, and breathe it very copiously." (Quarterly Review, 332, January, 1815. Lewis and Clarke's Travels to the Missouri.) 4. Chemical stimuli may be enu- merated. The nitrous fumes of the soil of Egypt, and especially the sharp effluvia after the retreat of the Nile, consequent upon its overflow, are of this sort. According to Sonnini and Sir Robert Wilson, these are among the most frequent causes of that disease: and hence they account for the fact, that in Cairo diseases OPHTHALMIA. 465 of the eyes are almost universal ; blindness and ophthalmia are met with at almost every step in that city. 5. Excessive exer- cise of the eye, as in looking at minute objects, sitting up late at night, and over exertion of the eyes in writing or reading. These sensible organs readily become affected, if not by active inflam- mation, great weakness is the result. 6. Excessive quantity of light suddenly let in upon the eye. The new born infant, is very liable to inflammation of the eyes, especially if its attention be long and steadily attracted by the fire or a candle immediately upon birth, when it has just emerged from its dark abode. In like manner ophthalmia is a common consequence of snow when of long duration on the ground. 7. The heat of climate. 8. Cold, by the sudden suppression of the secretions, is a very common exciting cause of inflammation, especially in persons who have before suffered an attack. 9. The diminished excre- tions attendant upon other diseases and sometimes the morbid materials of other diseases induce sympathetic ophthalmia, as syphilis; not by metastasis, as maintained b}^ Dr. Gregory, of London, but by the matter of gonorrhoea directly applied to the eye — scrofula, fever, erysipelas, measles, scarletina, catarrh, and small pox, and bowel complaints. Cases are related by Dr. Why the of Edinburgh, in which ophthalmia invariably followed disorders of the stomach and bowels; but these probably, as well as ophthalmia, were the effect of a suppressed state of the excre- tions by the skin. A tenth exciting cause is contagion. In this way inflammation of the eyes by the purulent matter excreted, is frequently communicated by contact, as at boarding-schools — in regiments of soldiers, and in families, where several persons fre- quently wash in the same basin, and wipe upon the same napkin; for it is now ascertained that the sphere of the contagion of oph- thalmia is limited, and as Mr. Edmonston observes, is chiefly ascribed to contact, analogous to the purulent ophthalmy of new born infants, which Mr. Gibson of Manchester, and Mr. Ware, suppose to be excited by the acrid discharges of the mother, that is, in cases of leucorrhcea preceding or attendant upon the birth of a child. But is this not always the case ? Other causes may satis- factorily account for this effect, as already remarked. By this communication between the soldiers in Egypt, it is probable this disease was rendered communicable, and in this way conveyed to Malta, Gibraltar, and England, as well as, in a few cases, to the 40* 466 LECTURE XXXVIII. United States. Some of the regiments returned with many sol- diers totally deprived of sight. Yet seeing that the matter of leucorrhoea and of gonorrhoea applied to the eye produces a simi- lar purulent eye, is not the purulent eye of Egypt thus propa- gated, and not by a specific material — seeing that such spe- cific material is not necessary, as any matter from another dis- eased surface will excite inflammation, applied to that tender organ the eye ? The contagious character of this disease, as it first appeared among the British soldiers, although it may have had its origin in that country, has been very generally believed. Numerous and decided testimonies, says the London Medical Review, (vol. i. p. 15,) leave us not at liberty to doubt that, though believed to be peculiar to Egypt, the same disease has been imported into England. (See also Welsh's Journal of the campaign in Egypt, p. 182. Power's attempt to investigate the ophthalmy of Egypt, 1803. Treatise on ophthalmia, Ed. 1806, p. 48. Dewar's Inaug. Diss. 1804.) Do not all the facts on the contagiousness of ophthalmia, admit of explanation in the manner already pointed out ? TREATMENT. In the treatment of idiopathic ophthalmia, our indication is, to remove the remote causes as far as possible. Where it arises from a foreign body, as sand, lime, or other substance, it should be removed by a probe or by immersing the eye in water. 2d. To diminish the quantity of blood flowing in the vessels of the eye and the neighbouring parts, and to diminish the gene- ral and local excitement attendant upon the inflammation of that sensible organ, and 3d. When such inflammation has been subdued, to restore the tone of the debilitated vessels, to remove the consequences of the preceding inflammation, and thereby to prevent a return of the disease. The exciting cause being removed as far as practicable, we are next to take off the momentum of the vessels of the part inflamed; that is, to diminish the volume and the velocity of the blood cir- culating upon the diseased part. This is to be done, 1st. By venesection general and local, by the lancet; it is not OPHTHALMIA. 467 necessary, however, that it should be carried to deliquium, as re- commended by Mr. Vetch; yet, copious, large, and repeated blood-letting is indispensably necessary. In like manner, cup- ping, leeching, and scarification, should be made use of to empty the vessels of the parts affected ; not, however, by the rough grains of wheat ! ! as recommended by the author of the Edin- burgh Practice of Physic; but by the lancet or a delicate knife, or the small curved scissors. In the use of scarification, let me also advise you to confine it to a division of the congeries of ves- sels at the inside of the lower lid, and not as is customary, pass your lancet and knife across the membranes of the eye itself. This mode of scarification is extremely painful, and adds to the irritation instead of diminishing it; but applied to the part men- tioned, and the vessels freely divided, or a portion of them cut away with the scissors, which is preferable when they are very numerous and large, you obtain every advantage that can be de- sired, for it empties the vessels of the whole eye, as far as scarifi- cation can accomplish it. 2. Cathartics are an important means of depletion in this dis- ease; and for the purpose of exciting large discharges, and at the same time diverting irritation from the part affected, they should be active; such as the saline cathartics and the active purge, so frequently recommended, calomel gr. vi., jalap gr. xv., and the super tartrite of potash gr. xv. combined. Kirkland objects to the saline cathartics in ophthalmia, particularly, but, I believe, without good reason; on the contrary, they are among the best purgatives we can employ in this or other inflammations. 3. Sudorifics, such as have been mentioned in phrenitis, are also called for in ophthalmia, viz: sp. mind, and laud., the anti- monial solution, small doses of antimonial wine and laudanum, or calomel and James' powder, with the addition of a small quantity of opium; or Dover's powder. Scarpa's prescription is, antim. tart. gr. i.; decocti hordei Ifeiss.; crystal tart. 3i., sacchar. 3ij. M. You perceive the addition of laudanum or opium in most of these diaphoretic medicines, not only because they aid in that respect the operation of the medicine with which they are com- bined, in relaxing the surface, but for the purpose of diminishing the great irritation which inflammation produces when seated in parts of so much sensibility : in such cases opium is peculiarly useful. The practice indeed of Mr. Ware is to apply the vinous 468 LECTURE XXXVIII. tincture of opium or laudanum itself to the eye, by dropping one or two drops into the eye, two or three times a day; he observes that, although it occasions a momentary excitement, it produces permanent ease to the patient ; and that he has prescribed it with great success, after the necessary evacuations have been made from the system. As in inflammation of the toes, opium was found useful by Dr. Pott ; so it may prove beneficial in diminishing ophthalmia. After venesection and purging especially, you need not fear its stimulating operation upon the system ; but before evacuations have been made, you have great reason to apprehend injury from its sedative operation upon the circulating system, and especially the smaller vessels, in consequence of which the larger are more distended, and thus inflammation ultimately in- creased; this you will find a common event of the too early use of opium in inflammatory diseases. Mr. Bedingfield also, I find, concurs in the use of opium after scarifications ; after the parts have ceased to bleed, he recommends that the eye be kept con- stantly moistened with a watery solution of opium, from one to two grains of the extract dissolved in an ounce of water, to be ap- plied cold or warm, as the feelings of the patient may indicate. I have no doubt of the benefit of this application. 4. Blisters behind the ears, to the temples, or between the shoulders, are also found useful remedies in diverting the inflam- mation from the parts affected. But let me caution you against their application immediately over the eyes, as directed by some. They are in that case so near the parts affected, that they are more likely to increase than diminish the inflammation; but the greatest objection is, that a portion of the ointment may find its way to the inside of the lids, in which case it must assuredly aggravate the disease. 5. Setons are advised, by many physicians, in ophthalmia, as preferable to blisters. In chronic inflammation, a remedy of more permanent operation is, perhaps, in many instances, to be pre- ferred ; but in a sudden and acute inflammation, you require the more active effects of a blister; but in habitual scorbutic or scro- fulous affections of the eyes, I prefer the more durable irritation of a seton; for, like the disease, setons may be considered as chronic remedies, for it indeed requires time for them to produce the necessary irritation and discharge. In like manner McBride recommends, in habitual ophthalmia, small issues to be made, by OPHTHALMIA. 469 passing a thread of silk or cotton through the lobes of the ears, and daily to render them still more active, by means of some blistering or other irritating ointment, applied upon the thread at the time of moving it. Issues in the arms applied by making an incision with the lancet at the insertion of the deltoid muscle, and inserting a pea, or by the application of the patent issue plaster, are also advised in ophthalmia by many practitioners. I have pre- scribed them in chronic cases of that disease certainly with bene- fit; but in acute ophthalmia, blisters are to be preferred. But, 6th. What applications shall be made to the eye itself, in this state of excitement and inflammation ? Many, even in recent cases of this sort, advise cold applications; others recommend the eye to be frequently bathed with cold water; some direct cold poultices of scraped potatoes, or the pulp of rotten apples, to be applied to the eye; and most agree in recommending cold lead water, and that constantly applied ; but cold applications are in my opinion injurious in all local inflammations, and much more so in parts of so much sensibility as the eyes; and you will find in all such cases that the pain and inflamation are both aggravated by the stimulating effects of cold. Samuel Cooper observes that if cold applications be painful, they should be applied warm. Ba- ron Pery, in his Memoirs of Military Surgery, also recommends not only the eyes but the head to be frequently washed with warm vinegar and water, not cold. This bad effect is to be expect- ed, when we recollect that the eye is a secreting surface, and that cold applications diminish those very secretions which, it is unde- niable, should be promoted. In the first years of my practice, I adopted this treatment in ophthalmia, but very soon found to my surprise, that although lead water might, in some cases, give mo- mentary relief, the burning, itching, and pain very soon returned with a manifest increase of the inflammation, probably from the check given to the discharge. But we may certainly obtain all the sedative and beneficial effects of lead without the disadvantage of cold applications; applied moderately warm, I have certainly found it an useful remedy; i. e. after venesection and other evacuations have been prescribed; but before these means of depletion have been employed, it is certainly a dangerous prescription and should be totally prohibited. In IS 14, a case occurred in this city, where very destructive effects proceeded from the application of lead water in erysipelas, accompanied with ophthalmia. The fol- 470 LECTURE XXXVIII. lowing is the form in which I make use of this medicine: 1£. acet. plumb. 3ss.; acet. distill, gss.; laud. Sij- ; aq. pluvial, gviij. M. I usually direct a linen cloth, folded and wet with the liquor, to be applied to the part affected, renewing the application when it may become cold. But before the system has been depleted, I usually have recourse, 7th. To applications of warm rain water, milk and water, to weak vinegar and water, or to diluted sp. mind. §iij. and laudanum 3ij., %vi. aq. pluvial.; or where the parts are extremely painful, to fomentations of poppy heads. This Dr. Bard found pe- culiarly serviceable in his own case; it is also highly recommended in the last edition of Cooper's Surgery. After the remarks already made, on the effects of opium, it is not improbable that the poppy heads were equally serviceable with the soothing effects of the fomentation derived from its warmth ; the practice of Mr. Ware is certainly favorable to this explanation ; he also advises all his collyriato be applied warm. Mr. Dawson (see Nosology, p. 56.) also observes, "where the eye is highly irritable and painful, I should prefer warm water, applied with a sponge and reserve the cold saturnine or similar washes, such as the sulphate of zinc, or the muriate of mercury, until the irritation and pain has partly sub- sided." Another application which you will find very service- able in promoting a secretion from the eyes in ophthalmia, and which is well calculated to allay the irritation and to diminish the sufferings of your patient, is the application of the common poul- tice of bread and milk ; but, for this purpose, it should be boiled until it is perfectly smooth, and then spread thin between a fold of cambric or fine old linen; this should be laid over the eye, and be frequently renewed, say every three or four, at most every six hours. Whatever application you may make through the day, you will find this cataplasm an excellent anodyne for your patient through the night, when the symptoms are usually aggravated. Another application, which many physicians prefer for active inflammation of the eyes, is a poultice of the slippery elm bark; some again make use of an infusion of quince seeds, flaxseed, or the pith of sassafras, a teaspoonful to gviij. of water, or common barley water. These applications are all mucilaginous, and therefore calcu- lated to allay irritation in the parts to which they are applied, at the same time that they afford a soft defence from the action of OPHTHALMIA. 471 the air, upon the inflamed surface of this very sensible organ. The hop poultice, by its anodyne qualities, is also found a very soothing and useful application in this disease. But notwith- standing all these various applications, in some instances the in- flammation continues, and even is increased with a manifest ful- ness of the eyes, and thickening of its coats; and perhaps a beginning protrusion of the cornea, and an opacity of that coat of the eye. In such case it has been proposed by Mr. Wardrop to lessen the bulk of the eye, and to take off the tension of the inflamed parts by a discharge of the aqueous humour, by punctur- ing the corner of the eye with the knife used for extracting the lens, and to introduce it at the same part where it is introduced for that operation, and to such an extent as to make an incision as broad as the knife. Many cases are lately published by that gen- tleman, of the success of this remedy. Mr. Ware has also made use of it with the best effects, and recommends it to be 'done early, to prevent rupture from some parts which might otherwise prevent the return of vision. It may therefore be considered as a very important addition to the means of diminishing inflamma- tion, especially when it involves the internal membranes of the eyes, and is likely otherwise to end in the destruction of that organ. (See Edin. Med. Jour.) In one case which I attended, in conjunction with an eminent physician of this city, I proposed, in such protrusion, to discharge the humours of the eye, as I once did in a former case, with the best effect. It was opposed. It ended fatally. I now exceedingly regret that this mode of punc- turing the eye had not been made use of at that time. The second indication being fulfilled; i. e. the inflammation be- ing removed, we are next to restore the tone of the debilitated parts, and to remove the consequences which such inflammation may have produced. 1st. A morbid sensibility frequently remains, attended with a lax and distended state of the vessels. A sort of passive inflam- mation remains ; the part yet unattended by pain, or the febrile symptoms of the first and active stage of the disease. In this stage a solution of the sulphate of zinc, composed of the strength of one grain to an ounce of rain-water is an useful application, and should be frequently applied. Let me here guard you against the absurd and unchemical 472 LECTURE XXXVIII. compound of vitriol and lead, made use of by some physicians, and recommended, too, even by Dr. Dorsey, in his System of Surgery, (vol. i. p. 293.) and I perceive by Dr. Gregory of Lon- don. It is like some of Dr. Brown's prescriptions for his mixed debility ; i. e. supposing direct and indirect debility, to exist at the same time. So you have here the opposite qualities of stimulant and sedative in the same prescription : viz. the sulphate of zinc and the acetate of lead. Their decomposition ensues, and new combinations are formed. In your prescriptions, let me advise you always to observe simplicity; otherwise your practice is uncertain, and for the most part inert. One of the greatest, improvements our profession has received, has been the abandonment of the complex farragos which made up the prescriptions of older physicians,' and the adoption of a more simple mode of administering medicines. While the former practice was intended to counteract particular predominating symptoms, the latter strikes at the root of the evil, by removing or counteracting its cause. In the first stage of the disease, if the means of diminishing inflammatory action be indi- cated, and lead be preferred as a sedative, make use of it ; but in the second stage, when stimuli are called for, use the vitriol, and which you will find a valuable stimulus. Many other means are employed for the purpose of restoring tone to the debilitated ves- sels: a w r ash of brandy and water, cold water alone, the alum curd — made by coagulating the white of an egg by alum. In the second stage of ophthalmia, when seated in the tarsus, it is not unusual for a chronic enlargement of some of the glandulae meibomii to remain, constituting the hordeolum or stye, attended with fresh inflammation; in other cases, the tumour remains in an indolent state, without, inflammation. In these cases, one of the best applications to resolve these obstructions, and to restore the excretion from those organs, is the white precip. of mercury, which is the sub-muriate of mercury and ammonia, the sal alembroth of the alchy mists. This is the basis of the celebrated ophthalmia ointment of Janin, so much recommended by Cooper and others; viz. ft axung. §ss.; bol. armen. 3ij.; prepared tutty, 3ij.; white precip. Zi. M. When ophthalmia terminates in the pteryguim, or film, covering a part or whole of the eye, and the active inflam- mation is removed ; in the first place, with the curved scissors OPHTHALMIA. 473 or knife, remove such portions as can be conveniently detached from the subjacent coats of the eye. In other instances, we may divide by the knife or the lancet, the principal vessels which may nourish such newly formed production. Still some portion will remain, obscuring the e)~e, or a part of it. Mr. Ware directs in such cases, aether to be applied to the part, by means of a camelV hair pencil. Sometimes he adds to it one-third or one-fourth of the solution of corrosive sublimate. With these even an opacity of the crystalline has been removed. Others again, under similar thickening of the coats or films, apply verdigris with sugar; viz. 1 part verdigris, 6 parts sugar; or red precipitate, I part, sugar 6 parts; or sugar and alum, equal parts; or sugar and nitre. In such case I have seen repeated instances of the removal of those remains, by the application of a still more simple remedy — molasses, drop- ped into the eye two or three times a day. It probably acts by ex- citing the absorbents which have become inactive. The same remedy, I recollect, was earnestly recommended by Dr. Shippen. When the disease is symptomatic, attend to the cause. If pro- duced by syphilis, mercury is the only resource; if the effect of scrofula, you must resort to bark, alteratives, seawater, and sea- bathing; and use tonics to prevent the return of ophthalmia. In this case, both the local and general application of cold will be beneficial. The diet, in ophthalmia, should be very simple — avoiding every thing that can excite the system — avoid light — keep your patient in a dark room — protect the eye by a piece of green silk, either hung loosely before it, or covering a piece of pasteboard; but especially avoid all close bandages — even goggles are too warm — they increase both the heat and sensibility of the eye. 41 474 LECTURE XXXIX. OTITIS.— ODONTITIS, &c. Otitis, inflammation of the ear, derived from ov$, an ear. The ear, like the eye, is an organ of great sensibility, more especially in children. It derives this sensibility not only from the distributions of the portio mollis of the auditory nerves upon the internal, and the portio dura, on the external parts of that organ; but the sublingual branch of the inferior maxillary nerve, that is, a branch of the fifth pair, also by its union with the chorda tym- pani, a branch of the portio dura, holds communication with the ear, and in consequence of this connexion we are led necessarily to attach more importance to the diseases of this organ, because through that medium such diseases sometimes affect the brain, and indeed the whole system. For an illustration of that con- nexion, let me refer you to the valuable work on the diseases of the ear by Saunders; the distribution of the fifth pair of nerves you will also see beautifully exhibited in the work of Walther, and a plate of the same in the Berlin Transactions. Otitis is generally considered as an inflammation of the meatus auditorius externus. Wilson defines it phlegmasia cum dolore auris interna^ saepe cum delirio. But it is not confined, as many suppose, to the external ear; nor is Wilson right in limiting it to the internal ear; both are frequently involved in the same inflammation, depend- ing on the degree of it, the cause producing it, and the habit of body in which it occurs. Slighter cases of it, especially from cold, will perhaps only affect the secreting surface of the external ear. and the inflammation confine itself to the ceruminous glands, and the excretories, analogous to the ophthalmia tarsi. It produces spongy granulations, (assuming the appearance of a poly- pus;) in others it leaves what Saunders denominates an herpetic otitis. 475 ulcerous eruption, and this sometimes such as to close the pas- sage, obstructing even the entrance of sound. These cases are generally cured by the forceps, injections, ointment of mercury, and caustic; while in other cases, it seats itself upon the mem- brane covering the tympanum, or even extends beyond it to the internal ear, and affects even the membrane lining the mastoid cells, and thence perhaps to the brain itself. Accordingly in Saun- ders you find cases terminating in the very destruction of all those organs; not only showing itself in the ordinary purulent secretion which takes place from the external ear, and which perhaps may remain for sometime comparatively harmless, but in other in- stances the tympanum is destroyed, and the whole chain of bones, and the nerves and muscles connected with it, even the very membrane lining the mastoid cells is destroyed, and the cells themselves filled with pus; followed, says Saunders, in some in- stances, by an exfoliation of the external lamina of the mastoid process: but this is not all, it not only ends in the destruction of the organ of hearing, it also extends itself to the brain, and in- volves the whole system in disease, and frequently proves fatal. Vogel states, that in this manner it sometimes proves immediately fatal on the first da} T , and very often destroys the patient before the seventh. The late Mr. M'Kie, of this city, an ingenious and promising youth, was thus cut off by inflammation of the brain, induced by inflammation of the ear, to which he had been very subject from childhood; it ended in a loaded state of the vessels of the brain, producing all the symptoms of apoplexy; that ter- gescence in all the vessels of the head, was manifest after death. But in other instances, this inflammation ends in abscesses and tedious ulcerations, with a total destruction of the organ of hear- ing. It appears, then, that there is not sufficient importance attached to inflammation of this organ; indeed some nosolo- gists omit it altogether. Vogel, however, has given it a place as a distinct genus, the forty-eighth among his inflammatory, calling it, " Inflammatio auris internae, dolor immanis in aure, febris, cephalalgia, agrypnia, delirium." With these facts before us, we are taught both to give it a place in nosology and to give attention to this disease not only as a disease of the ear, but, in some instances, as a disease involving the brain and the whole system ; for a disease that occasionally terminates fatally cannot be correctly viewed in any other light. The 476 LECTURE XXXIX. symptoms of this disease are, pain in the ear; this is very acute and distressing, and being seated in parts of great sensibility, and sometimes extending to membranes of a dense structure, as those composing the tympanum, and the membrane lining the mastoid cells, less severe when confined to the ceruminous glands, and the excretories: but in either case the pain attendant on inflam- mation of the ear is not always confined to the ear itself, but affects the side of the head. The general circulation is excited, attended with heat, thirst, delirium, coma, &c. The most com- mon exciting cause is cold, as the use of a cold bath when the body is heated, and persons once having suffered it are very liable to returns of it. It is occasionally also produced by other causes, as catarrh, scarlatina, cynanche maligna, and syphilitic ulcers of the throat. Hence, then, the disease is very properly divided into idiopathic, as that from cold, and symptomatic, when induced by other diseases, as those just enumerated ; this is the most dangerous TREATMENT OF IDIOPATHIC INFLAMMATION OF THE EAR. Every old woman or nurse thinks she understands this disease, and the treatment of it. Not so. Venesection sometimes is required in full habits, purges, or emetics, bathing the feet, small doses of antimonial wine and laudanum ; laudanum is useful here, as in other inflammations seated in parts of great sensibility. Dover's powder, or sp. mind, and laudanum; blisters behind the ears, or to the neck. These are very necessary and important; the application of a mustard plaster, fomentations to the side of the head. Poultices of bread and milk and laudanum, or of hops infused in vinegar and water, protecting the head at night by a flannel night cap du- ring the disease, but not afterwards, as it renders the person more liable to cold. If the pain be very severe, injections of warm milk and water will be necessary, or warm oil and laudanum may be ap- plied in drops, or by inserting a piece of cotton or wool moisten- ed with it. The common domestic remedy sometimes has a very soothing effect, as the clove of a roasted onion. In some instances much injury is done by stimulating and spirituous applications in this stage of the disease; for instead of effecting resolution they add to the excitement, and induce suppuration, if not the more ODONTITIS. 477 formidable evils, such as the destruction of the ear. or an inflamed brain. The diet, during such excitement, should be in general simple, as in the phlegmasia?. When resolution is not produced and it ends in suppuration, or purulent secretion, as soon as the inflammatory stage has subsided, stimulating injections are indicated to prevent such discharges from becoming per- petual issues or ulcers. The sulphate of zinc, as in ophthalmia, I have used with great advantage ; in obstinate cases small doses of calomel are said by Saunders to be an important remedy for this offensive disease, gr. ij. daily. Turpentine and oil equal parts, a few drops morning and evening, occasionally injecting and cleansing the ear with soap and water. General tonics are also indicated, as the bark, bitters, cold bathing, either sea-bathing or the shower bath ; washing the head and ears daily with cold water is also calculated to lessen morbid sensibility and thereby remove that liability which exists to returns of the complaint, whereas the common practice of washing the head in warm water., bathing the feet two or three times a week in warm water, adds to the sensibility of the system, which invites a return of this or other inflammatory complaints. When the disease has been of long duration, it will be useful both in the cure, as well as to guard against the evils which may arise from checking a dis- charge that the system has become accustomed to, to introduce a seton, to keep up a soreness behind the ears, or to establish a new irritation by issues in the arms. ODONTITIS, More properly than odontalgia denotes the nature of the dis- ease we contemplate under this head, for pain is only one of its symptoms. Dr. Cullen denominates it "Rheumatismus vel ar- throdynia maxillarum a carie dentium." This is a very deficient description of this disease; besides caries is but one cause of it; cold, plethora, gout, teething, also frequently induce it. Accord- ing to Wilson and Thomas, too, it is exclusively a local disease; and by Thomas it is actually so placed among his locales. It is certainly one of the phlegmasia?; for it is attended with inflamma- tion of the part, and usually with a general fever of the whole system. For the most part it comes on with pain of the part, and and some symptoms of general fever ; but also very frequently 41* 47S LECTURE XXXIX. the pain affects the whole side of the face, extends to the ear and the eye of the same side, involving the whole side of the head, the irritation following, I may say, the whole extent of the fifth pair of nerves in all its branches, to the eye, the whole of the up- per and lower jaw; and it is attended too with manifest tumor and other symptoms of active inflammation; and these are accom- panied, in many instances, with great heat, great thirst, increased action of the arterial system, and all the symptoms constituting inflammatory fever. In some instances, the inflammation of the part also, like other inflammations, ends in abscess, which is pain- ful and generally confined to the gum ; but sometimes it extends to the cheek, and discharges externally; in other instances it in- volves the membrane lining the antrum highmorianum and ends there in suppuration. Frequently it confines itself to the jaw, destroying the periostium, and producing a caries or ulcer of the bone itself, and this being connected with the external soft parts, unites them in one mass of disease, discharging the matter of the parts affected externally; this is vulgarly called (i tooth-evil." I knew a lady who, on a visit to the eastward, took cold, which she neglected as a mere tooth-ache; the consequence is a disease, which not only will disfigure her face through life, but render those parts liable to repeated attacks, whenever she may be ex- posed to cold. Can such disease then be disregarded by the prac- titioner? CAUSES. Odontitis usually is ascribed to a caries of the tooth. The nerve of a tooth that is decayed being exposed, doubtless is in condition to be easily acted upon by any exciting cause that may be applied to it; but caries of itself is rarely the exciting cause of such at- tacks of inflammation; it only acts by predisposing the parts to be excited by cold, by acrid materials, or by the alternate action of heat and cold; either by changes of the atmosphere, or by food and drinks taken either of too hot or too cold a, temperature. In such state of the parts, cold is the usual exciting cause of odonti- tis; its action too is very much dependant on the general irrita- bility of the system. Hence, females are more frequently the subjects of this disease than males, and especially those of a ner- vous temperament ; in pregnancy too, when the natural sensibility ODONTITIS. 479 of system is increased, this complaint is still of more frequent occurrence ; owing probably, in this case, to the plethora of the blood vessels, as well as greater sensibility of the nervous system and of the particular part. In some instances, however, tooth-ache and pain of the nerves of the face will occur without any previous destruction of the teeth; a fact which shows that such pain arises from pressure of the distended vessels upon the accompanying nerves. But a woman that has a carious tooth, I may say, is sure to have tooth-ache in pregnancy; for the most part even then it is removed by the lancet ; but in some cases extraction alone affords relief. I know a lady that has thus lost a tooth with every child she has borne; her teeth were carious, but they were only painful to her during her pregnancy; they were then a source of conti- nual suffering; they were the irritable part, for she experienced no breeding sickness or other evils of pregnancy; by her tooth- ache alone she knew herself to be with child. There is another affection of these nerves frequently met with that is allied to odontitis, I mean neuralgia, or tic douloureux, as it is commonly called when confined to this part, either the lower or under jaw, or the side of the face, it was called by Dr. Fothergill, a painful affection of the face, and under that appellation he describes it. (See his works. See Appendix to Thomas.) In such cases, it has been ascribed to lithiasis, or a floating gouty matter in the system, because it occurs frequently in gouty habits of body, an- other word for a full habit. Here too is another example of an imaginary virus in the system, floating about, and fastening itself upon the brain, upon the stomach, upon the face and jaws, or upon the great toe ; gout, cancer, and scrofula constitute a trio that, in the present fashionable views of pathology, disgrace our profession when we view it as a branch of science. Dr. Fothergill considered this to be the cause; but as we shall see that in gouty habits there is a combination both of sensibility and plethora, we need not have recourse to any peculiar humor to account for this disease. Indeed, I consider lithiasis, gout, and those painful affections to be frequently the produce of some causes, both predisposing and exciting ; for it is in such fulness of habit that we look for earthy or bony deposits, in the different parts of the body, and in such habits, especially when rendered irritable by free living, we also look for these nervous and inflammatory affections. It is for the same reason that such affections of the teeth and gums are the at- 480 LECTURE XXXIX. tendants on dyspepsia, and every dentist will tell you the fact that diseased teeth, the acid stomach, the foul tongue, sordes accumula- ting about the teeth, the offensive breath, are usually associated; not that the acid generated in the stomach is the immediate cause of caries of the teeth, but that the same condition of nervous system that predisposes to affections of the stomach, also renders the fifth pair of nerves liable to be acted upon by the same exciting causes of disease, as those of the stomach and its vicinity. Hence we find an early decay of the teeth connected with a general debility of constitution. In the present case cold, or rather the alternate operation of heat and cold, are the more frequent causes of odon- titis. For this reason, too, it is that we see this complaint, like other inflammatory diseases, the attendant on a variable climate; not so in the uniform temperature either of a hot or a cold cli- mate. The negroes of Africa are remarkable for their fine teeth ; so too are the inhabitants of northern countries : a Scotchman is rarely found without good teeth, and those too pretty early cut. (See Gait's Sir Andrew Wiley.) The treatment should be as in other phlegmasia^. In plethoric habits of body, and especially in pregnancy, venesection is necessary. Cathartics, salts, numerous cases of it are cured by this alone, without extraction of the tooth. This is certainly desirable, where the tooth is not much decayed; blisters in some cases necessary; warm drinks, and foot-bathing to relax the surface. With the same view, the spiritus mind, and laudanum may be occasionally administered, both to lessen pain and to remove fever ; at night, an anodyne is especially useful, for at that time the sufferings of the patient are most severe, as is usually the case in most of the phlegmasia?. The part itself should be kept warm ; fomentations of vinegar and water, or a vinegar poultice to the jaws, rinsing the mouth fre- quently with a gargle of vinegar and water, or a decoction of figs, and if suppuration threatens, in the form of a gum-boil, this is also very much facilitated by the same gargle; a poultice of bread and milk applied to the cheek will also assist in promoting suppura- tion. A prejudice exists against the use of this application, lest it induce suppuration externally: this is not well founded, if atten- tion is paid to temperature in the application. If the tooth be much decayed, as soon as the inflammation is either removed by resolution or by suppuration, whether internally or externally, extract the tooth ; in the latter case it is indispensably necessary ODONTITIS. 481 to close the wound. In the tooth evil, spirituous applications, a fold of linen, wet with rum; in some instances a projection of fun- gous flesh will require caustic daily, and rum. But extraction of a deca}^ed tooth is also useful, to prevent subsequent attacks of inflam- mation of the jaw. It is the common opinion, and well founded too, that it prevents the other teeth from becoming affected; not that caries beget caries, but that irritation is thereby kept up in the jaw, and that the other teeth, that are now sound, are liable to be- come carious by the same causes that affected the first. For this reason, the sooner a diseased tooth is removed the better ; if the tooth be not much affected, and the caries small, it will be pre- served by excluding the air and other materials from it, by plug- ging it with tin or gold foil, previously cauterising the nerve. The pain of this process is very trifling, and prevents a great deal of suffering by destroying the sensibility of the nerve. How are these affections of the teeth to be prevented ? and when once af- ected, how can we prevent the recurrence of these complaints ? Avoid the exciting cause. Avoid the habitual use of hot drinks. The practice of smoking, too, for the same reason, should be pro- scribed; for, notwithstanding the anodyne effects of tobacco, the hot air, especially from a segar, cannot fail to affect the nerves, as well as heat applied in any other manner. But if smoking must be permitted, the long Dutch pipe, or the Hooker, is less excep- tionable than the segar, as the air is less heated when it reaches the mouth. The most effectual means of guarding the jaw against these inflamatory affections are, to cleanse the mouth daily, with cold water, and the brush, and especially after eating, to prevent lodgments of acrid materials, or which may readily become so, and thus excite irritation. A variety of dentrifices are in com- , mon use, which are supposed to be useful, both in preserving the teeth, and to guard against these inflammatory affections, to which the jaw and gums are liable. Some of these are really innocent and useful; but others are positively injurious. All the mineral acids are injurious, for they very readily decompose the teeth. The salt and water recommended by Wilson, should be totally prohibited on account of the muriatic acid it contains; yet some persons are in the habit of using salt as the daily dentrifice; others again, make use of snuff. I do not know that this injures the teeth, but it certainly, in some cases, affects the nervous system, produces dyspepsia, and has led to intemperance. Charcoal is a 482 LECTURE XXXIX. common dentrifice. Where the mouth is offensive, from bad teeth, or diseased gums, it is peculiarly proper, as it counteracts the offensive breath which they occasion ; yet some dentists ob- ject to it on account of the pyroligneous acid which it contains; and they allege that by this acid it actually injures the teeth. This is certainly contrary to the experiments recently made on this subject. The best dentrifice, I believe, is that which is composed of calcareous earth, or powdered bone. Thomas recommends a composition of Bol armeniac and calcined bones or horns ; aa. 3ij. But besides cleansing the teeth of the foul materials that collect about them, it is also useful to preserve the gums in a sound and healthy state; otherwise they become of a very loose texture, and are detached from the teeth, which thence become loose in their sockets. One of the most beautiful sets of teeth I ever saw, was thus loosened. Not a single tooth was in the least affected. The lotions usually made use of to guard against these affections are, brandy and water, rum and water, with the addition of spirits of lavender, tincture of myrrh and water, or the combination, recom- mended by Thomas; viz. tinct. cort. per. gij.; tinct. myrrh, Xss. M. These things, although they may appear of inconsiderable mo- ment, merit a portion of your attention : for you will be frequently as physicians, interrogated on these points, as w T ell as called upon to cure the diseases that the neglect of them occasions. Recol- lect the reply of the celebrate 1 painter Raphael. He was once asked, by what means he had reached such perfection in his art? His reply was: " I think nothing that belongs to it beneath my attention." This reply should be recollected by every student of medicine who wishes to excel in the practice of phasic. Every subject which it presents has claims upon his attention. Inflammation of the gums, attendant on teething, may also, with propriety, be embraced under this head, and deserves our notice. The irritation arising from cutting teeth, manifests itself in various ways ; and in some instances, is attended with very serious consequences. The child usually begins at the age of about four months, to cut its teeth. In some instances, they ap- pear earlier, and in others, much later. The child first manifests this irritation, by putting the fingers in the mouth; by listlessness; the gum is swelled and thickened; it is also hot to the mother's breast; the irritation invites an increased flow of blood to the part; the heat of the mouth is increased. The child is restless, ODONTITIS. 483 heated, and feverish; starts in its sleep; the cheeks are flushed; skin generally hot and dry, especially in winter, when the per- spiration is less. On this account it probably happens, that chil- dren cut their teeth with more difficulty in winter than in summer; for perspiration, which is most abundant in the warm season, certainly obviates much of the fever attendant on teething. The stomach is disturbed by vomiting ; the matter ejected is acid and hot ; the breath frequently offensive ; the milk is thrown up fre- quently, and curdled. This disturbance of the stomach is attended with flatulence, griping in the bowels, drawing up of the lower extremities ; green evacuations ; and sometimes diarrhoea, and symptomatic dysentery ; i. e. more or less of tenesmus, and mu- cous discharges, tinged with blood. In some cases, the fever of teething is carried off by an increased secretion from the mouth; the child slavers or snivels, almost as in salivation from mercury. In this case, it is oftentimes relieved by this increased secretion. In other instances, an increased discharge, taking place from the bowels, also affords it relief — (hence the remark of Dr. McGrath, in his Scotch dialect, that the child that is teething, must slabber, purge, or die.) In some cases, too, it is relieved by an eruption appearing behind the ears. The eruptions sometimes take place in patches on the cheek, or on the arms and legs, hence called the strophulus confertus, by Dr. Willan. The eruption is so thick, that it resembles the rash in measles, tooth rash. Dr. Good erro- neously calls it the red gum — this disease is confined to the erup- tions immediately after birth — and, as in other eruptive* fevers, it sometimes proves critical. In other cases, again, the inflammation of the gums produces ulcers in the mouth: the tongue, the inside of the cheeks, and the gums are covered with small corrosive ulcers, commonly called the cankered sore mouth — the cancrum oris, as Dr. Coates calls it — and renders the breath of the child excessively offensive. Sometimes the irritation vents itself upon the glands about the jaw or the neck. They swell, and frequently proceed to suppuration. But the fever, not terminating by some of the evacuations that have been mentioned, or in the eruptions or abscesses, a determination to the brain, ending in hydrocepha- lus, is the consequence of the continuance of fever. "Hydroce- phalus interims," says Mr. Badingfield, " arises from no source of irritation more frequently than from painful and protracted den- tition." (p. 75.) This disease is, I believe, frequently thus pro- 484 LECTURE XXXIX. duced. But a still more common effect of teething is convulsions: yet common as it is, the cause is oftentimes most strangely over- looked by practitioners. TREATMENT. If the teeth are protruding, or ready to burst through the in- flamed gum, divide the gum freely. No evil can come from such division — no greater resistance to the teeth, as the French allege, from the cicatrix, for it is an established truth, that absorption more easily takes place of recently formed parts. (See Fox on the teeth 5 3d edition, p. 86, 87.) "Upon a free division of the gums we must chiefly rely for the prevention or removal of the diseases to which children are exposed by dentition. In less than two hours after the operation," says Mr. Badingfield, " I have seen the most violent symptoms diminished, and hy- drocephalus internus arrested in its progress, convulsions cease, symptomatic fever subside, and in a few days cutaneous erup- tions disappear." (Compend. of Practice, p. 75.) We thereby spare the little sufferers many distressing and painful moments. I have seen them actually gratified in the operation, as they evinced by the manner in which they submitted. In dividing the gum, too, where a dens sapiential is pressing upon it in the adult, we sometimes give it instantaneous relief. Manner of doing it. — A sharp instrument should be drawn in the direction of the tooth — feel it distinctly. The discharge of blood is also useful. But if the teeth are not so forward, a different treatment is to be pursued ; and in this nature almost points out the course to be observed. Increase the evacuations by the mouth, by the bowels, or by all combined. Magnesia and rhubarb night and morning. The advantage is to correct acidity, as well as to open the bowels ; but in case of more than ordinary costiveness, a dose of castor oil, and an ene- ma should be given ; or a dose of calomel and jalap may be ad- ministered. Afterwards procure two or three stools a day, by the use of calcined magnesia. To diminish fever, also relax the surface by warm bathing, general or partial ; antimonial wine, either to the degree of exciting full vomiting — say fifteen or twenty drops — or as a diaphoretic; gutt. x. or fifteen every two or ODONTITIS. 485 three hours. Or small doses of ipecac.; gr. i.; rhei, gr. ij. M. ; once or twice a day. Perhaps you have an aphthous ulcerated mou th — magnesia and the following detergent powder of Barnet, and loaf sugar — 1 borax, 2 sugar will be of service. But if the ul- cers appear like chancres, destroying the texture of the parts, have recourse to a solution of the sulphate of copper: gr. iv. to ^i. or gr. vi. Touch the parts frequently, say three or four times a day. A wash of yeast, water, and honey, with a lump of borax dissolved in it, also affords great relief in these painful ulcerations. But perhaps you are first called upon to see the child in convulsions. At this age, say from four months to two years, always recollect this source of irritation of the mouth, as well as in the bowels. But it is a great abuse of opiates when they are given to allay restlessness in children, without previous evacuations ; and in this case they frequently serve to beget convulsions. Recollect that convul- sions may arise from irritation from fever. Administer an opiate instantly, to suspend the irritation. The aq. ammon. gtt. v. to gtt. x. has been found useful. Warm bath sometimes — while the bath is preparing, an enema, and divide the gums. By this you remove the cause. Is the child relieved, give it a dose of purga- tive medicine. If the child habitually is liable to convulsions, as is the case sometimes, with every tooth, apply blisters behind the ears; or let the child wear a piece of tape covered with blis- tering ointment; or put some strong mustard behind the ears, or savin ointment. Like the natural sore ear, this artificial excite- ment will afford similar relief. Venesection, if of a full habit; afterwards air and exercise will generally, with an open state of the bowels, afford permanent relief. Indeed the confinement of the infant to the nursery, and the want of exercise in the open air, by the relaxation it produces, renders the child more liable to the different causes of irritation, and occasions it to suffer much more when indisposed than it otherwise would do. Sometimes it may be necessary even to administer some tonic, if the child be very much reduced. Chalybeates, gr. iv. or gr. vi. and bit- ters; elix. prop, if costive. Cold bathing is also among the best means of imparting vigour to a delicate child; for delicate children are usually the greatest sufferers from teething. 42 486 LECTURE XL PAROTIS. Ctnanche parotidcea, or as it is vulgarly called the mumps, is a contagious pyrexia which chiefly appears in an affection of the parotid gland; which gland receives its name of parotid, from its vicinity to the ear, being derived from the two Greek words jtapa, near, ov$, the ear. This disease, like other contagious dis- eases, is occasionally epidemic. For the most part it is so slight as to require little more than confinement and abstinence, with some mild cathartic, and perhaps a liniment and piece of flannel to the part affected. But in some cases it is more severe, both in its general effects upon the system, as well as in the part affected and its vicinity. It is most usually epidemic and manifestly contagious; but is universally met with as a sporadic disease attributed to cold. In some cases the general fever is severe, attended with considerable determination to the head, showing itself in delirium and other symptoms denoting an affection of the brain, and as stated by Dr. Cullen, in some cases it has proved a fatal disease. In such violent cases more active general treat- ment is called for. Again, in other cases the tumour of the part is so great as to end in abscess of the parotid gland, or terminates in a scirrhus affection of it; and occasionally the tonsils and neighbouring parts partake of the inflammation insomuch that you can scarcely determine which is the primary disease. Where either the general inflammatory fever is violent, or the local symp- toms are severe, have recourse to venesection, active purges, the volatile liniment, a blister applied over the part affected; and in young persons emetic medicines, become necessary. Afterwards MA6TITIS. 487 small doses of antimonials and other relaxing sudorifics should be continued until the violence of the disease be subdued. Leeches are advantageously employed, and blisters, as in ordinary buboes. Should the inflammation of the parotid or neighbouring parts ter- minate in abscess, notwithstanding the general and local anti- phlogostic treatment, soft poultices and other means of facilitating the secretion of pus, should be employed ; but this event is not likely to happen, if the physician does his duty in the early stage of the disease. Usually these active measures are not called for — a mild cathartic, a volatile liniment to the throat, and other parts affected, fomentations of vinegar and water, poultices of hops, with tepid drinks and the pediluvium are all that are necessary. In about four days the disease disappears. Some cathartic medicine should now be prescribed at the termination of the tumour of the parotid, and the subsidence or disappearance of the general febrile symptoms: otherwise it is not unusual for the mumps to be suc- ceeded by an affection of the breasts in women, or of the testicles in men, so peculiar is the operation of this disease upon the glan- dular system. A case is related by Hamilton, in the Edin. Trans., where the testicle subsequently was carried away, leaving the tunica vaginalis an empty bag ! Active measures are taken in the first stage, and upon the disappearance of the disease; but where purgatives are employed these sequelae are not usual. In some cases a transfer of inflammation, even to the brain, has taken place, constituting an active inflammation of that organ, and which demands all the active treatment called for in idiopathic phre- nitis.* When these additional local affections supervene, further depletion, emetics, fomentations, &c, as in the treatment of idio- pathic inflammation of these organs, must be had recourse to. MASTITIS. Inflammation of the breast and inflammation of the glands of the breast, or mamma, attended with pain, tumour, redness, and if the woman be suckling, a diminished secretion of milk, and fever of the synochal type. The term mastitis is derived from jtaj-oj, a breast. Besides the characteristic symptoms just mentioned, it * See the History of Mumps on board the ship Ardent, in Nov. 1807, by Mr. Noble, related in Edin. and Surg. Journal, July, 1808. 488 LECTURE XL. is accompanied with the usual characters of fever, viz: a chill, of sense of coldness, and followed by a stricture upon all the excre- tions, particularly of the lochia and of the milk, as well as of the skin and other secreting surfaces. As the breast contains a great deal of cellular matter, both covering it, and distributed through- out the body or glandular portion of it, there is a great tendency to suppuration; for such is the sensibility of this organ, and pecu- liarly after parturition, when such affection of the breast is of most frequent occurrence, that the current which sets to the part is very great, and the distention it produces is both very sudden and exceedingly painful. If, however, early and active measures be adopted in the commencement of the disease, resolution is also a frequent termination of the inflammation that affects this organ. Another tendency of this disease is that of scirrhus or permanent chronic obstruction of the glandular part of the breast ; but this is the more frequent occurrence late in life, and after the cessation of the menses, and oftentimes is the result of intemperance. Such obstruction, too, frequently ends in a subsequent ulceration, called cancer. But the acute disease of the breast, now more immedi- ately under our view, takes place most geuerally in women soon after parturition, and during the period of suckling. In one case I have known it to proceed to abscess before labour. It ended well, and the lady makes a good nurse. In another the abscess did not form until labour had taken place. And we may thence consider the debility and sensibility which belong to this condi- tion as in a peculiar manner predisposing to such inflammation. A sanguine temperament and plethoric habit, are also among the predisposing causes of this disease. The milk generally appears in the breast of lying-in women about the third day after de- livery, except where they are unusually full habited, and have already suckled many children; in such cases the milk appears the first day, and sometimes even a few days before labour. Not so in the first child bearing — a few days, sometimes even five elapse before the milk vessels are sufficiently developed to pour out a well formed milk. The first discharges are more of a serous nature — nevertheless it is a good practice to put the child to the breast in the first twenty-four hours after delivery, that the breast may perform its functions as soon as possible; for in the mean time, especially after the third day, it is tumid, painful, and distressing, and usually attended with fever, which is thence de- MASTITIS. 489 nominated a milk fever, or the fever attendant upon the first coming of the milk. By early application of the child to the breast and paying attention to the bowels, milk fever may often- times be prevented altogether; at least it will be rendered much more moderate, both in violence and duration. In this state, too, the local fulness of that organ predisposes to inflammation upon the least imprudence in diet, change of dress, or exposure to cold. But when the milk has flowed freely, and the breast is inordi- nately full, it is also liable to inflammation; upon the least impru- dence or neglect. Under such circumstances the usual exciting causes are, 1st. Neglect to empty the breasts. 2d. Soreness of the nipples. This is common with a first child. It may be pre- vented by washing with rum or brandy during the last month of pregnancy. When it occurs, lead water, borate of soda and brandy, or alum in brandy, may be used as lotions; and the breast should be defended by a nipple shield. 3d. Fever, the effect of cold. 4th. Costive state of the bowels. 5th. Suppression of the lochial discharge, whatever may be its character. 6th. The paroxysm of an intermittent. 7th. The premature use of ani- mal food instead of the abstemious diet necessary during the first week after parturition. 8th. The excessive use of hot drinks, spirituous and vinous drinks, gin, panadas, caudle, and those too highly spiced, are frequent exciting causes of this disease, espe- cially among the lower classes, and among the more fashionable. 9th. A heated atmosphere, closed curtains, an excessive quantity of bed clothing, and especially too much covering of the breasts themselves with flannel, and the subsequent exposure of them to the air, which is unavoidable in nursing, also frequently produce an inflamed breast. 10th. Too much company and conversation, depriving the lady of her necessary rest, and by positively excit- ing her nervous system will frequently be the cause of fever, and consequently render this very sensible and irritable organ, the seat of irritation and consequent inflammation. Under these cir- cumstances, the milk ceases to flow, the breast becomes hard and swelled, and very sensible to the touch; the whole system shows the febrile state, and the other secretions being interrupted, the whole excitement that is the result vents itself upon the breast. What is now to be done ? or rather, let us ask first, what is usually done? A most preposterous practice prevails in the sick room upon these occasions. One of the first applications usually 42* ; 490 LECTURE XL. made, is that of applying a composition of rum or brandy and pepper to the parts, the oil of mint, or perhaps a stimulating plaster with nutmegs, oil of mace, and most usually with the view to allay the pain that the poor woman suffers; and in order to counteract the chilliness and sense of coldness attendant upon the first stage of the disease, the nurse administers the usual favourite potation on these occasions. The cup of hot gin toddy, and that perhaps, rendered still more stimulating by combining with it some stimulant herb, as the tansy, mint, or rosemary. On the contrary, instead of these local and general means of adding to the excitement of the system in this disease our indication is as in the other phlegmasia^, to diminish the volume of blood flowing to the part, to relax the system, and by restoring the various excre- tions to divert the excitement from the part affected. And such is the sensibility of this important organ, and such is the sensibility of the whole frame under these circumstances, that we must be active in our means of accomplishing these objects or we may be too late; abscess, scirrhus, and sometimes sphacelus, and the total destruction of the breast may be the re- sult. In the forming stage a cathartic, a bolus of calomel, and attention in emptying the breast by the child, or by other means,* will oftentimes put a period to the inflammation ; but if the in- flammation be considerable when the physician is first called upon, other means must be resorted to, as — 1. Venesection in full ha- bits, and leeches; 2. The bowels must be relieved by salts, castor oil, calcined magnesia, or a dose of calomel and jalap; these, suc- ceeded by some of the usual diaphoretic medicines, as the anti- monial solution, sp. mind, and laudanum, antimony and calomel, aided by the moderate use of tepid drinks. When these means have been directed and the tumor and inflammation continue, blisters are also very useful and necessary in counteracting the inflammation. Dr. Smith, of Rochester, informs me he has used them with great success in preventing suppuration. This gentle- man was our pupil, and does great credit as a practitioner to the * Should the child give pain, the nurse must apply her own mouth, or glasses must be employed. Some have recourse to the application of a young pup to the breast. In this city there are nurses who make this their living ; and go about for this express purpose. One woman more celebrated than the rest, has had her teeth drawn to qualify her for this employment, and lives altogether upon breast milk. MASTITIS. 491 school in which he was educated. He was not one of your fashionables, who prefer their breakfast to a lecture. He was al- ways at his post. He now reaps the reward of his talents and his industry. * Fomentations of vinegar and water, or a soft poultice of bread and milk, or of hops and vinegar, laid lightly upon the parts, and of moderate temperature; these frequently disperse such accumulations; or in slighter cases, covering the breast with a plaster consisting of wax and oil so united that they are of soft consistency. Apply a blister if not soon relieved. The diet in this active stage of inflammation should be strictly antiphlogistic, abstaining from every possible source of excitement in this very susceptible state of the whole system; no less attention should be paid to the regimen of the patient. You must have regard to the temperature of the apartment, of the drinks, and of the local applica- tions; forbid company and conversation, light, noise, and all do- mestic business and concerns. If the tumor should not be dis- cussed but go on increasing, and symptoms of approaching sup- puration show themselves, well boiled poultices of bread and milk, with an additional quantity of ground flax-seed should be immediately applied, or a poultice of the elm bark, (ulmus fulva,) until it be dispersed, or suppuration shows itself at a particular part. An early and free opening to discharge the matter should be made up and down : why ? remember the peculiar structure of a gland; if the matter be retained the disease continues, and fre- quently ends in the destruction of the organization of the breast. This may be prevented by a free incision, and the pain is nearly * I have received the following- letter from him on this subject : "New York, January 31, 1822, " Dear Sir : — Without apology I take the liberty of calling your attention to a remedy for mastitis, which I do not recollect to have heard you mention while lecturing- on that subject; and I do it, sir, the more willingly, believing it almost a specific when applied early. I allude to blisters. The mode in which I have used them is, after general and local bleeding if required, to encircle the whole basis of the mamma with an emp. epispast. from two to two and a half inches wide, to remain until free vesication is produced. For the last four years, during which I have frequently applied it, when used early, and aided by the usual auxi- liaries, I have not seen an instance of suppuration to follow. And instead of my patients complaining of its being a cruel remedy, they represent its operation as being comparatively mild, for it speedily diminishes the pain and irritation of the organ. Respectfully yours, "A. G. SMITH." 492 LECTURE XL. the same whether the incision be large or small; poultices should be applied for a few days after opening, to diminish the inflam- mation, and to facilitate the discharge, but no violence should be made use of in effecting the discharge.* The discharge plentiful and the inflammation removed, then use plasters of wax and oil, soap cerate, or a mercurial plaster, and perhaps a dose or two of gentle purgative medicine, or a few grains of calomel and anti- mony may be occasionally administered if you suspect any thing like a chronic obstruction of the gland. It is a good rule to return gradually to a more full diet, otherwise before the local excitement subsides there is danger of renewing the inflammation, and of having more abscesses formed. But in some cases, from want of a proper and free opening of the breast, from repeated attacks of inflammation, or perhaps from the fulness and obstruc- tion that succeed to the natural cessation of the menses, or from sympathetic connexion with a diseased womb, you are called upon to prescribe for a more permanent disease of this organ; the breast is hard and unusually full, the patient complains of acute lancinating pains through the body of it, the glands of the axilla are enlarged, constituting a scirrhus or concealed cancer, or per- haps an active inflammation has been produced in it, commonly but improperly called chronic inflammation, and ulceration has been the result: in other words an open ulcer exists. In this case your only resource is the extirpation of the glandular portion of the breast — not a part of it but the whole of it, agreeably to the very important rule of Professer Richter, of Gottingen. Save the skin if possible, that is, if not diseased, but let all the glandular part of the breast be removed; the consequences otherwise are, a disease of the remainder of the gland; the inflammation created by the operation has probably too some share in producing it; besides, the pain of the operation is nearly the same whether the whole or a part be taken away, and the remainder of the breast is of no use even if not afterwards diseased. I have operated in fifteen cases. In the first I removed only the part affected. I had afterwards to remove the remainder. In all the others I took * Let me here notice in a word, another abuse of the same nature in the sick room. I mean the practice of nurses in the management of the small tumors of the breasts of new born infants. Squeezing them to discharge supposed milk, and applying rum and pepper and strengthening plasters, instead of the soft poul- tice, or wax and oil plaster. The violence of nurses generally produces abscesses. MASTITIS. 493 away the whole breast. I need not detain you with observations on the mode of operating; all this will be delivered in another department of this college by the able and practical professor of surgery. There is a great advantage in exposure of the part, to the air after the operation, lest hemorrhage prove troublesome. See my paper on the advantage of exposing wounds to the air; (Medical and Philosophical Register;) that is, immediately after the operation, to guard against the return of hemorrhage by a more permanent contraction of the vessels; the parts are then to be brought in apposition and secured by well made adhesive plasters, and a light compress of patent lint laid over the whole wound, both for the purpose of preserving a comfortable degree of warmth and to absorb any discharge that may take place from the wound. But it not unfrequently occurs that an active inflammation takes place in the part and its vicinity, producing considerable tumor, heat, and pain. In such case bathing the parts affected with weak vinegar and water, or a light simple poultice laid over the tumor will be useful; it should be thin, moist, and light; the bowels should be kept easy, and the strictest abstinence enjoined. But after a few days, say five or six, have elapsed, and the inflamma- tory symptoms have been subdued, and the same is evidenced by a discharge of serous and a mixture of sanguineous and puru- lent matter, it will be proper to remove the dressings, to bathe the parts with soap and water and rum, to renew the plasters, and the patient to return gradually to her accustomed diet. The part should be dressed daily, and to promote a healthy growth of the parts within, it will be proper to have recourse to the bark, bit- ters, or some other tonics, with the moderate use of porter, &c. Such is the practice I have pursued in a great number of cases, and with the most favourable results; but to the practice inculca- ted by Richter, that of removing all the glandular portion of the breast, I ascribe the patient's escape from all subsequent cancer- ous affections, and which, as I have before remarked, clearly shows that these affections of the mammae, do not proceed gene- rally from that vice of the constitution to which they usually are ascribed. 494 LECTURE XLI CATARRH, OR A COMMON COLD. This in itself is, for the most part, a disease comparatively of little importance, but in its consequences, if it recur frequently, or be neglected by the patient or practitioner, is of very serious import, and brings in its train other diseases, which inevitaby prove fatal. Catarrh I believe to be the parent of more consump- tions than all the other diseases collectively to which that disease has been ascribed. Gregory, of London, treats it as of too little importance, and without proper lines of demarkation between its different species. McGrath, when sent for to a patient ill of a cold, was told by the sick man that it was nothing more than a common cold ; he replied, with much good sense, " Man, what could you have worse? would you have a plague ?" He was doubtless aware of the alarming consequences to be apprehended from this cause; and indeed it may be said, with truth I believe, that colds have destroyed more than the plague. In this manner I have frequently known a neglected cold end in phthisis, and in those, too, in whom there was not the least predisposition to a pulmonary disease. Seeing, therefore, that such is frequently the termination of a common catarrh, it merits our attention. The term catarrh is derived from the Greek word aatfappc, to flow down ; *a*a signifying augmented action ; (See Good's Account of the affixes and suffixes of medical terms, in his Nosology, and in the first volume of the London Medical Society's Memoirs, 2d series.) thereby denoting the defluxion or discharges from the head and other parts, the seat of the disease. I have formerly told you that catarrh and dysentery both hold an improper place CATARRH. 495 in Dr. Cullen's Nosology. Dysentery, as I have already shown you, is not only a febrile disease, but altogether of a different cha- racter from those which belong to the profluvia. The least atten- tion, too, to the nature of the disease constituting catarrh, will also convince you that Dr. Cullen has very improperly separated that disease from the other phlegmasia?; indeed Dr. Cullen himself ad- mits, in his note, that although he has placed catarrh and dysen- tery among the profluvia, that catarrh, from the fever attending it, and the phlogistic diathesis which it exhibits, is most nearly allied to the phlegmasia?. "Catarrhus quidem pyrexia et diathesi phlogistica, phlegmasiis maxime affinis est." Definition — Pyrexia saepe contagiosa; muci ex glandulis membrana? narium,* faucium vel bronchiarum excretio acuta; saltern hujus excretionis moli- mina. This is certainly a bad definition; it exhibits nothing of the inflammatory character of the disease; in my opinion it should be defined an inflammation, not enlargement, as I have through mistake designated it in my Nosology, of the mucous membrane lining the nares, fauces, trachea, and bronchia?; attended in the be- ginning with a diminished, but terminating in an increased and morbid, excretion from these surfaces. Sometimes it affects chiefly the head, but not the throat or lungs, and produces a sharp acrid discharge from the membrane lining the nares. This form of the disease Hippocrates called coryza, thereby denoting the sharp defluxion which takes place from the head, and which defluxion he also supposed, by falling upon the other parts of the throat, fauces, &c, to. create the inflammation that affects those parts. In some instances it affects the head, producing a great sense of weight and fulness; in that case the Roman physicians gave it the name of gravedo. In some instances it affects the nose with great vio- lence, ending in ulceration ; it is then called, from the offensive character of the disease, ozena, from o^y, stench, or o£«, to stink. In other instances it fastens itself principally on the tonsils, be- ing then called cynanche tonsillaris. In others the larynx or * The membrane called Schneider's membrane ; so called from the person who first described it, and who has written six quartos on catarrhal inflammation of this membrane. He, as well as Hoffman, is disposed to extend the term catarrh to the mucous glands in general. Parr also extends it still further, considering even affections of the mucous membranes of the" bladder, intestines, urethra, &c. under the same genus, taking in all the mucous tissues of the French. 496 LECTURE XLI. trachea becomes the seat of its violence, forming cynanche laryn- gea or cynanche trachealis. In others again the surface of the lungs or bronchiae suffer most, constituting bronchitis, as Dr. Bedham calls it, which is no more nor less the peripneumonia notha of Sydenham, the catarrhus bronchialis. The old couplet limits catarrh as follows, " Si fluit ad pectus dicatur rheuma catarrhus ; Ad fauces, bronchus; ad nares esto coryza." It may be observed, that whenever it is thus confined to any one particular part, it is much more violent than when the inflamma- tion is more diffused over a greater surface of the membranes mentioned, and whatever may be the part affected, whether the head, tonsils, trachea, or bronchise, and the inflammation in that case is not always confined merely to the mucous membranes, but frequently extends to the dense membranes beneath, and to the very substance of the organ affected; the symptoms too are in all respects more violent when thus circumscribed to a part or to a particular organ, but depending also very much on the texture and importance or degree of vitality of the part thus affected. Hence, Celsus was led to remark on this subject, that this disease, when it affects the nostrils, is mild; when it falls upon the fauces, it is worse, but still worse when it attacks the lungs. " Distillat autem humor de capite interdum in nares, quod lene est; inter- dum in fauces quod pejus est ; interdum etiam in pulmonem, quod pessimum est." (Lib. iv. cap. 4.) The tendency to those differ- ent forms in which catarrhous affections invade the system, is very much governed by peculiar circumstances ; it depends on the pre- disposition derived from former attacks, whether it be in the form of hives, affection of the tonsils, or a peripneumony. The sensibility of the trachea, from time of life, and the inability in infancy to excrete or to eject the excreted matter, may lead to the former disease or croup ; for we find that disease chiefly confined to in- fancy, but not exclusively, for adults in some cases are the subjects of it ; and in some instances, says Huxham, even the famous epi- demic contagious catarrh shewed itself as a pleurisy or peripneu- mony; so various are the forms which the same disease shall as- sume, depending on peculiarities of constitution, time of life, the CATARRH. 497 sensibilities of particular parts of the body, and other circum- stances. But catarrh, as it ordinarily appears, comes on with the usual symptoms that announce phlegmasia? in general, with more or less of chilliness and other irritations of the nervous system ; and such local affections as arise from the stricture of the excre- tions of the part, the more immediate seat of the disease. Besides the sense of coldness, the person so attacked is sensible of a degree of fulness about the nose, the eyes, the forehead, and the fauces, with more or less of dryness about those parts ; this check to their secretions is also frequently attended with an unusual propensity to sneeze, and the voice too becomes changed in its tone, exhibit- ing a degree of roughness or hoarseness. With these symptoms there is also a slight irritation about the throat and trachea, and more or less cough, but which is dry, and in the commencement attended with very little pain or soreness. The eyes also manifest the irritation; their secretions are restrained, and there is a sense of stiffness in their movements, and sometimes the vessels of the adnata very early exhibit a degree of turgescence resembling in- flammation, and in a short time the whole arterial system becomes affected with all the symptoms of continued fever — but the cha- racter of this fever will be varied according to the cause produ- cing it ; whether it proceeds from cold or from contagion, and which are its two great sources. When the disease proceeds from cold, as wet feet or sudden changes in the atmosphere, the person coming from a warm room into the cold external air, or from change of clothing, cold bathing when the body has been pre- viously heated ; in that case the symptoms will be those of the synochal form of fever, the frequent pulse, the white tongue, and diminished excretions generally, a disturbed state of the natural as well as the vital functions, and all other symptoms of the phleg- masise in general ; and with these, the irritations of the parts more immediately affected are all, in proportion to the general action of the system, sensibly increased in violence; the cough becomes more frequent and severe, pain of the head is also increased, the muscles of the head, the neck, the chest, the back, and the limbs, also are more or less affected with pain, especially upon motion, not unlike the irritations from rheumatism. The secretions from the mucous membranes are also now increased, but instead of the mild bland discharges ordinarily poured out in health, they are acrid and excoriating to all the surfaces over which they flow ; 43 498 LECTURE XLI. the eyes, the cheeks, the nose, the upper lip, the pharynx, the glottis, are all scalded and sore from the sharp defluxion that attends this stage of the disease. But the stricture being taken off from the different excretory vessels, the fever abated, and the disease yielding, these dis- charges from the membranes, the more immediate seat of inflam- mation are also changed; they become more purulent, and the tone of the system being afterwards restored, they return to their natural character, both in quality and quantity. But when the disease proceeds from contagion, the character of the complaint, both general and local, is sensibly different from the pure un- mixed inflammation arising from cold. Even in its attack when from contagion the nervous system is more violently effected, the chill is more severe; delirium in some cases appears almost in the very commencement of the disease. The eyes are more excited, and sensible to light, the adnata more loaded, as in the yellow fever ? plague, &c, the pains more acute; pregnant women are disposed to miscarry and flooding is sometimes fatal. (Good, vol. ii. p. 438.) The whole sufferings of the patient are more severe; yet, at the same time the arterial system appears to be less violently affected, the pulse is less full and frequent, and oftentimes shows manifest depression very early in the disease; the tongue, too, as in other contagious diseases, is frequently moist — instead of the white and furred tongue of inflammatory catarrh. This I recollect was re- markably the case in the influenza of 1790 — 1; and the same was observed in the disease as it appeared a few years since. See Dr. Rush's remarks on the influenza. The Doctor was then full of contagion, with a regard to a great number of diseases, not only yellow fever, dysentery, but catarrh and our consumption he con- sidered of this character. In his observations on catarrh, he re- marks that other animals did not escape. And there is a peculiar tendency to the typhoid form of fever. There appears to be a peculiar poison operating upon the system in the case of conta- gious catarrh, added to the suppressed excretions; and it is re- marked, too, that the excretions from the affected surfaces are more acrid in the influenza than in common cold. It is attended too, with greater depression of all the vital powers, especially too, if the system be debilitated by the usual treatment pursued in simple inflammatory catarrh — the exhaustion in that case is fre- quently very sudden and very alarming. In the treatment of the CATARRH. 499 two forms of catarrh, the same distinctions must be observed. In the treatment of inflammatory catarrh, occasioned by cold, or by the sensible changes of the atmosphere, the whole treatment must be strictly antiphlogostic and active in proportion to the violence of the symptoms. In some cases, when the disease is diffused over the mucous membranes of the parts, eyes, fauces, throat and lungs, and the fever not very violent, it is oftentimes so mild that by confinement to the house, abstinence from customary food and stimuli, with the use of tepid drinks, bathing the feet in warm water, and perhaps some mild aperient medicine, the disease is removed without anything else being done; but when the febrile symptoms are violent, the secretions : all suppressed, general as well as local, the habit of body athletic, more active measures then become necessary. In that case venesection must be em- ployed to take off the general force of the circulation, and the determination to the inflamed parts. Emetics, active cathartics, salts, calomel and jalap, sudorifics, antimonials, crem. tart, and tart. emet. antimony, or sp. mind, with tart, antimony, Dover's powder; warm bathing, general, local, paying due attention to temperature, aided by tepid drinks, especially mucilaginous drinks ■ — barley water and raisins, with lime juice or currant jelly, flax seed and honey, toast water, rice water, common tea- — these should be taken frequently, but in small quantities. The steam of warm vinegar and water, or an infusion of hops and vinegar inhaled every two or three hours for one quarter of an hour, from a com- mon teapot, Mudge's inhaler, or from an inverted funnel. Dr. Bard's mode was inclosing a pot inside of curtains drawn around the patient. But these means are seldom called for where plenti- ful evacuations have been made from the blood vessels. It is a feeble and inert practice that has led to these expedients. But if the soreness of the throat and chest are more severe, and threaten pulmonary complaints, blisters should be had recourse to, the antimony and calomel continued, antimonial ointment, with an occasional sudorific anodyne, sp. mind. §i. laud. gtt. xxx. and through the day, the pectoral mixture as follows, to soothe the cough and irritation of the throat at the same time from its combination with antimony to preserve the relaxation of the surface. The formula is as follows: sugar, spermaceti aa 3ij.; the yolk of an egg; Golden sulphuret of antimony gr. vi. ; or tartarised antimony, gr. ij.; or antimonial wine 3ij. 500 LECTURE XLI. with from 3ij. or 3iij. to ?ss. of paregor. elix. or land. 3ss. water ^viij.; M. coch. mag. every two hours; the paregoric or anti- mony to be increased or lessened according to circumstances. Caution with regard to laudanum or opium — recollect, as Dr. Badham happily expresses it (p. 109), that if there were no other objection to opium, " it interposes a veil between the disease and the observer, and obscures the symptoms. " But in the first stage there are certainly other objections; but after evacuations have been made, and the irritation is kept up by the sensibility of parts and the acrid secretions, opiates are especially beneficial. When the irritation is not very great, the following mucilaginous mixture may be administered, with the same intention, viz: mucilag gum. arabic, gij.; tart. emet. gr. ij.; oxym. scill 5L; elix. paregor. : ; iij.,M. Another pleasant combination, J£. sacch. chrystal. vel syrup glycirr. §i. ; gum arabic £ss.; vit. antim. §ss.; elix. paregor. ^i.; aq. font rbj. coch. mag. every two hours. Another favour- ite prescription of Dr. Badham, is gr. iij. dried squills in powder; gr. i. calomel; gr. i. of digitalis, M. to be taken every night at bed time. (Badham, p. 107 ) The diet should strictly correspond with this antiphlogostic treatment — all stimulating food should be laid aside. Regimen should be strict, and tem- perature of the room should be about 65°. But in contagious catarrh, the influenza, due regard must be had to the peculiar character of the disease, its typhoid tendency* its greater violence as it regards the vital powers, the debility that ensues, the inaction or loaded state of the lungs, the serous effusion in the chest, &c. Be cautious in the use of the lancet. It was tried copiously in the influenza of 1782, but with unfavoura- ble results; also in 1790, or 1791. Be cautious also in the use of violent cathartics, otherwise you prostrate the powers of the sys- tem, which are peculiarly depressed by the poison of the disease. Emetics may be used in the forming stage with great advantage, as they of all other febrifuges, unlock the excretions. These are all important in the treatment of the disease when excited by a foreign material introduced into the system; for the same rea- son expectorants, sudorifics are also indicated, and early, both for the purpose of diminishing febrile excitement in general, and to divert the peculiar irritation of the disease from affect- ing those organs upon which it is otherwise disposed to act with violence, whether the membranes be the original seat of CATARRH. 501 the disease, or the vital organs of the system. Dover's pow- der is peculiarly useful; there is no disease in which it has been found more useful; without it the cough continues obsti- nate, and aggravates the inflammation attendant upon these affections. When the powers of the system are sensibly impaired, or the typhoid tendency begins to appear, make liberal use of the more stimulating drinks, such as at the same time that they keep the excretions open preserve the general strength, as Virginia snake-root, the Seneka snake-root, wine whey, vinegar whey, &c. Suitable diet too should be directed with the view to sup- port the strength of the patient; and in such typhoid tendency vegetable nourishments, with wine, are to be preferred. Blisters, I may remark, in this stage and form of the disease, should be cautiously applied, and should be early removed, after their stimu- lating effects for the removal of local symptoms have been ob- tained. Such are the remarks which occur to me with regard to the treatment of catarrh in these two different forms. But there is another stage of common catarrh yet to be noticed; I mean its passive stage. Thus far our observations have been confined to the treatment of the inflammatory, or first stage of catarrh. I told you that when catarrh affects the head it may leave an ozena behind it; a soreness of the nares, and perhaps involving the membrane, and possibly the bones themselves in the neighbour- hood of the ethmoid bone and the frontal sinuses, attended with a purulent discharge; and such local disease, if neglected, may last for months, to the great annoyance of the patient and his friends. How is this discharge to be restrained ? If a mere laxity of the vessels remain, or, in case of ulceration, what are the means to be employed to arrest its progress and to effect a cure? Treat as you would any other relaxed or ulcerated surface, this passive state, by stimulant applications; let the patient snuff up into his nostrils, three or four times a day, a small quantity of common rum, or rum mixed with a proportion of the tincture of myrrh, or eau de cologne, or bay-water, or the spirits of laven- der, and let the nares internally and externally be freely washed with the same; a solution of white vitriol may also be applied in the same manner, or yeast, if the parts are very offensive, may be made use of. But it more frequently occurs that after a com- mon catarrh, if it has fallen upon the bronchiae, or surface of the 43* 502 LECTURE XLI. lungs, and especially if the chest be weak, a tendency exists to pulmonary complaints, or the patient be far advanced in life, that the relaxation of the excreting vessels remains. The vessels do not recover their natural diameters and they are attended with great increase of their natural sensibility, as well as increased dis- charge; and with such discharge, which oftentimes appears of a purulent character, the whole system daily loses strength. The patient is considered as exhibiting the symptoms of confirmed pulmonary consumption; and such too it will prove if not imme- diately arrested. How is this form of the disease to be arrested or removed ? In this state of things, when you have ascertained by attention to the circulation, state of the tongue, skin, respira- tion, degree of pain on respiration, absence of hectic excerba- tions, that all local inflammation has been removed, and nothing but laxity of the vessels remains, with general debility, and per- haps slight attack of fever at night, followed by night sweats — the indication is to give tone to the system; thereby both evils, the increased sensibility of the lungs, and the increased discharge from the excretories, are removed at the same time. To fulfil this indication, immediately remove your patient from the warm air, and the confined apartment in which he has been shut up; for warm air to the relaxed lungs, like a warm poultice to an ulcer when inflammation is removed, continues the discharge, and renders it a perpetual issue. Gradually, then, let your patient be taken out into the external air; and especially combine the benefits of exercise with it — at first in a carriage, but as soon as possible, the more stimulating exercise of riding on horseback. In this form of consumption, Sydenham may indeed say it will as assuredly effect a cure as bark will remove an inter- mittent. Not so, I assert, when ulcerations and destruction of the lungs have taken place, though in some few instances they also have been healed. If possible, too, as in the treatment of hooping cough, let your patient be removed from the land to the sea air — a voyage, too, will also, in such case, frequently prove beneficial. Bitters — the bitter infusion; chamomile, anthemis nobilis — (but there may be abuse of it in the first as well as the last stage— if useful as a tonic, surely it is prejudicial when there is too much excitement already existing, as in the inflammatory stage) — horehound, marubium vulgarre; boneset, eupator. perfol; lichen islandicus, should also be combined. The mineral acids, CATARRH. 503 gtt. xv. to gtt. xxx. three times a day. The emplastrum calidum. Stimulating expectorants. Lac ammoniac — how made: take of the gum 5ij., aq. frigid, gviij., elix. paregor. 5iij. Diet. — Animal food; milk; eggs, soft boiled, raw; oysters, roast- ed; onions; garlic; mustard; mangos; porter; table-beer; ale; wine; should be made moderate use of. You cannot be too cautious, lest inflammatory symptoms be present. In that case, you easily detect it by an aggravation of all the symptoms. Regimen. — To sleep moderately covered ; temperature of the room ; flannel next the skin, to prevent a renewal of the inflam- mation. CATARRHUS SENILIS. There is another form of catarrh, to which I request your at- tention. I mean the catarrh of old age, and hence very properly denominated catarrhus senilis. But before I enter upon this sub- ject, allow me to make some preliminary observations upon the remarkable changes which the human constitution undergoes at different periods of life, and which are recognised by physiolo- gists and physicians under the appellation of climacterics. Se- condly, some introductory observations on old age, and that dis- ease of advanced life called climacteric disease; or as denominated by Sir Henry Halford, in the Med. Trans. " marasmus climac- tericus," called marasmus in reference to the waste of flesh, and diminution of bulk and strength, without any manifest cause. The human constitution undergoes, at different periods of life, various and remarkable changes, which are recognised by phy- siologists under the appellation of climacterics. These remarkable epochs the Greeks considered five in number, and from the regu- lar gradation which they exhibit in the human system, they thence denominated them climacterics, deriving the term from the term x%ifxax, signifying gradation. They considered the se- venth year as the first climacteric; the twenty-first the second; the forty-ninth the third ; the sixty-third the fourth ; and eighty- one the fifth. You perceive they are regulated by the multipli- cation of the figures 3, 7, 9 into each other, and are afterwards equalled by the multiplication of the figures 3, 7, 9, into each other. — Three times 7 = 21; seven times 7 = 49; seven times 9 __ 63; nine times 9 = 81. The two last they denominated 504 LECTURE XLI. the grand climacterics, being those in which the life of man was supposed to have consummated itself, and beyond which nothing was to be done but to make preparation for the grave. In some instances, the changes referred to have been productive of favour- able issue to the system ; but for the most part, they are in them- selves morbid, or are introductory to the formation of diseases. This is so frequently the case, that Sir Henry Halford has ac- cordingly considered them as constituting disease, which he hence calls marasmus climactericus. The same appellation has been adopted by that learned nosologist, Dr. John Mason Good. (See vol. ii. p. 721.) It is true, that in advanced life, even after those periods denominated the grand climacterics have arrived, wonder- ful and salutary changes have taken place ; a most extraordinary invigoration of the powers of the body and mind has occasionally shown itself. Persons who had lost the sense of hearing twenty years, have been known suddenly to recover it. Others have, as unexpectedly, recovered their lost vision, and were afterwards enabled to see accurately without the aid of glasses. Others, under this new impulse given to the constitution, have undergone a second dentition, and have recovered even new and entire sets of teeth, and in the place, too, of those that had been gradually lost through life. And, according to Forestus, the hair has known a similar regeneration. This last fact is less surprising, as we know the hair possesses the properties of a vegetable, as well as an animal nature, to grow, and change colour even after death. But at this advanced period of life, we more commonly see changes less favourable, and which prove injurious and destruc- tive of the powers of the constitution. At this time the strength, the spirits, the appetite, digestion, the passions, sleep, and indeed most of the functions of body and mind usually manifest declen- sion. In women it is remarked by some writers that these changes are of less frequent occurrence and less manifest than in men. So says Sir Henry Halford, who ascribes the fact to the greater exposure of men than women. This I believe, is not the true cause; another explanation occurs to me as much more satis- factory, viz: that the accumulation of blood in the female habit, by the cessation of the menses and the consequent excitement which it imparts to the system, renders women less likely to ex- perience this sudden expenditure of the powers of life. The ex- posure, however, of men to a check of the functions of the surface CATARRH. 505 of the body and their less temperate habits, I believe have con- siderable agency in the production of the diseases of old age. Among the more prominent of this class of diseases is the one now under consideration. The catarrh of old age, or catarrhus senilis. HISTORY OF THE DISEASE. 1st. With regard to the history of this disease, I remark first, that it is more especially peculiar to advanced life, and for the most part, makes its first appearance without any apparent exciting cause. 2d. It occurs with most violence in those of the nervous tem- perament; and where such sensibility exists in a remarkable de- gree, it also appears at a much earlier period of life than in those of a different temperament. 3d. It appears also with most violence and comes on earlier in those of a feeble, delicate constitution, whether naturally so, or induced by great mental exertion, by bodily labour, by intempe- rance, or by disease. The intemperate, if not cut off by more acute diseases, are sure, like Lord Ogilvie, in the play, to mani- fest this evidence of debauchery and premature old age. Recol- lect while the old gentleman was boasting of his vigour, he was interrupted by what he called his damned cough; this exposes him upon all occasions. 4th. It attacks those with most severity, who are predisposed to pulmonary complaints, or who have an irritable state of the lungs from previous attacks of disease in those organs, such as hemoptysis, catarrh, pleurisy, peripneumony, &c, induced by this predisposition, the consequence of an attack of hemoptoe in early life. It appeared early in the case of Dr Rush. In his letters written many years before his death, he speaks of his catarrhus senilis as the only exception to his enjoyment of perfect health. 5th. Debauchery also early induces this irritatable state of the lungs. A very remarkable instance of this local affection of the chest occurred a few years since in a gentleman of the city of New York — a sedentary life, chiefly spent at the card table, with loss of sleep, followed by an impaired state of the digestive or- gans produced this disease in the gentleman referred to, in a very remarkable degree, and at a much earlier period of 506 LECTURE XLI. life than otherwise would have been expected. Again, it is to be observed that there are circumstances which in a peculiar man- ner prevent the occurrence of this disease. Those of a sanguine temperament, of an athletic frame of body, a well formed chest ? whose occupations or pursuits have led them to great exertion in the open air, are frequently exempt from this evidence of age until they have arrived at a very advanced period of life. 2d. The inhabitants of a warm climate are usually exempt from this attendant upon old age. 3d. In like manner those who are in the habit of using the warm bath, usually escape these irrita- tions of the chest to a very advanced period of life. We see this exemplified in a remarkable manner, in the south of Europe, particularly among the French and Italians, and among the nations of the east. A Frenchman, accordingly, who is a sort of amphibious animal, half his time in a warm bath, is toujours gai, toujours garcon keeps his vigour to the last, burns his candle to the very socket* The first symptoms of catarrhus senilis show themselves at the approach of cold weather; and to the change of seasons the dis- ease is usually ascribed as the exciting cause, being considered as the commencement of an ordinary catarrh to which it certainly bears great resemblance; doubtless the cool weather of autumn has its agency, for in summer the disease undergoes a manifest remission. The disease also becomes first apparent in the morn- ing, when the cough is the most troublesome and dry, the expec- toration being obtained with great difficulty. The cough comes on also in paroxysms which continue many minutes, somewhat similar to the reiterated efforts in hooping-cough; at length, with great difficulty, an expectoration follows of an adhesive sharp phlegm; more or less of a similar acrid rheum takes place at the same time, from the nose and eyes, followed by a soreness which is apt to become a permanent and troublesome symptom. Probably sore eyes are so frequently associated with old age, as connected with and proceeding from a morbid state of the excretions, except where great vigour appears in the system. The skin, too, be- comes remarkably dry, and to a degree shrivelled and covered with dry scurf or dandrifF. The excretion from the bronchia? and lungs is gradually in- creased by the irritation and frequent returns of the cough; and as the body becomes enfeebled the phlegm accumulates in the CATARRH. 507 cellular part of the lungs, so as in some degree to impede the due circulation of the blood through the pulmonary vessels, and thereby to interrupt the perfect decarbonization of that fluid, analogous to the impeded circulation through the lungs, in the advanced or passive stage of peripneumony. In this manner, too, death very unexpectedly takes place, and in feeble old age, without a struggle, the interchange between the blood and the atmosphere being suddenly cut off by the interposing mass of phlegm that is accumulated. Under ordinary circumstances, a slight degree of febrile action, the attendant upon this complaint, the cheek exhibits more or less of a hectic flush; and in some cases a livid purple appearance of the face shows itself, with a correspondent quantity of circulation, and heat of the surface, especially in the palms of the hands. An accumulation of blood sometimes takes place upon the brain, producing great heat, and sense of burning. At other times there is giddiness, and sometimes coma or propensity to sleep. Captain G- — d frequently complained of a sense of burning upon the top of the head, attended with ver- tigo, both of which were increased during the paroxysms of cough- ing, and indeed were probably created by his frequent fits of coughing. The chest also, shows more or less of oppression — sometimes exhibiting an asthmatic fulness. In one instance, this appeared to be the predominant symptom. The heart, too, occa- sionally partakes of the irritation — it becomes irregular in its ac- tion, owing to the interruption in the pulmonary circulation. When these irritations of the brain, and whole system appear, there is also more or less disturbance of the digestive organs, especially loss of appetite, cardialgia, and flatulence ; and, vice versa, these latter symptoms are occasionally the means of in- ducing the catarrhal affection, and the consequent irritations of the brain that have been mentioned. But whence proceeds the disease? The remote causes have been already enumerated in the history of the disease; viz. a debili- tated habit of body, whether constitutional or acquired; the nerv- ous temperament; a variable climate ; debauchery and disease. When this catarrh appears early in life, it is generally remarked to appear as a consequence of most of the predisposing and ex- citing causes making up the foregoing enumeration. We are now led to ask the more important question, What is the proximate cause of catarrhus senilis? For upon the solution 508 LECTURE XLI. of this question depends the principle upon which the physician is to proceed in palliating or removing the disease. I have never met with a satisfactory reply to this question, or a solution of the symptoms which have been enumerated. When we keep in view the facts that have been related, as it regards the subjects of the disease; the causes which induce it; the season of the year at which it commences; the variable climate in which it is of most frequent occurrence, we are prepared to believe that the proxi- mate cause, in part, exists in a general debility of the whole sys- tem; and an increased sensibility of the lungs, in common with that of the other parts of the body, the effect of such relaxation. The result of the debility thus induced, is that the determination to the surface of the body is thereby lessened; less blood flows to the surface; an accumulation of the fluids in the head and chest is the consequence. An increased fulness, therefore, of the heart and larger vessels will necessarily affect the head and lungs, both of which manifest the irritations which are attendant upon ca- tarrhus senilis. Are not the dryness of the skin, as well as the heat and other febrile symptoms, generally met with in this state of body, thus in part accounted for? The consequence of such determination is necessarily an increased excretion from the bron- chial, and from the pulmonary vessels, terminating upon the sur- face of the lungs. I now speak of the quantity of fluids, and those operating as such mechanically. But there is another source of this peculiar irritation in the lungs, attendant upon advanced age. I refer to the quality of the circulating fluids, as well as their mechanical accumulation, and the consequent increase of the excretions from the head and chest. It is a fact well known to the physiologist, that it is the peculiar province of the skin, as well as the kidne)^s, to separate from the circulating mass of fluids various saline and earthy ma- terials. Modern chemistry has very clearly made known to us the ingredients which constitute those discharges.* These being retained by the diminished diameter, and the obstruction and de- struction of many of the extreme vessels, what follows? I an- swer, an accumulation of those ingredients in the blood, unless they may be ejected from the constitution by the other outlets ; * See Thompson, Murray, Henry, and others. See Cooper's Observ. in the Portfolio, Jan. 1818. Observations on Gout and Stone, See his last Introductory Lecture. CATARRH. 509 viz. the kidneys, the bowels, and other exhaling surfaces, includ- ing the extensive surface of the lungs. Not that there is a direct transportation of the peculiar matter that ought to be thrown off from the skin to the lungs, but an accumulation of it in the whole circulating mass. Thence more of it necessarily shows itself in those discharges passing off by the other excretions, especially where those excretions are most abundant, as the kidneys and bowels; and in old age, the lungs. But do the excretions of the kidneys also manifest this change in the properties of the urine? The reply all concur in, that they do. Hence, then, we are pre- pared to expect the great irritation of the bladder and kidneys, which is so frequently met with in old age. Hence gravel and stone appear more frequently in advanced life. Hence the acrid urine, and the painful passage of it, especially in the winter sea- son. Hence, too, arise the earthy, or bony deposits, which take place in different parts of the body in advanced life, as in the valves of the heart, in the coronary arteries, and other parts of the body, as in the pineal gland, in the membranes of the brain, and lungs, in the pericardium, &c. (See Baillie's Morbid Anato- my. ) Hence, too, arises the propensity to eruptive diseases, as erysipelas, pemphigus senilis, (Willan's Plates, &c.) and other diseases of the skin, which more or less belong to old age. But we see an exemplification of this change in the urinary ex- cretion in most persons in the winter season. Every person at- tending to these changes, and the influence of temperature upon the functions of the kidneys, must have observed the clear pellu- cid urine that is voided in the summer season, while that of the same person in winter is loaded with earthy and saline materials, doubtless owing to the suppression of the discharge of lithic mat- ter that ordinarily passes through the surface of the body. (See Wilson on Dyspepsia and Gravel. ) I might illustrate the same fact by a case which has fallen under my notice in the New York hospital, where mercury taken to a considerable extent in syphi- lis became deposited in the cells of the bones, instead of being discharged by the emunctories of the body; this was illustrated by dissection, the bone being still preserved by Dr. Porcher. An ana- logous case is related in a late English journal. Dr. Coxe ob- serves the same thing occurs in the winter of life, when the func- tion of the skin is to a certain degree suspended, at least impaired, from the obliteration of many of the small vessels of the surface, 44 510 LECTURE XLI. and the obstruction of others. The question then presents itself, can the secretions which take place upon the extensive surface of the bronchia^ and lungs be free from those acrid materials which show themselves in the other discharges of the body, and which have no longer their natural outlet ? I believe not; the peculiar- ly acrid quality of the fluids, as well as the inordinate quantity, creates the irritations attendant upon tussis senilis. The indications to be derived from this view of the sub- ject are plain. 1st. To preserve the tone of the whole system, and thereby the secretion by the extreme vessels upon the surface of the body, by which the determination to the chest is diminished; hence appears the importance of exercise, nutritious and stimulating food, especially animal food with the usual con- diments of the table, and the moderate use of wine and other stimulating drinks, especially where the person may have been habituated to the use. Wine, therefore, is not merely to be taken as St. Paul recommends it, for the stomach's sake, but for the sake of the whole system; hence, too, the importance of bitters, chalybeates, and other tonics to preserve the healthy action of the digestive organs and of the whole system. A second indication is to preserve open all the other excretions of the system, that the discharge by the surface of the lungs may not be increased; we thence also infer the importance of warm dress; flannel worn next the surface of the body, and that frequently changed, to give it all the excitement which such dress occasions; hence the use of friction by the flesh brush. Dr. Bond, senior, was so sensible of the importance of this excitement of the skin, that he was as re- gularly curried as his horse, and thereby attained to a very ad- vanced age. Hence the importance of the warm bath, both as an emollient to the surface as well as an excitement of its numerous excretories; for the same reason the bowels should be kept open, and attention paid to the kidneys. Such are the general means of preventing, and indeed of removing the evils attendant upon this disease. A third indication is to preserve the tone of the lungs themselves, and thereby to lessen the morbid sensibility to the causes, the more immediate agents in exciting the disease; but these have already been fully enumerated when speaking of chronic catarrh. 511 LECTURE XLII. CYNANCHE TRACHEALIS, OR INFLAMMATION OF THE TRACHEA The subject which next falls under our attention, trachitis, is one of great importance: it is a disease of frequent occurrence, violent and rapid in its progress, and if the necessary remedies be ne- glected, or not early employed, like laryngitis, is generally a fa- tal disease. Although this complaint has been noticed by ancient as well as by many modern writers, as you will see by consulting the aphorisms of Boerhseve, (pp. 801, 802.) yet it has never been minutely described, or the nature of the disease understood, until within a very few years. Dr. Francis Home, the late pro- fessor of the M. Medica in the University of Edinburgh, was the first who investigated the seat and pathology of this disease, and he was also the first who pointed out its proper mode of treat- ment, or rather the principles upon which the case is to be con- ducted. Dr. Cullen, in his aecount of the disease, has nearly tran- scribed Dr. Home's observations on this subject. But notwith- standing the publication of Dr. Home, physicians generally did not make themselves acquainted with this complaint. When I was in Edinburgh in 1792-3, Dr. Hamilton, though the professor of midwifery and the diseases of children, did not understand its nature, and applied both to Dr. Post and myself, for information on this subject ; for in this country it is a disease of much more fre- quent occurrence than it is in Great Britain. We both stated to him very particularly the inflammatory character of the complaint, and the benefits arising from the antiphlogistic plan of treatment; yet fj 3m his late publication, on the diseases of children, it appears fnat he has still a lesson to learn, for he disapproves of venesection, and the only medicine upon which he relies for the cure is calo- 512 LECTURE XLII. mel. In like manner, in the late standard work on the diseases of children by Underwood, you find it considered not as an inflamma- tory disease, but one of a spasmodic nature, and the cure to consist in the use of assafoetida administered in glysters. But a late pub- lication by Dr. Cheyne, contains certainly a very correct practical view of this subject, and constitutes an exception to the general accounts we meet with in British books. Dr. Thomas has made free use of Cheyne, in his chapter on this subject. In France it has been so fatal a disease, and was so little understood, that the late Emperor Buonaparte offered, some years since, a premium of 12,000 francs for the best dissertation on this subject ; but although the periodical works since have been inundated with the contents of the various papers which were presented, they most abundantly show the want of correct knowledge, either of the nature of croup, or of its mode of treatment. Even Dr. Albers, of Bremen, who has written a most able paper, and who obtained one of the prizes, does not understand the nature of the disease ; and his treatment, consequently, is inert and of little import. The names under which this disease is described by authors are various. In common language it also receives different appella- tions: In Ireland it is called chock, or stuffing; in England and Scotland, croup; but more usually in this country it receives the name of hives, a corruption of the term heaves, which is probably ao called from the heaving or violent efforts of the muscles of the chest and abdomen, which take place in this disease during the process of respiration. Croup, according to the imperfect and lame definition given of it by Dr. Cullen, in his first lines, consists " in an inflammation of the glottis, larynx, or upper part of the trachea, whether it affects the membranes of these parts or the muscles adjoining." In one particular this definition is defective, as the disease is not confined to the upper portion of the trachea, but also most usually extends itself throughout the whole of the windpipe, even into the bron- chise, and to a degree over the whole surface of the lungs. The effusion of the lymph, or other materials, constituting the mem- brane, which is the effect of this disease, also very frequently ex- tends into the bronchia?, though of a less firm texture than that part of it which is found in the upper portion of the trachea. Some preparations in the anatomical museum of Columbia college show this fact. Dr. John Augustine Smith, the late professor of CYNANCHE TRACHEALIS. 513 anatomy and surgery in this university, informed me, that in a case of croup met with by him, in which he was called upon to examine the parts after death, he observed the membrane to ex- tend as far as the bronchias could be traced by the knife. Conversing also on this subject with the late Dr. Bard, the late president of the college of physicians and surgeons of this city, and who had probably been more conversant with this disease than most practitioners, he informed me that he had commonly obser- ved in those cases which he had examined after death, that the membrane extended into the bronchia? as well as the trachea. Dr. Bard also remarks, that the disease is not even limited to the trachea and bronchia?, but that the lungs, throughout their whole substance, to a certain degree participate in the affection ; insomuch that he has seen those organs rendered so dense and solid, that they exhibited in their appearance a great resemblance to the firm and dense structure of the liver, instead of the spongy, loose texture which the lungs naturally present. The appearances upon dissection, related by Dr. Cheyne in the last edition of his valuable work on this subject, correspond with the observations made by Dr. Bard : " When the child dies after an illness of four or five days, there is found lining the windpipe a white substance, sometimes of considerable tenacity, varying in thickness, and somewhat in density. It arises at, or a little be- low the larynx, and is prolonged into the divisions of the trachea: and generally a quantity of a white fluid like purulent matter, with which they are filled, is seen working up from the lungs. The inner coat of the windpipe, to which the membrane is at- tached, is inflamed. Generally the inflammation is also discerni- ble along the whole course of the membrane of the bronchia?. A serous fluid appears to fill the cells of the interstitial substance. The lungs have a solid feel, from the interstitial effusion, the ful- ness of the blood-vessels, and the puriform fluid in the bronchial tubes. There is little or no recession of the lungs when the tho- rax is opened. There are sometimes evident marks of increased vascularity in the pleura pulmonalis. There is serous effusion in the cavity of the thorax and in the pericardium. The cavities of the heart are in general unusually full of blood." Dr. Cullen very properly observes, that croup may arise, " first in these parts, and continue to subsist in them alone, or it may come to affect these parts from the cynanche tonsillaris or malig- 44* 514 LECTURE XLII. na spreading into them." This observation was long since made by Dr. Cullen, and has been abundantly established by the cases and dissections published by Dr. Bard, whose treatise is referred to in the nosology of Dr. Cullen, under the head of cynanche maligna. (See an Inquiry into the nature, cause, and cure of the Angina Suffocativa, or Sore-throat Distemper: by Samuel Bard, M. D. Professor of Medicine in King's College, New York. New York, 8vo. 1771. See also American Philosophical Tran- sactions, vol. 1. p. 388.) Other writers, however, do not appear to have paid sufficient attention to this distinction. Some years since I was called in consultation to a case similar to those described in the valuable treatise of Dr. Bard. The dis- ease began with an inflammation of the tonsils, but was soon suc- ceeded by ulceration, attended with foetid breath and a foul ap- pearance of the parts affected. About the third day the inflam- mation extended into the trachea, producing the laborious respi- ration, and hoarse, hollow-sounding cough which characterize idiopathic croup; in twenty-four hours it proved fatal. The at- tending physician informed me, that during the first three days the child had not manifested any symptoms denoting croup; but, as in the cases recorded by Dr. Bard, they were probably induced by the inflammation and subsequent acrid secretion extending from the tonsils into the trachea. Since that time I have met with several instances of a similar nature succeeding to malignant sore-throat. Other practitioners in this city, who have had fre- quent opportunities of seeing croup, confirm the observation that this termination of cynanche maligna is not an unfrequent oc- currence. Dr. Bard informs me that since the publication of his Essay, in 1771, he has frequently observed this disease as the sequela of cynanche maligna. Two cases of croup supervening as an accessory disease in ulcerated sore-throat are also related by Dr. Ferriar in his valuable paper on that subject. "Though there were large ulcerations in the tonsils," he observes, " there was nothing uncommon in the symptoms till the inflammation extended to the trachea, when faint, shrill coughing, hissing res piration, and restlessness came on, which were soon followed by death." (See Med. Hist, and Reflec. vol. 3. p. 205.) Croup also, in some instances, is the attendant upon scarlatina. A case of this kind occurred in a child of Mr. Peter P. Goelet, of this city; in that case ulcers of the tonsils, which were attended with CYNANCHE TRACHEALIS. 515 considerable inflammation, and an acrid offensive discharge, pre- ceded the symptoms of croup: but by the use of emetic medicine the patient was relieved of these alarming symptoms, and by the use of bark and yeast, which were afterwards administered, both internally and as a gargle, completely restored. In Mr. Cheyne's treatise before referred to, a case of scarlet fever is recorded which proved fatal, in which the membrane was actually formed as in croup, and was removed after death by Dr. Rollo, surgeon of the Woolwich hospital. (See Cheyne, p. 37.) In some instances, especially where ulcerations take place in the larynx, croup also succeeds to measles. (See Cheyne, p. 39.) In a case related by Dr. Cheyne, it also succeeded to the secon- dary fever of small pox; and by Dr. Underwood it has been known as the attendant upon the putrid thrush. (See Diseases of Children, 4th edit. vol. 1. p. 333.) Croup also, says Dr. Cheyne, very often supersedes a common catarrhal affection. In a singu- lar instance, Dr. Ferriar also observes, that he has seen pneumo- nic inflammation converted into a croup on the tenth day of the disease. (Med. Hist, and Reflec. vol. 3. p. 205.) Dr. Rush re- marks, '"I have seen it accompany as well as succeed the small pox, measles, scarlet fever, and apthous sore-throat. In the late Dr. Foulke it succeeded acute rheumatism. The late Dr. Sayre informed me he had seen it occur in a case of yellow fever in the year 179S." (Med. Inq. and Obs. vol. 2. p. 376. 3d edit.) With these facts before us, therefore, there appears to be just ground for dividing this disease into two species: viz. idiopathic and symptomatic croup: idiopathic where the disease is primarily and exclusively seated in the trachea, bronchia? and surface of the lungs; symptomatic, where it is the consequence of other pre- vious diseases. It is asserted by some writers, but denied by others, that cynanche trachealis is an infectious disease. As the cynanche maligna and scarlatina are communicated by contagion or infection, doubtless they may also be so in their consequences; and in this way croup may be transferred by those diseases as the vehicle of communication. The cases related by Von Rosenstein, (see Von Rosenstein on the Diseases of Children, translated by Sparmann,) in evidence of the infectious nature of croup, were probably cases of cynanche maligna, simiiar to those described by Dr. Bard. We hence see the propriety of Dr. 516 LECTURE XLII. Cheyne's observation, that " when a physician has to visit more children than one, with a croupy affection, in a family or neigh- bourhood, he ought carefully to examine the state of the fauces." (Von Rosenstein on the Diseases of Children, p. 19.) But that idiopathic cynanche trachealis is infectious, I believe there can be no ground for supposing. I should as readily believe that an in- flammation of the brain or of the pleura should be thus commu- nicated, as an inflammation of the membrane lining the trachea; and I believe it may be safely asserted that the fact is otherwise. In the numerous families in which I have prescribed for this dis- ease, I have never known it to be thus communicated, either to the attendants upon the sick, or to other children, even though sleeping in the same room, and frequently in the same bed; but I have more than once been called in the same night to two chil- dren of the same family, both having been exposed to the same cause, and especially where there is a great predisposition to at- tacks of this disease, as is the case in particular families. It also happens that when a child has suffered one attack of croup, it becomes liable afterwards to repeated returns of the same complaint, and that too upon the application of much slighter causes than had induced the first invasion. The same observation is made of pleurisy, sore-throat, rheumatism, and most inflammatory complaints. I am credibly informed of a lady who has suffered twenty-one attacks of pleurisy. How much more susceptible of impressions is the sensible membrane lining the trachea, especially during infancy ? But happily as this sen- sibility diminishes by age, the returns of the disease become less frequent, and when children arrive at the tenth year, it is com- paratively of rare occurrence. I have never visited a child upward of twelve years of age in this complaint, except where it had suffered previous attacks of it; yet in some instances, as before remarked, adults are the sub- jects of this disease. In the winter of 1809, I was called to a lady who had lately removed to this city from the state of Vir- ginia. She went to bed in perfect health; she was awakened by coughing, attended with pain, and a sense of burning in her throat. These symptoms were soon followed by difficult, hoarse, and laboured respiration ; her husband became very much alarm- ed, and called upon me between twelve and one o'clock ; I found her in great distress, coughing almost incessantly, every inspira- CYNANCHE TRACHEALIS. 517 tion being attended with the peculiar noise of croup. Her cough was dry, accompanied with the usual deep hollow sound, that characterizes this disease in infancy. I immediately bled her freely from the arm, gave her an antimonial emetic, and applied a blister to the throat. I also left directions, that if the difficulty of breathing should continue, to take a dose of calomel and James's powder, composed of five grains each, every two hours, and to dilute freely with warm toast-water, herb-tea, or barley- water, which are the drinks I usually direct in this disease. By these means she was relieved in a few hours. I was also in like manner called upon about three years ago to another lady attack- ed in a very similar manner, and who was relieved by the same means that have been enumerated in the former case. During the year in which I resided in Virginia, in 1790 — 1, I visited, with Dr. Dick, in the neighbourhood of Alexandria, a man dying with every symptom characteristic of this disease. Dr. Mitchill, the learned professor of natural history in this univer- sity, suffered a severe attack of croup in the spring of 1801, dur- ing his attendance at Washington as a member of Congress. But there is an instance of this disease attacking the adult, which can never be forgotten, as it deprived our country and the world of one of their most illustrious citizens, George Washington, late President of the United States. Most writers have followed Dr. Home, in representing the dis- ease as more particularly confined to maritime situations; but it is now well ascertained, that although croup is of most frequent occurrence on the sea coast, where the air is loaded with moist- ure, and the changes of weather are most sensibly experienced, that it is still oftentimes met with in the interior of the country. The publications of Dr. Rush and Dr. Currie,* of Philadelphia, Dr. Stearns, of the county of Albany, in the state of New York, and Dr. Archer, of Maryland, afford evidence of this fact, for they have described the disease as it appears in places very dis- tant from the sea. Dr. Cullen observes, that it is met with in inland countries as well as on the coast. Most usually it is * Currie's View of the Diseases most prevalent in the United States of America, at different seasons of the year, with an account of the most approved method of treating them, &c. 518 LECTURE XLII. ascribed to cold as its exciting cause. It is true, it is frequently produced during the severe cold of winter; but as far as I have noted its occurrence, it appears most frequently upon the ap- proach of winter, and in the spring. I have also observed, that during severe blowing and stormy weather the cases of it are most numerous. During the summer season it is also produced by the same cause. I have frequently traced an attack of croup to the imprudent exposure of a child to the night air after a hot day, or to a stream of air to which it had been exposed in a hall or window. This disease is described by Dr. Cullen, and by most, practical writers, as consisting in an inflammation of the secreting mem- brane lining the trachea. But Dr. Millar, (Millar on Asthma and Hooping-cough,) Dr. Underwood, Mr. Field, (Edinburgh Practice of Physic, vol. i. p. 355,) and Dr. Archer, of Mary- land, describe two species of croup; one inflammatory, another, which they denominate spasmodic croup. This disease is of very frequent occurrence in this city; yet, although I have been a practitioner of medicine since 1794, and in that time have prescribed for many patients in this disease, I have never met with a single instance in which it assumed the spasmodic cha- racter described by those gentlemen, that is, unaccompanied by symptoms of local inflammation. Dr. Bard, whose practice has been more extensive than that of any other physician of this city, informs me, that from the year 1762 to the present time, he has never met with a case of croup that was not attended with symptoms of inflammation. Dr. Scott, of New Brunswick, who has practised medicine with great repu- tation in the state of New Jersey, more than fifty years, makes a similar observation. It is true that this disease attacks the patient very suddenly, and that in its commencement the affection of the throat is frequently without pain, and is attended with very little fever, even during the first two or three hours after the attack; while the cough, peculiar noise, and labour of respiration which characterize croup, are very considerable, and to the friends, ac- quainted with the nature of the disease, and apprised of its dan- gerous consequences, very alarming. Most usually, however, in those cases in which the child is old enough to express its sensa- tions, there is a sense of pricking, burning, or irritation in the windpipe, sufficient to denote the seat of the disease ; and such is CYNANCHE TRACHEALIS. 519 the sensibility of the windpipe to the impressions made upon that delicate organ, that the local affection, as in the first attack of pleurisy, is out of all proportion to the general febrile excitement of the system; for neither the pulse or heat of skin are much affected during the first two or three hours of the disease. These facts, and the sudden relief which the patient sometimes obtains from the means prescribed during the first stage of the complaint, have, perhaps, led the authors mentioned, to consider croup as, in some cases, a spasmodic disease of the windpipe; sometimes, too, especially when occurring in a delicate habit of body, the use of the common domestic remedies, viz: warm bathing and warm drinks, are sufficient, by the relaxation they induce in the system to restore the suppressed excretions, and thereby to remove the irritation from the part affected. But notwithstanding this happy termination, it does not follow that the disease is only spasmodic, and not inflammatory; for we frequently see catarrh, and some- times even incipient pleurisy, by all acknowledged to be diseases exclusively of an inflammatory nature, removed without having recourse to the more active remedies usually resorted to; but un- happily this disease generally attacks children of the most robust habit of body, and if not immediately arrested, terminates in vio- lent inflammation, accompanied with fever, which are only to be removed by the most prompt and decisive practice. In cases of this sort, to trust to the prescriptions ordinarily directed for the removal of the most violent spasmodic affections, is to do nothing; it is worse than nothing; for while the physician temporises, the child perishes. Many lives, I believe with Dr. Ferriar, " have been sacrificed to the imaginary powers of assafostida, or small repeated doses of antimonials, from unfounded theories of spas- modic constriction attending the disease. " (Med. Hist, and Re- flec. vol.lii. p. 210.) Dr. Cullen observes, that the antiphlogistic regimen is neces- sary in every stage of the disease, and that he has not found anti- spasmodic medicines of any use. It is, therefore, most safe for us to consider with Dr. Rush, that all the varieties which this dis- ease assumes, " are the effects of a difference only in its force or in its duration, " and, to continue to use the language of that ac- curate clinical observer, that " they all depend upon one remote and one proximate cause." It also fortunately happens, that the 520 LECTURE XLII. practice which is found most effectual in inflammatory croup, is is not opposed to that which would be indicated if the disease were exclusively spasmodic; on the contrary, the remedies found most useful in counteracting inflammation, are also among the most powerful antispasmodics. This leads me to add some fur- ther remarks on the TREATMENT OF CROUP. Writers upon this subject differ as widely as they do about the nature or character of the disease; but none, in my opinion, ap- pear to have sufficiently discriminated between the different stages in which the remedies they severally recommend ought to be employed; even Dr. Cheyne's late valuable work, and which contains the best pathology of this disease, is in some degree de- fective in this respect. I have been led at the bed side to distin- guish three distinct stages in croup: the first may be denominated the forming stage of the disease; in this the affection is local; the irritation has not yet extended to the whole system ; the child even sits laughing and playing upon the lap of its mother, mani- festing a very unusual but morbid degree of exhilaration; its skin is cool and moist, its pulse not perceptibly accelerated; but its hoarse, hollow sounding, and frequently returning cough, its wheezing inspiration, its restlessness, and especially its cries after a fit of coughing, all denote to the physician and parent acquaint- ed with the disease, the consequences that will soon ensue, if ac- tive means be not employed to prevent the second, or febrile stage. In this stage the whole system partakes of the irritation; the pulse is frequent, the skin hot and dry, the respiration hur- ried, the tongue covered with the usual white fur indicative of in- flammation, the lips and cheeks remarkably florid, the cough fre- quent, but attended with a more acute sound than that of the first stage; every inspiration too, is attended with more uniform wheezing than that which appears in the first, when occasionally an interval occurs in which the child breathes as if in health. But in this second stage no such interval is perceived; the tra- chea, bronchia^ and lungs become so surcharged by the circulating fluids, that the child has not even a momentary relief from its oppression; and in a short time, if left to itself, especially if the CYNANCHE TRACHEALIS. 521 patient be plethoric, the countenance exhibits a purple, livid colour, not unlike that of apoplexy, and is even attended with a degree of stupor, or propensity to sleep. This loaded state of the lungs and interruption to the free return of blood from the head I have frequently witnessed in this stage of croup: if the patient be now neglected, or the evacuations be sparing and insufficient, an effusion from the exhalent vessels opening into the windpipe, bronchise, and surface of the lungs, inevitably takes place. In the two former, the effused matter assumes a membranous ap- pearance, probably owing to the forcible passing and repassing of the air through those preternaturally constricted tubes; but in the lungs themselves it appears in the form of a viscid fluid, partly resembling both phlegm and pus. When this effusion has actu- ally taken place, the febrile symptoms sensibly abate, and some- times disappear altogether; the child is also apparently free from pain, but it suffers violent paroxysms of cough and difficult breathing, attended with an irregular and spasmodic respiration, as in asthma, or dropsy of the chest, and with similar intervals of ease. These paroxysms, in young children, continue but a few hours before dissolution. But in children arrived at eight or ten years of age, they frequently continue several days. A daughter of Gen. Morton, whom I saw in consultation, continued to strug- gle with those painful paroxysms at least four or five days after the febrile stage had terminated, and the effusion of matter, con- stituting the membrane, was supposed to have taken place. In some cases the impediment to inspiration, and the distress attend- ing the paroxysms are so great, that the only position in which the patient can respire, is with the head thrown back. In this situation the trachea is extended, and thereby its capacity in- creased, and adapted to the membrane which it encloses. In some instances before death, general convulsions ensue, which speedily terminate the sufferings of the patient. This stage, in which the membranous effusion takes place, I denominate the membranous, or purulent stage: from this advanced state of the disease recovery is so rare, that it is not to be expected; it might almost be denominated the fatal stage of croup. These distinctions it is, in my opinion, important for the practitioner to keep in view, as they lead to important conclusions in practice. They teach us, during the first or forming stage of this disease, to adopt the most active means of restoring the suppressed secre- 45 522 LECTURE XLII. tions of the trachea and surface of the lungs, and by open bowels and perspiration to guard against the general excitement of the system. For this purpose, when called to a patient labouring un- der the first symptoms, in which the disease appears to be confi- ned to the parts primarily affected, it is my practice to administer an emetic composed of tartarized antimony and ipecacuanha; to a child under two years of age, I direct from one to two grains of the emetic tartar, with from five to ten grains of ipecacuanha every fifteen minutes, until it operates to such a degree, as to induce a plentiful secretion from the trachea and lungs. It is surprising, in some instances in this disease, to see the immense quantity of viscid, ropy phlegm discharged by the operation of an active eme- tic at this period of the complaint ; but when this discharge has been accomplished, and the cough has become loose, which is an evidence of the natural secretion being restored upon the surface of the parts affected, we may, in most cases, consider the patient secure from danger. It is usual with many physicians, upon these occasions, to ad- minister large quantities of warm water to the patient, under the operation of an emetic: this practice, in my opinion, by washing the medicine out of the stomach, and diluting it, diminishes the nausea and general relaxation which it otherwise produces, and upon which its beneficial effects in a great degree depend. When the emetic has no other effect than to produce vomiting, I imme- diately direct the bowels to be emptied by the common domestic injection, and a dose of calomel from five to ten grains to be given, unless the child may be completely relieved ; for it frequently happens that an emetic alone, by restoring the excretions from the windpipe and lungs, and the other evacuations, by perspiration and stool, which it creates, affords immediate relief, especially if the physician be called early in the disease. The same result is thus noticed by Dr. Rush, in his excellent practical remarks on cynanche trachealis: " In the forming state of this disease, which may be easily known by a hoarseness, and a slight degree of stertorous cough, a puke of antimonial wine, tartar emetic, ipecacuanha, or oxymel of squills,* is for the most part an immediate cure. To be effectual, * As the operation of the squills is very much limited to the stomach, and does not produce the same general relaxing effects upon the whole system that are pro- CYNANCHE TRACHEALIS.. 523 it should operate four or five times. Happily, children are seldom injured by a little excess in the operation of this class of medicines. I have prevented the formation of this disease many hundred times, and frequently in my own family, by means of this reme- dy." (See Med. Inq. and Obs. vol. 2. p. 377. 3d edition, 1809. Philad.) But it too frequently happens, that many of the common family prescriptions are in the first instance employed, and much valua- ble time lost, before the physician is called upon ; in that case, if the febrile symptoms have already manifested themselves, other remedies are indicated. In this second stage of croup, such is the determination of the circulating fluids to the part affected, and such the general febrile excitement of the system, that the most efficient means of diminishing the plethora of the blood vessels, and of diverting the irritation from the part affected, become ne- cessary. With this view, the patient should be bled freely, in proportion to its age and powers of constitution; say, for a child under two years, from two to four ounces; from two to six years ? from four to six or eight ounces, and to be repeated as the urgen- cy of the symptoms may require. Most writers recommend the blood to be taken from the jugular veins ; as I have never, even in the youngest children, experienced any difficulty in opening a vein upon the back of the hand, and of drawing a sufficient quan- tity of blood from that part, especially after immersing the hand a. short time in warm water, I have never had occasion to open a vein in the neck; and as the child is generally very restless in this disease, and there is on this account more hazard in opening one of the jugular veins than those on the back of the hand, I have uniformly preferred the latter. It is also preferable on other accounts: it is difficult to ascertain the quantity of blood drawn from the jugular; the vein cannot be so readily closed, and the orifice is apt to open afresh by a violent fit of coughing. I con- fess I read with surprise the observation of Dr. Cheyne, that it is difficult to procure a sufficient quantity of blood from any other than the jugular vein. Dr. Ferriar makes a similar remark, " that in the case of very young children, we must almost despair, for it is extremely difficult to procure any blood from them by the duced by antimony and ipecacuanha, and having frequently been altogether disap- pointed in the emetic effects of it, I have totally abandoned the use of this medi cine in the first stages of this disease. 524 LECTURE XLII. lancet." These difficulties I have never experienced ; the vein on the back of the hand, even in children six weeks old, being always perceptible to the finger, if not to the eye. Although I am not an advocate for small bleedings in croup, let me here take occasion to express my disapprobation of the practice of some physicians, especially that recommended by the late Dr. Bayley, of this city, Dr. Ferriar, of Manchester, and Dr. Dick, of Alexandria. (See 3d Supplement to Dr. Barton's Med. and Physical Journal, for May, 1809, p. 242.) I mean that of bleeding the patient until fainting be induced. The relaxing effects of blood-letting upon the system are no doubt desirable in this complaint, and were probably the objects which the advocates of this mode of treatment had in view; but having observed, in some instances, very serious and permanent evils to the constitu- tion, occasioned by the debility which this profuse evacuation had produced, and knowing that even the most violent attacks of croup will yield to a less excessive evacuation by the lancet, when conjoined with other remedies, I have hitherto objected to this practice in the extent it has been recommended. After blood- letting generally some partial relief is immediately obtained; res- piration is less frequent; the peculiar noise of inspiration is also diminished ; the cough becomes more loose and yielding ; the skin is rendered moist, and the pulse less tense and frequent. But these favourable symptoms are oftentimes deceptive, and of short duration: the cough, laboured respiration, and heat of skin, are perhaps all renewed in the course of an hour. In that case the antimonial emetic must be immediately employed. Although the force of the disease may have been greatly subdued by blood-let- ting, the alarming symptoms so frequently return, that I am now in the constant practice of prescribing the emetic immediately after blood-letting has been performed, without waiting to ascer- tain the effects which the bleeding alone might produce ; if, how- ever, after the operation of the emetic, the symptoms still conti- nue violent, I usually repeat the bleeding, immerse the patient in a warm bath, apply a large blister to the throat, covering the la- rynx and trachea, and administer a cathartic of calomel, from five to ten grains,* repeating this medicine every two hours, until it * Such is the efficacy of calomel in the treatment of croup, that some practitioners place their chief dependence upon it in every stage of this disease, even in its most violent forms. Dr. Stearns, of this city, a physician of great reputation, and who CYNANCHE TRACHEALIS. 525 produces some sensible effect in this respect, at the same time soliciting its operation upon the bowels by injections occasionally administered. These several remedies have been employed, and having failed completely to subdue the febrile symptoms, and to divert the irri- tation from the trachea and lungs, I next direct small doses of calomel and James' powder, from two to five grains of eaeh, to be given every two hours, to a child under four years of age ; but when sufficient evacuation from the bowels may have been pro- cured, I frequently prescribe the antimonial wine, or a solution of tartar emetic, in such doses as to excite a considerable degree of nausea and relaxation; with these I occasionally blend a small portion of laudanum, where it may be indicated either in conse- quence of the profuse evacuation by the bowels, or when the cough may be very harassing to the patient, which is sometimes the case when the febrile symptoms are greatly moderated; in other respects laudanum should be administered with great cau- tion in this disease. The physician is sometimes called upon at a late period of the disease, where the means which have been described have not been employed; or if they have been, may not have succeeded, and in which the third stage of the disease has become apparent. Respiration, as in the two preceding stages, is still laborious, ac- companied with the same wheezing noise upon every inspiration; the cough also continues violent, without the least expectoration, and returns in paroxysms, in which the patient is threatened with is said to have been singularly successful in the cure of croup, prescribes it in con- nection with the cerated glass of antimony, at the same time administering a de- coction of the seneka snake-root, (polygala senega): for a child of a year old, when the disease has assumed its most alarming symptoms, he directs 20 grs. of calomel with 8 grs. of the cerated glass of antimony ; for a child of two years of age, the dose is increased to 25 or 30 grs. of calomel, with a proportionate increase of anti- mony. This combination, Dr. Stearns observes, generally operates two or three times as an emetic, and as often by stool; but if the disorder continues after the operation of this dose, he gives the decoction of seneka, and at the expiration of every eight hours repeats the dose of the calomel and antimony, until the cure is complete. In common cases he remarks that one dose is sufficient, and that he has never found it necessary to give more than four. Dr. Stearns, considering croup to arise from a torpor in the absorbents of the trachea, and not primarily an in- flammatory affection, disapproves of blood-letting, " as a very hazardous remedy, and which ought never to be prescribed in simple cases of croup." (See Coxe'ss Med. Museum, vol. 5. p. 195.) 45* 526 LECTURE XLII. immediate suffocation; the countenance exhibits a blueish livid appearance, at the same time that the patient manifests the great- est anxiety and distress ; occasionally, however, it has intervals of ease, in which its sufferings are apparently inconsiderable; but these intervals are of short duration, and afford no prospect of relief, for the effusion before mentioned, and the consequent for- mation of a membranous matter lining the trachea and bronchia, has already taken place. In this stage of the disease, it has occa- sionally happened that portions of the membrane have been thrown off by coughing, by which the patient has happily been preserved. Two cases of this kind are related by Dr. Home, (p. 53, 54,) which have induced him to hope that "art, though not in the way of internal medicine, may attempt effectuating the same end." But although nearly fifty years have elapsed since the publica- tion of Dr. Home's treatise, in which this suggestion is contained, we do not learn that in a single well authenticated case the ope- ration of opening the trachea has been successfully performed; and when we recollect what has already been stated, that the dis- ease is not limited to the trachea, that the inflammation and effu- sion of matter are spread over the greater part of the surface of the lungs, that the membrane itself frequently extends below the division of the trachea, the inference is plain, that even if the membrane alone could be detached, it would still be doubtful how far the disease would be removed by the operation. In one case, related by Dr. Home, "part of the membrane was thrown up, yet the patient died." (p. 53.) But although it were certain that the membrane was confined to the trachea alone, such must be the difficulty of detaching it from its connexion, and such the embarrassments, from the restlessness of the child, the constant movement of the larynx in respiration, the discharge of blood, &c. that must necessarily attend an operation of this sort, that I should be inclined to rest the whole hopes of relief, even in this advanced stage of the disease, upon the use of internal medicines. Calomel, in small but repeated doses, squills, the syrup of on- ions, the seneka snake-root, ammoniac, and assafoetida, and the vapour of vinegar and water, are the medicines upon which I am inclined to place most reliance at this advanced period of croup. As they are a class of remedies calculated to excite the secretion from the lungs, without impairing the general powers CYNANCHE TRACHEALIS. 527 of the system, they afford, if steadily persisted in, the best means of loosening and of ejecting the membranous matter, as well as the fluid materials effused over the surface of the lungs. The following case, related by Dr. Rush, of the good effects of calomel in the advanced stage of croup, should incite us to the diligent use of this remedy, even after the effusion of the matter constituting the membrane has been ascertained to have taken place. The doctor odserves, " I once attended a man from Vir- ginia, of the name of Bampfield, who, after an attack of this dis- ease, was much distressed with the stertorous breathing and cough, which belong to it ; I suspected both to arise from a membrane formed by inflammation in his trachea. This membrane I sup- posed to be in part detached from the trachea, from the rattling noise which attended his breathing. He had used many remedies for it to no purpose. I advised a salivation, which in less than three weeks perfectly cured him." (Med. Inq. and Obs. vol. 2. p. 380.) But these stimulant remedies, excepting calomel, the use of which, in the first stages of croup, has already been noticed, should, in my opinion, be confined to the third stage of this dis- ease. Many families of this city, and some physicians too, are in habits of prescribing the syrup of onions in all stages of croup, without discrimination. So powerful a stimulant cannot certain- ly be administered with safety where blood-letting and other means of reducing the increased excitement of the system are in- dicated. Dr. Archer, of Maryland, has rendered an important service to medicine by reviving, not introducing, (see Wood- ville Drinker's remedy,) into general use the polygala senega, as a remedy in croup. Hitherto, however, it has certainly disap- pointed the expectations of most practitioners, because, like the old woman's onions, it has been prescribed indiscriminately in every stage of the disease; whereas, for the very reason that it is so useful in exciting the vessels of the trachea and lungs to a powerful excretion of the materials oppressing them in the last .stage of croup, it is certainly a hazardous prescription when those organs are preternaturally excited, as they are both in the form-' ing and febrile stages of this disease. Lest you may not have seen Dr. Archer's treatise, I subjoin his formula for preparing and administering this medicine : he observes, " The decoction of the root is the manner in which I have ge- 528 LECTURE XLII. nerally seen it used ; the strength must be determined by the physician : it must be so strong, as to act sensibly on his own fauces, in exciting coughing, &c. Half an ounce of the root of seneka, bruised and simmered in a close vessel in half a pint of water, until reduced to four ounces, will probably in most cases be sufficiently strong. A teaspoonful of this to be given every half hour or hour, as the urgency of the symptoms may demand; and during these intervals a few drops occasionally, to keep up a sensible action of the medicine in the fauces, until it acts as an emetic or cathartic ; then repeated in small quantities, and so fre- quently, as to keep up a constant stimulus in the mouth and throat." (pp. 33, 34.) " The powder," he adds, u has lately been used in doses of four or five grains, mixed in a little water, with effects equally pleasing as the decoction." For the same reason that stimulant remedies are thus indicated, blood-letting, emetics, the warm bath, and such other medicines as relax and debilitate the system, and which were indicated dur- ing the two first stages, ought in this to be prohibited ; for in this debilitated state of the system they not only diminish the power of secretion, but of ejecting the matter secreted. If circum- stances, however, should indicate an emetic in this stage of the disease, and the decoction of seneka should prove insufficient, the sulphate of zinc or copper is certainly preferable to that of anti- mony or ipecacuanha, the former being less debilitating, while they afford all the advantage which can be obtained from the mechanical operation of vomiting, and which is all that can be desired at this advanced period of the disease ; at this time it is also necessary to sustain the strength of the patient by more nu- tritious food than is proper in the first stages ; a cup of sago, ar- row root, chicken soup, or weak wine whey, are now indicated ; but the latter should be carefully abstained from during the in- flammatory stages of this disease, when the patient should be confined to such drinks and nourishment as are least calculated to excite the system. Seeing then, that so little remains to be done in this third stage of croup, we are taught the importance of very active treatment during the first and second stages of this disease. Candour, however, obliges me to acknowledge, that in the course of my practice I have lost two patients in this complaint : the one in the month of September, 1797, a child of Mr. Nex- sen j the other, in April, 1808, a child of Mr. Herman Hen- CYNANCHE TRACHEALIS. 529 dricks of this city. Generally speaking, I consider croup in its early stage as much under the controul of the remedies which have been enumerated, as a pleurisy or any other inflammatory disease. But as Dr. Ferriar justly remarks, " if the alarming symptoms are not mitigated during the first six hours, the disease will generally prove fatal." (Med. Hist, and Reflec. vol. 3. p. 203.) 530 LECTURE XLIIL PERTUSSIS. Pertussis, or hooping-cough; or, as it is very appropriately denominated by Sauvages, tussis convulsiva. The term hooping- cough, by which it is vulgarly known, refers to the convulsive, long inspiration, or hoop which attends the fits of coughing in the advanced stage of the disease. Another name by which it is known, is chin, or kin cough, derived from the Saxon or Ger- man term "kind," a child, referring to the early age of child- hood in which the disease most generally occurs. The ancients, from its violence, called it the wild or untameable cough — by the Greeks it was called bex theria — by the Romans, tussis farina. Dr. Good, with his love of novelty as to the names of diseases, calls it bex convulsiva. So little has been known of hooping-cough among either the Greek, Roman, or Arabian writers, that we refer to Dr. Willis, who wrote in 1664, for the first accurate description of the disease. It is contained in his " Pathologia Cerebri et Nervosi Generis," cap. xii. Dr. Willis practised medicine in London, between 1650 and 1680, as a cotemporary of Sydenham — he delivered his views of this disease in the University of Oxford. But the most ample and complete description of it is said to be that published by Dr. Watt of Glasgow, in 1813, who views the disease as one of inflammation. Sauvages, judging from his practice, in which he recommends venesection and emetics, also takes this view of its inflammatory character. Huxham, too, advises the same treatment — venesec- tion, an emetic every evening, and a blister to the chest. Dissec- PERTUSSIS. 531 tions made since, by Sir Astley Cooper, also demonstrate its in- flammatory nature. (See Dawson's Nosology.) This disease, notwithstanding all that has been written upon it, is constantly to be found among the daily outlets of human life. Although the world has had a long acquaintance with this dis- ease, very little appears to have been done in lessening its violence or its malignity. The cause of this, in my opinion, has arisen from the incorrect views that have been taken of the nature and peculiar character or proximate cause of the disease. (Badingfield, p. 288.) Judging from the place which this disease holds in the system- atic arrangement- of Dr. Cullen and others, and indeed from the mode of treatment which you find directed by most practical writers, you would suppose hooping-cough to be exclusively a disease of the nervous system. Indeed, as you have already seen, Dr. Cullen places it among his spasmi, which conveys both a very inadequate and incorrect view of this disease, as we shall see by attending to its symptoms, and the means which have been found most successful in the treatment of it. Dr. Cullen defines it, "morbus contagious; tussis convulsiva strangulans, cum inspiratione sonora iterata; ssepe vomitus;" i.e. a contagious disease, attended with a convulsive strangling or suffocating cough, which is rapidly repeated or reiterated, with a sonorous inspiration or hoop, and oftentimes with vomiting. Dr. Cullen should have added, et initio cum febre synocha, or at least febricula; i. e. that in the commencement, or the first stage, it is attended with a synochal fever, at least in a moderate degree; for doubtless, during the first few days of this disease, a febrile excitement, as in common catarrh, is very manifest. No- thing is more common than for the physician to be sent for in the very commencement of hooping-cough, and to be told that the child has taken a cold. (Children are most affected, but not always. Dr. John Gregory took it from his son James, when six months old.) And only by the continuance of the complaint, and the train of symptoms which supervenes, is it known to be hoop- ing-cough. Indeed, I never did see a case of hooping-cough that was not attended, in its first stage, with more or less of the symp- toms denoting synochal and catarrhal fever, attended with a de- gree of active inflammation, and which are usually ascribed to cold; but which constitute an essential part of the character of 532 LECTURE XLIII. the disease, and should accordingly receive the attention of the physician. Dissection has frequently manifested the effects of inflammation ; sometimes in the glottis, larynx, trachea, bronchia?, lungs: the air cells filled with a purulent matter, which denotes necessarily a preceding inflammation. Serous accumulations some- times have been found in the pericardium — the effects are not confined here — tuberculated lungs, visceral obstructions, and en- larged maxillary glands, have been found to be the consequence. I have hence been induced to place pertussis among the phlegmasia?. And let me add, that by treating it as one of this class of diseases, you render it comparatively both a short and a mild disease. With the same view, I divide this complaint into two stages. In the first, or inflammatory stage, you find mostly the symptoms of common catarrh; viz. a dry cough, without any expectoration; or if any, the patient discharges a thin, sharp humour; the tongue furred, attended with thirst; a dull, watery eye; and occasion- ally, as in some other contagious diseases, with some degree of soreness; head-ache; pain of the chest; and not unfrequently a bleeding from the nose; extravasation of the vessels of the eyes, or even in some cases, hemorrhage from the lungs. At the same time the general symptoms of fever are present, as a dry and hot state of the skin, diminished excretions, and a loss of appetite or quickened circulation. These febrile symptoms are usually slight. In some cases, the disease assumes a much more violent character, and has proved fatal before it has run through the ordi- nary course; and after death, inflammation of the trachea and lungs, with effusion, have been found. Adhesions of the pleura of the lungs to that lining the ribs has also, in some instances, taken place early in this disease. Generally however they conti- nue during the first fortnight, when they abate, and give place to others, which are of much longer duration. After the inflamma- tory stage has subsided, the disease frequently continues, not only for weeks, but for several months — six or seven — and perhaps a twelvemonth. When mild, it generally lasts two or three months^ when severe, six or seven; and when it has nearly ceased, it has been revived by the slightest exposure to cold. So great is the sensibility which follows the disease when long protracted. In this second, or passive stage, the vessels of the lungs be- come relaxed, and the excretion from them very profuse. In this stage, too, the fits of coughing become more tedious, attended PERTUSSIS. 533 with a spasmodic affection of the lungs, or a painful and long con- tinued-inspiration, called hooping, or the back draught, in Scot- land. Indeed the spasms in some instances, become so severe that they amount to a general convulsion of the whole frame. In some instances, delirium is produced. This is in part to be accounted for from the increased debility, and consequent sensibility of the whole system, which are both increased by the duration of the disease, even though the original exciting cause be in a great degree expended. Habit continues the fits of coughing. But another reason is to be given for the gene- ral irritation and convulsion which attend on the fits of cough- ing that occur in the advanced stage of the disease. It is that the passage of the blood through the lungs being interrupted by coughing when long continued, the head becomes surcharged, and the brain more or less affected by congestion, in some in- stances producing convulsions; in others hemorrhage, from the nose or ears, or from the lungs themselves, which has proved fatal; and in some cases it has terminated in hydrocephalus, in an apoplexy } or perhaps in permanent blindness. Five hundred are stated to die annually of this disease, in London — in 1822, seven hundred and fifty-seven deaths are recorded in the bills of mor- tality, exceeding the deaths by small-pox. Hooping-cough, if not actively treated in the first stage, in some instances ends in a chro- nic catarrh, in asthma, or where there is the least predisposition to pulmonary complaints, phthisis pulmonalis has been the con- sequence. Contagion constitutes the exciting cause of this dis- ease. It is however, very much to be aggravated by other causes operating at the same time as cold, exercise, either of mind or body, or improper diet, either as it regards quantity or quality. These additional means of excitement should all be carefully avoided when the system may be under the irritation of this disease. In the treatment of this complaint, two indications correspond- ing with the two stages of the disease which we have pointed out, present ^themselves. 1st. To restore the secretion from the lungs, and the general excretions of the system, which are sus- pended or interrupted in the first stage of this complaint, and to moderate the excitement of the whole system. 2d. In the second stage, to give tone to the system, and thereby to counteract the 46 534 LECTURE XLIII. spasm and irritation which arise from the increased sensibility of the lungs and of the system in general. The remedies for the purpose of accomplishing the first, are, 1st. Venesection, if the inflammatory symptoms be acute, and the patient of a full habit of body. 2d. Purging. 3d. Blisters are in some instances called for. Dr. Robertson, in the January No. (1821) of the Lond. Med. Repository, states that of all the remedies he has ever employed in hooping-cough, frictions on the region of the stomach, with the tartarized antimonial oint- ment, have been the most undeviatingly useful. 4. Emetics are especially useful in this disease, and should be frequently re- peated, at least every other day, until the secretion from the lungs be completely restored; that is, until the expectorations be abun- dant and easy upon the return of the fits of coughing. In the mean time, too, small nauseating doses of the antimonial solution, or of antimonial wine, will be found useful in removing the febrile symptoms of the first stage of this disease. In this stage of the disease the sudorific anodyne, consisting of a few drops of laud, proportioned to the age of the child, and sp. mind, or antimonial wine may be given occasionally, with great benefit. Another external application of the same character, in hooping-cough, is Struve's Lotion, viz: tartarised antim. 3i-> aq. font 5ij., tinct cantharides gj. M. (See Paris.) With the same view, the drinks of the patient should be calculated to aid the secretions, and should be given frequently, and moderately warm ; he should also breathe a warm air, and frequently bathe the feet in warm water • — in a word, all the means that have been recommended in the treatment of common catarrh, should be made use of in this dis- ease until the surfaces are all relaxed, and the secretions re- stored ; for this purpose, too, the diet and regimen of the patient should be of the antiphlogistic kind during the first stage of hoop- ing-cough. Another remedy which has been lately recom- mended in this stage of hooping-cough, is a combination of lauda- num, ipecacuanha wine, and the carbonate of soda; this combi- nation was introduced by Dr. Pearson, and is said to be very efficacious in the first stage of hooping-cough, and is usually pre- scribed after an emetic has been given — it is composed as follows; Jfc. tinct. opii. gtt i. ; vin. ipecac, gtt. v. ; carbon, sod. gr. ij. ; mixed in sweetened water— to be repeated every four hours for several days. As it usually produces more or less confinement of PERTUSSIS. 535 the bowels, some mild purge, such as magnesia and rhubarb, should occasionally be given. Dr. Pearson states that he was led to the use of this alkaline prescription by the sour smell of the matter discharged in hooping-cough. (See Med. and Chir. Trans. Art. 3d. ) In the second stage of this disease, the patient is free from fever; but the fits of coughing become more severe and of a con- vulsive nature, with a very abundant secretion of phlegm, and which it is alleged by some, is remarkably acrid and irritating to the lungs. The object of the practitioner at this period of the disease is, by the use of tonics, to diminish the morbid sensibility of the lungs and of the whole system, and thereby to diminish the lax state of the excretory vessels of the lungs, and to lessen the discharge, analogous to the treatment advised in the passive stage of ulcerated surfaces, or of catarrh, or phthisis. Various re- medies are in use for this purpose. All practitioners agree in the advantage of change of air in this complaint, and especially in removing patients from inland situa- tions to the air of the sea coast. 2. In this second stage of the disease, exercise in the open air should be made use of daily, and is among the best means of restoring both the strength and appe- tite of the patient, both of which are sensibly impaired by the continuance of this complaint. 3. Stimulant and tonic medicines are also found beneficial in lessening the sensibility of the lungs to the cause of the disease, for this purpose some administer the tincture of bark, or the tinctura amara, others the tincture of can- tharides, and occasionally these combined. (See Lettson's Medical Memoirs. ) Practitioners have been led to this internal use of the cantharides by the salutary operation of blisters, particularly when they produce strangury; (the sulphate of quinine is a good substi- tute in some cases.) Some prescribe the stimulant or foetid gums, as the lac ammoniac, or myrrh; musk has been much used, but has failed often. Others again have recourse to the oil of amber, or Margreef's artificial musk, which is considered by some as very efficacious in this disease. In my opinion it has no peculiar advan- tages over any other tonic usually administered in this complaint. Margreef 's receipt is, ol. succini. (amber,) 3j. nitric acid 3iij. M. to stand two or three days well mixed; to be then well washed, and to be given dissolved m w T ater to the amount of twelve grains a day, beginning in small doses. Thomas directs it to be dissolved in alcohol, and to give it in doses of four or five gtt. three or 536 LECTURE XLIII. four times a day. But in this stage of the disease, such is the great quantity of phlegm secreted and inundating the lungs, that it is with difficulty discharged_by the ordinary efforts of expec- toration; in this case a mild emetic, and one that does not greatly debilitate the system, may be occasionally administered with great advantage; such an emetic we possess in the antipertussis, or what appears to be the same medicine, the solution of white vitriol, as directed by Dr. Moseley, and hence called Moseley's solution, as follows: sulphat zinc 3iij.; coccinell. contus. gr. iij.; aq. bullient. ibj.; sp. lavend. 3ij- M.; from a dessert to a table- spoonful to be given, and repeated in ten minutes if the first does not operate. This should be daily given while the phlegm is oppressive and in great quantity. Practitioners recommend a variety of other remedies in this disease, but without any definite object in view. Arsenic is recommended hy Dr. Simmons, of Manchester, (see Annals of Medicine, for 1797,) who states that by the use of Fowler's solution he is enabled to effect a complete cure in the course of a fortnight; but it is to be remembered, that he also makes use of venesection and emetics, which are proba- bly more useful than the arsenic. Others again make use of the acetate of lead, first recommended by Dr. Forbes, of Edinburgh, but this is certainly a hazardous prescription, especially for chil- dren. The oxide of zinc, from gr.ss. to a grain, two or three times a day, has been employed ; the nitrate of silver also, from the 12th to the 8th part of a grain has been given with benefit; the sulphate of quinine, especially where the fits return periodi- cally, is useful as well as the arsenic solution. Another valuable external application in hooping-cough is the oleum succini, mix- ed with common oil, and made more stimulating by the addition of the oil of cloves. This combination is now sold as a quack medicine, under the title of Roche's embrocation for the hoop- ing cough; it consists of olive oil §ij.; oil succin. oil earioph aa. §s. M. (See Paris Pharmacologia, vol. 2, p. 305.) I have used it with excellent effect on a sick child. In like manner Hem- lock, the cicuta, conium maculatum, has been used, and is a favour- ite remedy with Dr. Butter, giving a grain in the course of a day to infants under six months, and ten grains a day to adults, grad- ually increasing it. I have never found benefit from it. His prac- tice, and his theory of this disease, are alike to be disregarded. He places the disease in the alimentary canal ! ! He too has been tak- PERTUSSIS. 537 ing a lesson out of Broussais' book, like our New York physi- cians who consider croup a disease of the stomach, and prescribe for it the corosive sublimate — " credat Judaeus Appella, non ego." Hyosciamus, Belladonna and Digitalis have been made use of; but in the second stage of this disease such narcotic and debili- tating remedies should all be avoided; and we certainly have more efficient means of removing the more violent s)-mptoms at- tendant upon the first stage. Another means of exciting the system in the second stage of hooping-cough is by the internal and exter- nal use of various stimulants, particularly of the alliacese, viz. garlic and onions; the syrup of those articles administered inter- nally, and the ointment for external purposes, are certainly not only admissible, but are very proper in the second state of this disease; but in the first, they should be altogether avoided as too exciting to the system. Prussic acid has been lately adminis- tered with great success by Majendie, gtt. xx. gtt. xxx.; aq. font, ^iiij.; sp. lavender gtt x. M.; a dessert spoonful three times a day, gradually increase it to ^ss. three times a day. I have made great use of it, and with benefit, but caution should be observed in the use of it; be careful too to ascertain the strength of the pre- paration, and whether it is fresh made or old, or has been ex- posed to the action of light, which ehanges its qualities and thus leads to deception; fatal cases from its use have occurred in France. Fresnoi makes use of the extract of the leaves of the Rhus vernix,gr. iv. of the extract dissolved in giv. of syrup; a tablespoon- ful every three hours to a child. The diet of the patient, in the chronic stage of this disease, should consist of animal food; the moderate use of wine, porter, milk-punch, and other means of invigorating the system; while in the first stage of the disease, as in the phlegmasia in general, it should be simple and antiphlo- gistic. 46 1 53$ LECTURE XLIV. PNEUMONIA. Pneumonia is well defined by Dr. Cullen, viz: "Pyrexia, dolor in quadam thoracis parte, respiratio difficilis, tussis." The symptoms of pneumonia in general, are those of the phleg- masise, viz: 1. In its invasion, chills of irregular duration. 2. The symptoms of general febrile excitement, pulse frequent, respiration hurried, skin hot, in some cases flushed, excretions all diminished, tongue dry, generally furred, with great thirst. Its local symptoms are, pain in the chest, more especially in the part the seat of the inflammation, but attended with some pe- culiar or diagnostic symptoms, according to the texture of the particular part in which the inflammation may be seated. If seated in dense membranous parts, as the pleura, either that lining the ribs, that inclosing or dividing the lungs, or that constituting the pericardium, it will exhibit one train of symptoms, while in- flammation affecting the mucous and secreting membranes of the bronchia? and lungs will present a less violent concourse of symp- toms. So again, inflammation affecting the membrane connected with the diaphragm, will be attended with phenomena which are peculiar to that form of pneumonic inflammation ; while again, the same inflammation, if seated in the parenchymatous or cellular portion, constituting the chief substance of the lungs, which is less sensible and more yielding than the dense and comparatively inelastic membranes before mentioned, will be more insidious in its character, and will present appearances altogether opposite to those which we meet with in those that have already been referred to. Let me here remind you of the divisions or species PNEUMONIA. 539 of inflammation, as seated in different organs, viz: 1st. The loose cellular membrane and muscular fibre, and its corresponding tendency to suppuration. 2d. The mucous membrane performing excretion, and which, to a certain degree, moderates the violence of the inflammation. 3d. The inelastic dense membrane, whieh has no outlet. 4th. Parts highly organized by a plentiful supply of nerves, as the skin, stomach, intestines, uterine organs, &c. The different terminations of these varied forms of inflamma- tion, and the treatment they severally demand, according to the texture of the part and the cause that may be operating, will be fresh in your recollection. So, in like manner, we have the dif- ferent species of inflammation exemplified in the various forms of pneumonic inflammation. In pleuritis we have an example of inflammation seated in the dense membrane. In bronchitis or peripneumonia notha, we find the mucous membrane showing the less active grade of inflammation, wiiile in the cellular or parenchymatous substance of the lungs we have the tendency to purulent effusion; and in the more sensible organ, the diaphragm, we have those that point out a peculiar connexion with the brain and nervous system. Inflammation of the pleura, pericardium, and diaphragm, as con- trasted with that of peripneumony. We will at this time recount the symptoms the three first possess in common; when we come to carditis and diaphragmitis, their peculiarities will be then no- ticed. Dr. Cullen's definition is this: " Pneumonia pulsu duro dolore plerumque lateris pungente sub inspiratione praesertim acuto; decubitu in latus molesto; tussi dolentissima, initio sicca, postea humida ssepe cruenta." Pneumonic inflammation, when it affects the parts first mentioned, for the most part attacks the robust and full habited, those of a sanguine constitution, and fre- quently young children. Br. Cullen most strangely says that it rarely attacks those under the age of puberty. Pulse hard, corded, small, frequent; tongue white, furred, covered with paste and attended with great thirst. Pain acute in the part, especially upon taking a full inspi- ration there is some interruption and cough, countenance fre- quently pale, even at the attack. The extremities sometimes cool from the same cause, with even a sense of coldness. The secre- tions from the lungs and whole system diminished, the cough at- tended with an acute sound, great pain, the child cries, the cough 540 LECTURE XLIV. is dry, harsh, and frequently repeated in the same paroxysm of coughing. Position frequently in pleurisy erect Sometimes painful on one side: sometimes on the side affected, at other times the opposite; there is great variety in this respect. Again, as in the varieties I have introduced, the inflammation some- times has been observed to be seated more especially in the mediastinum, in which case the pain extends from the sternum to the back between the scapulae. As this form of pneumonic inflammation exhibits the same general symptoms, and re- quires the same treatment as in common pneumonia, it is therefore unnecessary to be solicitous about its characteristic symptoms ; not so with regard to carditis and diaphragm itis: these require more expedition, especially carditis, and some peculiar attention to the affections of the nervous system attendant upon diaphrag- mitis. I have, therefore, assigned to carditis and diaphragmitis to each a distinct generic place. And in carditis such is the great dyspnoea attending inflammation when seated in the heart, that the erect posture is the only one the patient can endure. After this enumeration of the symptoms attending pneumonic inflam- mation, we cannot commit the error of Baron Haller, by con- founding this disease with that rheumatic affection to which the muscles between the ribs are liable, called bastard pleurisy; for as I before told you, Haller believed pleurisy to have its residence in the intercostal muscles ; for the membranes of the lungs he considered to be insensible. In such rheumatic affections, attend- ed with spasm, cough, fever, &c, venesection, a purge, vol. or camphorated liniment, a blister, will generally effect a cure in a very short time. Pneumonic inflammation, left to itself, generally in a few days runs its course and proves fatal, unless the symp- toms may be moderated by the remedies that may be employed, or by the spontaneous evacuations that sometimes take place, such as hemorrhage or diarrhoea. Here again we ought surely to be surprised at the remark of Dr. Cullen, that a diarrhoea in the com- mencement of pneumonia, is not a favourable symptom ; on the contrary, like a blood-letting, it frequently affords immediate re- lief. Pneumonic inflammation has various terminations; it takes place either in resolution or in adhesion to the pleura lining the ribs, and a purulent effusion constituting empyema, in which the, matter finds its way between the ribs, and points externally. But although an adhesion will most usually take place, and the matter PNEUMONIA. 541 be circumscribed in the manner just mentioned, this is not always the case. The matter, 3dly. is in some instances effused into the cavity of the chest. Sometimes again, 4thly. the inflammation, though originally seated in the pleura, involves the cellular sub- stance of the lungs, as well as the membranes — i. e. a vomica or collection of purulent matter, is formed in the substance of the lungs themselves, as abscess takes place in other cellular mem- branes ; and if the collection be large, upon bursting, it frequently proves instantly fatal, entirely covering the surface of the lungs, and immediately suspending respiration. Sometimes fifteen or twenty days elapse before the collection bursts through the pari- etes that enclose it. But how is such vomica known to exist ? By the frequent chills, by the dyspnoea, cough without expecto- ration, a livid colour of the body, and a regularly formed hectic; two paroxysms in every twenty-four hours. If such collection be small, and the habit not scrofulous, i. e. not previously debilita- ted, and there be no peculiar predisposition from make of chest, or habit of body, to phthisis pulmonalis, it is frequently thrown off without any permanent injury to the constitution, analogous to the sudden rupture of a blood vessel in the lungs. The patient as readily recovers, as from the rupture of a blood vessel, or an ab- scess in any other part of the body, provided there be no predis- position to consumption ; so in some cases where abscess is pro- duced, it ends without permanent phthisis. (Case of Abm. Franklin's child; recovered by bark and vitriol, after such accu- mulation and discharge of matter, the result of pneumonic inflam- mation.) 5. In some instances, again, the matter may be absorbed, and the parts remain in a sort of scirrhus state, i. e. from the union of many of the cells in a solid mass, as you may see illustrated by the dissections made by Quarin, and the indurated lungs as they are described by Cleghorn. But 6. If the collection be large, and it occurs in phthisical ha- bits, it most usually ends in consumption of the lungs, attended with hectic fever, frequent chills and spasmodic affections of the chest, showing'them selves in pain, cough, difficult breathing, and general emaciation, constituting what is vulgarly called a gallop- ing consumption. 7th. In some cases a profuse discharge takes place from the sur- face of the lungs, without the destruction of the lungs themselves, 542 LECTURE XLIV. attended with comparatively little fever, but the patient, neverthe- less, gradually wasting.* In such case it frequently proves a dis- ease of long duration. But where such predisposition to phthisis does not exist, and expectoration is going on without chills or fever, as in chronic catarrh, the patient may be frequently re- lieved, especially if well managed by the physician; I mean by suitable stimulant and tonic means, but not by relaxing the patient; (remember the analogy to ulcers). It is in such state of the lungs that the Lichen Islandicus, like the horehound, has been found very beneficial, and has given credit to physicians as possessing skill in the cure of consumption. Pneumonic inflammation, too, in some cases ends in sphacelus. The lower portion of the mem- brane covering the lungs has been found adhering to the membrane lining the ribs, and some parts of it sphacelated; not merely gan- grenous, but actually sphacelated — (facile lacerabilis). But when pneumonia is seated not in the dense membranes in- closing the lungs, or lining the ribs, but the mucous membrane and cells of the lungs, its symptoms differ considerably from those enumerated. This form of inflammation has also been well charac- terised by Dr. Cullen. Read his definition of peripneumonia, (No- sologia, vol. 2. p. — .) "Pulsu non semper duro, aliquando molli, dolore thoracis obtuso; respiratione perpetuo difficile, ssepe non nisi trunco corporis erecto exarcenda; faciei tumidse colore purpuero; tussi plerumque humida, ssepe cruenta." This includes the perip- neumonia notha of Sydenham, Huxham, and Boerhave/ and the bronchitis of Dr. Badham, which is a milder form of the same dis- ease, being confined chiefly to the mucous membrane; but, by the by, sometimes more dangerous, especially when it attacks the aged. I will just remark that the discharge of blood does not very often take place in the beginning. The pulse is always soft, compared with pleuritic inflammation. Dr. Thomas makes a singular ground of distinction between what he calls true and spurious peripneumony. He says when it arises from sizy blood ob- structing the vessels of the lungs, it is called true peripneumony; but when it proceeds from a thick viscid matter producing a similar effect, it is known by the name of spurious peripneumony! What is the meaning of this language ? The truth is, the peri- * See Bedingfield, p. 97. "Pus thrown from the bronchia?, yet not the slightest vestige of an abscess in the substance of the lungs." PNEUMONIA. 543 pneumonia notha is a mere catarrhal affection confined to the bronchia? and secreting surface with little or no pain; the other involves the whole cellular substance — they are mere grades, however, of the same affection, though Dr. Badham thinks other- wise. (See Thomas, p. 136, 4th edition.) Peripneumony generally attacks those more advanced in life ; frequently the aged; not always; in some cases the young are the subjects of it ; especially where they are, from make of chest, or from some hereditary scrofulous taint, predisposed to pulmonary complaints; or in cases where a premature old age may have been induced, by intemperance, peripneumony is apt to occur, and usually proves fatal. In like manner, a previous attack, even in the young, lays the foundation of subsequent returns of the same form of pneumonic inflammation upon exposure to cold. In this disease the pulse is frequent, soft, and full; not as in pleuritis, corded ; not like the tenor string of a musical instrument, as de- scribed by Dr. Thomas. Although, in many cases, Dr. Thomas is an excellent compiler, it is plain he does not draw his distinc- tions from the bedside, in the disease now under consideration. The pain is less acute, and under the sternum, and more gene- rally diffused over the chest; not restricted to a particular spot, as in pleuritis. But the distress is sometimes very great, and attend- ed with much anxiety; the labour of respiration, and the sense of oppression in some cases, especially in the aged, is such, that the patient cannot possibly lie down or the feeling of suffocation ensues. In these cases the violent spasmodic affection of the lungs re- sembles the dyspnoea of asthma, and although occurring in old age it is only to be relieved by the means of counteracting in- flammation; in younger subjects, and in the ordinary attacks, when the patient lies down it is one of the peculiarities of this form of pneumonia that he lies upon the back, not upon the side. Dr. Kuhn observed, that he could always distinguish by pos- ture alone the form of pneumonia, whether it be a pleurisy or a peripneumony; but add to this the spasmodic wheezing in respira- tion, and the comparatively loose cough also attendant upon it; the countenance in peripneumony too is flushed, livid, purple, swelled, and manifesting from the want of that interchange be- tween the blood and the atmosphere, the expression of great 544 LECTTTRE XLIV. anxiety and solicitude; the tongue is frequently moist, or slight- ly furred, not the white fur noticed incorrectly by Thomas! the expectoration is diminished, but not as in pleurisy totally sup- pressed ; the discharge is thin and sharp ; the skin not so hot and dry as in pleurisy; the urine is even turbid, not so transparent or high coloured as in pleuritis. The disease, therefore, is more insidious; its termination too is usually different and more varied than pleurisy; true it frequently ends by resolution; and in some instances, especially in young subjects, and where the cases have been misconceived, it has ended in abscess, and that too notwith- standing the partial discharge by expectoration, that so common- ly takes place in peripneumony; in other instances again, in an effusion of blood, or by serum poured into the cavity of the chest, or in the interstitices of the cellular substance of the lungs, as was the case with Dr. Charlton, (he objected to venesection and died in twenty-four hours.) In full habits of body; and in aged persons if not immediately relieved by depletion, the symptoms of effusion may be generally looked for in three or four days; they die of hydrothorax. In others again it ends in a purulent- like mucous secretion from the surface in the form of a chronic catarrh; while in others an inflation of the lungs ensues, in which all the small vessels are overloaded, and without any or very inconsiderable discharges. In this case, if the disease be protracted it assumes the typhoid form of fever; in young subjects this event is of frequent occurrence; a new accession of symptoms now takes place, and is occasioned by a vitiated state of the habit, the consequence of long continued fever, and probably in part from the want of a due determination of the blood, which is no less essentially connected with a healthy state of the circulating fluids than it is with life itself. In this new state of things the expectoration becomes changed from its natural state; in the early stage of the disease it was thin, now it becomes glassy and more or less tinged with blood; the tongue too shows the typhoid character; it becomes brown, the lips ex- hibit more or less of a similar dark colour, the excretions are all offensive, delirium ensues, with the usual evidences of typhus. A peculiarly active treatment is now called for in this advanced stage of the disease, to secure the safety of the patient. The disease now continues depending upon constitution, from seven PNEUMONIA. 545 to twenty days. These are not the terminations usually of pneu- monia when seated in the dense membranes investing the lungs; in the last the symptoms are more acute, and end in suppuration or sphacelus, nor is that typhoid termination of peripneumony frequently met with in the aged and the full habited; there it ends by effusion in two or three days, when it proves immediately fatal, or in hydrothorax which soon proves so; or sometimes, when the attack is slight it ends in a chronic catarrh. CAUSES OF PNEUMONIA. Those predisposing to pleuritic inflammation are — 1st. The sanguine temperament and plethoric habit, in those remarkable for a vigorous state of the digestive organs; for a weak stomach liable to dyspepsia is rarely of the sanguine temperament. 2. A pre- vious attack renders the part liable to a repetition of the same disease. Hoffman prescribed for the same disease in the same person four or five times in the same season; so of hives. S. The season of the year predisposes to returns of pneumonia ; it is accordingly of frequent occurrence in wet and cold wea- ther, and less frequently met with in the summer season. In a wet and cool atmosphere, it is not unusual at any season, say the army physicians. 4. Peculiar situations, as the seaboard and islands. 5. Make of chest; hence those who are inclined to phthisis are very liable to pneumonic inflammation; so far, then, there is a hereditary predisposition in some families to pneumonic complaints. The restraints imposed upon the chest by dress, or the habit of stooping, may also be included under this head. 6. Scrofulous habits of body are said to be liable to pulmonary complaints, especially in Great Britain, where the climate, moisture and cold are combined with scrofula, to produce diseases of the chest. 7. The predisposition to peripneumony in particular, is in some cases the reverse of the former, not confined to the vigorous and the young. To the last form of pneumonic inflammation we find the aged, those of sedentary habits, and those of lax fibres combined with fulness of the vessels, peculiarly liable. In habits, too, debilitated by intemperance in the use of spirituous or fermented liquors, especially those predisposed to phthisis, peripneumonia is readily induced. 8. Those, too, who 47 546 LECTURE XLIV. are debilitated by previous affections of the windpipe are very easily acted upon by the exciting causes of pneumonic inflamma- mation. Mr. T. P. was, in infancy, frequently affected with croup; it has left great liability to pneumonic inflammation in the form of peripneumony. Probably these facts are to be accounted for by the debility which more especially shows itself in the ve- nous system of the chest, in the aged, and in the feeble, and thus produces this surcharged state of the lungs in peripneumony. The exciting causes are — 1. Those applications which are calcu- lated to diminish or check the excretions, as, (1.) Cold, exposure to cool air when coming out of a heated room ; or exposure to a stream of air; (2.) change of dress; or not adapting the dress to the vicissitudes of the weather. 2d. Acrid materials applied to the lungs, whether mechanical or chemical; as the fine dust in- haled from various employments. Hair-dressers, stone-cutters, workers in marble, scythe grinders, &c. are hence liable to pneu- monic inflammation, and consumption of the lungs. The fumes of the different acids, in like manner, produce excitement in the lungs which ends in inflammation. In like manner it has been ascribed to the noxious exhalations of Mount Vesuvius; Vivenozi, Besonius, and Bovillet, in his Memoirs on Epidemic Pleurisies, have all recorded this disease as derived from this source. (See Good, vol. 2. p. 358.) 3. Extraordinary exertions of the lungs in public speaking, especially when those exertions are made after long intervals; in that manner, pneumonia and hemoptysis are frequently induced in clergymen, by their Sunday exertions — their " pulpit sweats" — after remaining quietly in their studies during the week. In some instances, as in hypochondriacs, with their gorged aad distended viscera, from full feeding and sedentary lives, they are greatly benefited by such inordinate exertion. The gentlemen of the bar, who take more bodily exercise, and who are in^daily habits of public speaking, are by no means in a peculiar manner liable to pulmonary attacks ; on the contrary, a steady ex- ertion of the lungs is rather calculated to invigorate those organs. 4th. Bodily exercise carried to excess, as dancing, especially in a heated room, with the usual accompanying excitements of wine, beauty, &c, exposes the lungs, in some instances, to an attack of this nature, especially where they may be otherwise predisposed. PNEUMONIA. 547 CURE. The first indication after the avoidance of the remote causes, is to diminish the determination of the circulating fluids to the part affected, keeping up the irritation, the proximate cause of the inflammation, by evacuations from the blood-vessels, and by such means as will, at the same time, relax the system, and there- by restore the excretions in general. Venesection. — Formerly there was great dispute, whether the blood is to be drawn from the side affected or the opposite to that of the seat of the disease. The earlier Greeks contended for the for- mer, the Galenists and Arabians for the latter. The dispute rose so high at last that the colleges not being able to settle the point, referred it to the emperor Charles the IXth; but he, to the confu- sion of all parties, himself died of a pleurisy, before he delivered his judgment — his death being ascribed to the blood.being drawn from the wrong side. This is usually directed to be done from a large orifice. It is certainly proper that the orifice should be so large that we can take the necessary quantity of blood, to afford permanent relief; but it is not required that we should produce deliquium, except in very feeble habits, where you do not wish to draw much; for taking blood from a very large orifice, you fre- quently produce deliquium before you have taken one-third of what should be drawn. Eighteen or twenty ounces should be taken under ordinary attacks; but if the disease be a pleurisy, it is often- times necessary to draw thirty or thirty-six ounces. If the ori- fice be very large, you will not do this before you produce faint- ing; even then it will be proper to place your patient in an horizontal posture. As to the quantity to be drawn, some caution too, is to be exercised, according to time of life, and habit of body. In the athletic adult, you can scarcely take too much, or repeat it too frequently, until the pain is subdued, or the respira- tion relieved. In some infants, and one, too, at six weeks, I have been obliged to draw blood half a dozen times before they were relieved. Avoid, however, any unnecessary waste of the vital fluid. Be careful, too, not to be misled by the singular appearance of the blood drawn, for frequently this appearance is found in the advanced stage, and not in the first. There is nothing more de- ceptive. You will see this fully noticed in many authors ; as by Wilson. (See vol. ii. p. 235) — by Macbride, Manning, Rush, 548 LECTURE XLIV. Millar in his Diseases of Great Britain, and others. Bedingfield too, frequently notices the fallacy of the buffy coat as a test of inflammation. Even in phrenitis, as well as in pneumonia, he found cases of the most active inflammation, without the buffy coat. Bailly, too, in Laryngitis. * Look at the consistence of the blood, especially the quantity of coagulum; the dark colour, too, is some evidence of the quantity in the system, and that it circulates less freely through the lungs. This is the case, espe- cially in adults — in children, the blood is generally of a bright florid red colour. The circulation is more active in infancy, con- sequently it passes more rapidly through the lungs, and its carbon is disengaged in proportion to the frequency of respiration. This circumstance accounts for the very bright red colour which even the venous blood exhibits in children and in youth — especially in the hurried circulation during inflammatory diseases. I know a physician who, on drawing blood, became alarmed at the florid colour of the fluid, and its rapid flow per saltum, and concluded he had opened an artery. We must also regard the period of the disease at which we draw blood, with some attention. In the case of Counsellor Sampson, bleeding was not resorted to till the ninth day— but he was cured by it. In a patient of Dr. Dick's at Alexandria, I advised venesection on the eleventh day, and he was cured. In the case of a black man, who had been six weeks ill, and in whom the symptoms had remitted, being moderated by spontaneous discharges, or the means that had been prescribed for pneumonic inflammation, the lancet was employed with success. Dr. Cullen's fourth day, or even his fortnight, becomes then of little importance, as our guide in the use of the lancet. The best and only rule, I believe, is to bleed while there is difficulty or pain upon taking a full inspiration, or it excites coughing. 2. By cathartics. The saline are especially useful. It is a general rule to avoid emetics, especially in adults — in children they are useful — but then most beneficial after venesection and cathartics. A late practice, however, has been introduced in Italy, to treat this disease by large doses of tartarised antimony. Blisters — both in pleurisy and peripneumony. Sudorifics — antimony tart — James' powders. Use caution as to pectorals, except those consisting of antimony and calomel. Laudanum, or opiates * See Med. Trans, vol. iii. ; one of the cases had no buffy coat* PNEUMONIA. 549 in any form, should be sparingly administered, except where the cough is very troublesome, and out of all proportion to the other symptoms of inflammation; or in young children, when the phleghm is generally swallowed, and, as in hooping-cough, pro- duces griping, and sometimes diarrhoea — laudanum is then neces- sary, and may be given in combination with spiritus mind.; or the Dover's powder may be used. You may also use the general bath, warm, not cold, as Thomas recommends; and may employ foot bathing, tepid fomentations, inhaling the steam of warm water. Here, too, digitalis, perhaps, may be well resorted to. DIET Simple, and strictly corresponding with the antiphlogistic course that has been advised. Mucilaginous drinks should be taken frequently, but in small quantities, as bran tea, rice water, barley water, flax-seed tea, and those not of too great consistency — we otherwise fill the blood vessels and counteract what we have been doing by our depletion. Toast water and common tea are also proper beverages in this state of the lungs. The acid fruits in water, as weak lemonade, currant jelly and water, apple water, are also suitable drinks, except when the patient may be in the use of mercury or antimony; in that case they give pain, and in some cases, bring on an inordinate catharsis. Regimen. — Pay attention to the temperature of the drinks admin- istered; the air of the room; the baths which may be employed; the quantity of bed clothing; and avoid the stimulus of company and business. The treatment of pneumonia will also be regulated by the va- rious terminations of the disease, when we fail by the means pointed out to effect resolution. When resolution takes place, the disease frequently ends in a copious expectoration, when all stricture is removed, and the various functions are restored. But it also, in some instances, especially when a predisposition to phthisis exists, leaves an obstinate chronic cough. This is to be immediately counteracted by the means already pointed out when treating of the passive state of the lungs in chronic catarrh, viz: by exercise in the open air, by tonics, and especially by the stimulant pectorals, and suitable stimulating nourishments. This leads me to a few observations on the treatment of peripneumony. 47 550 LECTURE XLIV. 1st. As this form of inflammation occurs most generally in the aged and infirm, and in those debilitated by intemperance, it leads us to be more cautious in the use of the lancet, which some- times aggravates the oppression in the lungs by the debility in- duced. But we for the most part, have as much occasion for blood-letting in this form of pneumonia, as in pleuritic inflamma- tion, though not to the same extent. In peripneumony, too, we depend for relief upon expectoration more than in a pleurisy. In the use of cathartics therefore, we must be guarded lest we prostrate the system so much as to interfere with this discharge from the lungs. When expectoration has begun, the cathartics employed should be mild in their operation, lest they suspend that discharge which, of all others, unloads the diseased cells and vessels of the lungs, and removes the congestion. Sydenham remarked that, in the last stage of small pox, active purging inter- fered with the natural terminations of the disease. So in peri- pneumony, so also during the lochial discharge, much purging induces a check of those discharges, followed by an aggravation of the disease that may exist at the time, and in the latter case induces uterine congestion and inflammation. Our chief depend- ence in peripneumony is to restore the natural excretions, par- ticularly by the skin. With this view, small doses of calomel and James' powders, antimonial wine and laudanum, the antimo- nial solution, Dover's powders, or the sp. mind, are called for.* If the oppression is great, blisters to the chest become necessary. In- haling the steam of warm water, or of an infusion of hops, will also greatly contribute to unload the chest in this state of congestion — this, too, will be greatly aided by the frequent use of some mild diluents, taken frequently, and of a proper temperature, they act as fomentations to the bronchise and lungs, at the same time that they promote the general excretions of the system. In the young, after venesection, emetics are advantageously prescribed for the purpose of unloading the lungs of the matter oppressing them, as well as their general operation upon the sys- tem, when the inflammatory, or active stage, has been subdued, and symptoms of a chronic catarrh remain, especially in the aged; and indeed in the young sometimes great sensibility of the lungs frequently remains from weakness alone. It becomes necessary * The pectoral mixture in some cases -will be preferable. PNEUMONIA. 551 to preserve the tone of the system, and to excite the lungs and organs concerned in expectoration by the use of appropriate sti- muli. The lac ammoniac, or the myrrh, the snake-root, the horehound, bone-set, lichen, are now indicated, and when the chest is free from obstruction, bitters and other tonics, adapted to the general system, will rapidly contribute to the recovery of the patient. A more stimulant nourishment, as sago, with wine, sy- rups, and a portion of animal food, as oysters, a soft boiled egg, &c. may now be allowed, and with great advantage to the sick. In the young, peripnuemony, like pleurisy, sometimes ends in abscess or a vomica; sometimes in gangrene, by hemorrlrege, by an effusion of serum, or it ends in typhus fever. If a peripneu- mony ends in the effusion of pus, constituting a vomica, or em- pyema, it usually does so in six or seven days, exhibiting a pecu- liar train of symptoms denoting such purulent effusion, viz. fre- quent chills, a dark purple visage, and dyspnoea, especially in the horizontal posture ; but the matter may not be evacuated, that is, the abscess may not burst, in less than fifteen or twenty days. The matter, when it extends to the pleura lining the ribs, and in- volves the muscles between the ribs, forming a tumor externally, calls for an operation to discharge it; in this operation care must be taken always to cut upon the upper portion of the rib, in order to avoid wounding the artery which runs in the groove at the lower portion of the rib. In some cases the matter is discharged between the lungs and ribs into the cavity; it is then usually fatal; but when conveyed as just mentioned, externally, the patient sometimes escapes. When matter has been poured out from the diseased parts, whether in vomica, empeyma, or from the surface, whether in the cavity of the chest, or externally from the surface of the lungs, tonics and stimulants are then to be resorted to, to heal the ulcerated surfaces, or phthisis is the inevitable result The remedies have already been enumerated under the head of ulcer, and in the treatment of the passive stage of common catarrh. Again it ends in serous effusion, or hydrothorax. If symptoms of irritation still remain while such effusion is going on, the means of moderating inflammatory action must still be employed, and a diet merely sufficient to sustain the system to be directed; but when pure debility and hydrothorax follow without febrile ex- citement, accompanied too as it frequently is, with anasarca and a general leucophlegmasia, then the active use of tonics becomes 552 LECTURE XLIV. necessary; chalybeates, bitters, with the mineral acids, and astrin- gents, wine, &c. If the disease terminates in gangrene, nothing is to be done; it ends, and suddenly, in three or four days. A more common termination of peripneumony in the aged or the feeble, is in typhus, or as denominated, typhoid peripneumony; in such case the disease is frequently protracted to fifteen or twenty days continuance, depending upon the power of the con- stitution and time of life. This stage is evinced by impeded and laborious respiration; the countenance livid, with stupor, deli- rium, and in some cases with convulsions, which generally prove fatal. The cough too is dry and unyielding, and the matter ex- pectorated glassy and adhesive, and oftentimes tinged with blood. I would here, however, remark, that bloody expectoration is itself not an unfavourable symptom, for it relieves the lungs of the great congestion that exists in them. The pulse is now soft, irre- gular, and frequent; the skin dry and attended with the same pungent heat as in idiopathic typhus fever. The tongue too is brown as in typhus; and there are delirium, subsultus tendinum, shiverings,and regular exacerbations, with a hectic cheek somewhat similar to phthisis pulmonalis. The remedies indicated in this case are similar to those recommended in typhus fever and in cynanche maligna. Always too, attend to the general state of the system, and especially avoid large evacuations; among the best means to be employed are such as operate upon the excretions, viz: aristo- lochia serpentaria, the Virginia snake-root; the Poly gala senega 3ij. to gviij. of water; calomel with opium; the vol. alkali, in gr.iv. or v. in bolus, every three hours; vegetable nourish- ments, especially such as contain a large proportion of mucilage; arrow-root, sago, barley, &c. and these to be given with wine, the quantity of which is to be adjusted to the state of the system; or wine may be given in the form of wine-whey ; inhaling the steam of vinegar and water, by Mudge's inhaler, or with closed curtains. By these a favourable change is generally effected in all the secretions of the system, by the skin and the lungs, the expectoration is more natural and plentiful, and the discharge more easily promoted; the tongue cleans, the pulse fills, and be- comes less frequent, the mind and the senses are improved and restored; now too may be given tonics, such as bitters, sulphate of quinine; the mineral acids, &c. may advantageously be used. 553 LECTURE XLV. DIAPHRAGMITIS AND CARDITIS. Diaphragmitis was anciently denominated paraphrenias, from rtaga, and