CASE VII.
A young woman of eighteen years of age, a hired servant in the family of Mrs. Elizabeth Smith, had been subject to a head-ach every spring for several years. The unusually warm days which occurred in the beginning of April, 1793, produced a return of this periodical pain. On the eighth of the month, it was so severe as to confine her to her bed. I was called to visit her on the ninth. I found her comatose, and, when awake, delirious. Her pupils were unusually dilated, and insensible to the light. She was constantly sick at her stomach, and vomited frequently. Her bowels were obstinately costive, and her pulse was full, tense, and so slow as seldom to exceed, for several days, from 56 to 60 strokes in a minute. I ordered her to lose ten ounces of blood every day, for three days successively, and gave her, on each of those days, strong doses of jalap and aloes. The last blood which was drawn from her was sizy. The purges procured from three to ten discharges every day from her bowels. On the 12th, she appeared to be much better. Her pulse was less tense, and beat 80 strokes in a minute. On the 14th, she had a fainting fit. On the 15th, she sat up, and called for food. The pupils of her eyes now recovered their sensibility to light, as well as their natural size. Her head-ach left her, and, on the 17th, she appeared to be in good health. Her pulse, however, continued to beat between 50 and 60 strokes in a minute, and retained a small portion of irregular action for several days after she recovered.
I am the more disposed to pronounce the cases which have been described to have been internal dropsy of the brain, from my having never been deceived in a single case in which I have examined the brains of patients whom I have suspected to have died of it.
I could add many other cases to those which have been related, but enough, I hope, have been mentioned to establish the safety and efficacy of the remedies that have been recommended.
I believe, with Dr. Quin, that this disease is much more frequent than is commonly supposed. I can recollect many cases of anomalous fever and head-ach in children, which have excited the most distressing apprehensions of an approaching internal dropsy of the brain, but which have yielded in a few days to bleeding, or to purges and blisters. I think it probable, that some, or perhaps most of these cases, might have terminated in an effusion of water in the brain, had they been left to themselves, or not been treated with the above remedies. I believe further, that it is often prevented by all those physicians who treat the first stage of febrile diseases in children with evacuations, just as the pulmonary consumption is prevented by bleeding, and low diet, in an inflammatory catarrh.
Where blood-letting has failed of curing this disease, I am disposed to ascribe it to its being used less copiously than the disease required. If its relation to pneumonicula be the same in its cure, that I have supposed it to be in its cause, then I am persuaded, that the same excess in blood-letting is indicated in it, above what is necessary in phrenitis, that has been practised in pneumonicula, above what is necessary in the cure of an acute inflammation of the lungs. The continuance, and, in some instances, the increase of the appetite in the internal dropsy of the brain, would seem to favour this opinion no less in this disease, than in the inflammatory state of pulmonary consumption. The extreme danger from the effusion of water into the ventricles of the brain, and the certainty of death from its confinement there, is a reason likewise why more blood should be drawn in this disease, than in diseases of the same force in other parts of the body, where the products of inflammation have a prompt, or certain outlet from the body. Where the internal dropsy is obviously the effect of a fall, or of any other cause which acts directly on the brain, there can be no doubt of the safety of very plentiful bleeding; all practical writers upon surgery concur in advising it. The late Dr. Pennington favoured me with an extract from Mr. Cline's manuscript lectures upon anatomy, delivered in London in the winter of 1792, which places the advantage of blood-letting, in that species of inflammation which follows a local injury of the brain, in a very strong point of light. “I know (says he) that several practitioners object to the use of evacuations as remedies for concussions of the brain, because of the weakness of the pulse; but in these cases the pulse is depressed. Besides, experience shows, that evacuations are frequently attended with very great advantages. I remember a remarkable case of a man in this [St. Thomas's] hospital, who was under the care of Mr. Baker. He lay in a comatose state for three weeks after an injury of the head. During that time he was bled twenty times, that is to say, he was bled once every day upon an average. He was bled twice a day plentifully, but towards the conclusion he was bled more sparingly, and only every other day; but at each bleeding, there were taken, upon an average, about sixteen ounces of blood. In consequence of this treatment, the man perfectly recovered his health and reason.”
Local bleeding by cups, leaches, scarifications, or arteriotomy, should be combined with venesection, or preferred to it, where the whole arterial system does not sympathize with the disease in the brain.
II. A second remedy to be used in the second stage of this disease is purges. I have constantly observed all the patients whose cases have been related, to be relieved by plentiful and repeated evacuations from the bowels. I was led to the use of frequent purges, by having long observed their good effects in palsies, and other cases of congestion in the brain, where blood-letting was unsafe, and where it had been used without benefit. In the Leipsic Commentaries[56], there is an account of a case of internal dropsy of the brain, which followed the measles, being cured by no other medicines than purges and diuretics. I can say nothing in favour of the latter remedy, in this disease, from my own experience. The foxglove has been used in this city by several respectable practitioners, but, I believe, in no instance with any advantage.
III. Blisters have been uniformly recommended by all practical writers upon this disease. I have applied them to the head, neck, and temples, and generally with obvious relief to the pain in the head. They should be omitted in no stage of the disease; for even in its inflammatory stage, the discharge they occasion from the vessels of the head, greatly overbalances their stimulating effects upon the whole system.
IV. Mercury was long considered as the only remedy, which gave the least chance of a recovery from a dropsy of the brain. Out of all the cases in which I gave it, before the year 1790, I succeeded in but two: one of them was a child of three years old, the other was a young woman of twenty-six years of age. I am the more convinced that the latter case was internal dropsy of the brain, from my patient having relapsed, and died between two or three years afterwards, of the same disease. Since I have adopted the depleting remedies which have been mentioned, I have declined giving mercury altogether, except when combined with some purging medicine, and I have given it in this form chiefly with a view of dislodging worms. My reasons for not giving it as a sialagogue are the uncertainty of its operation, its frequent inefficacy when it excites a salivation, and, above all, its disposition to produce gangrene in the tender jaws of children. Seven instances of its inducing death from that cause, in children between three and eight years of age, and with circumstances of uncommon distress, have occurred in Philadelphia since the year 1795.
V. Linen cloths, wetted with cold vinegar, or water, and applied to the forehead, contribute very much to relieve the pain in the head. In the case of Mr. Cypher's son[57], the solution of ice in the vinegar appeared to afford the most obvious relief of this distressing symptom.
A puncture in the brain has been proposed by some writers to discharge the water from its ventricles. If the theory I have delivered be true, the operation promises nothing, even though it could always be performed with perfect safety. In cases of local injuries, or of inflammation from any cause, it must necessarily increase the disease; and in cases of effusion only, the debilitated state of the whole system forbids us to hope for any relief from such a local remedy.
Bark, wine, and opium promise much more success in the last stage of the disease. I can say nothing in their favour from my own experience; but from the aid they afford to mercury in other diseases, I conceive they might be made to accompany it with advantage.
Considering the nature of the indirect causes which induce the disease, and the case of a relapse, which has been mentioned, after an interval of near three years, as well as the symptoms of slow convalescence, manifested by the pulse, which occurred in the first and seventh cases, I submit it to the consideration of physicians, whether the use of moderate exercise, and the cold bath, should not be recommended to prevent a return of the disease in every case, where it has yielded to the power of medicine.
I have great pleasure in adding, that the theory of this disease, which I have delivered, has been adopted by many respectable physicians in Philadelphia, and in other parts of the United States, and that it has led to the practice that has been recommended, particularly to copious blood-letting; in consequence of which, death from a dropsy of the brain is not a more frequent occurrence, than from any other of the acute febrile diseases of our country.
Footnotes:
[46] Prælectiones, vol. I. p. 254.
[47] Historia Anatomica-Medica, vol. II.
[48] Treatise on the Infantile Remitting Fever.
[49] Medical Memoirs, vol. I. p. 174.
[50] Essays, Medical, Philosophical, and Experimental, vol. II. p. 339, 340.
[51] Historia Anatomica-Medica, vol. II. lib. tertius. obs. 380, 394, 1121.
[52] Obs. 383, 431.
[53] Medical Journal.
[54] Medical Memoirs, vol. I. p. 171.
[55] Medical Journal, vol. VIII.
[56] Vol. xxix. p. 139.
OBSERVATIONS
UPON
THE NATURE AND CURE
OF THE
GOUT.
In treating upon the gout, I shall deliver a few preliminary propositions.
1. The gout is a disease of the whole system. It affects the ligaments, blood-vessels, stomach, bowels, brain, liver, lymphatics, nerves, muscles, cartilages, bones, and skin.
2. The gout is a primary disease, only of the solids. Chalk-stones, abscesses, dropsical effusions into cavities, and cellular membrane, and eruptions on the skin, are all the effects of a morbid action in the blood-vessels. The truth of this proposition has been ably proved by Dr. Cullen in his First Lines.
3. It affects most frequently persons of a sanguineous temperament; but sometimes it affects persons of nervous and phlegmatic temperaments. The idle and luxurious are more subject to it, than the labouring and temperate part of mankind. Women are said to be less subject to it than men. I once believed, and taught this opinion, but I now retract it. From the peculiar delicacy of the female constitution, and from the thin covering they wear on their feet and limbs, the gout is less apt to fall upon those parts than in men, but they exhibit all its other symptoms, perhaps more frequently than men, in other parts of the body. The remote causes of gout moreover to be mentioned presently, act with equal force upon both sexes, and more of them I believe upon women, than upon men.
It generally attacks in those periods of life, and in those countries, and seasons of the year, in which inflammatory diseases are most common. It seldom affects persons before puberty, or in old age, and yet I have heard of its appearing with all its most characteristic symptoms in this city in a child of 6, and in a man above 80 years of age. Men of active minds are said to be most subject to it, but I think I have seen it as frequently in persons of slender and torpid intellects, as in persons of an opposite character. I have heard of a case of gout in an Indian at Pittsburg, and I have cured a fit of it in an Indian in this city. They had both been intemperate in the use of wine and fermented liquors.
4. It is in one respect a hereditary disease, depending upon the propagation of a similar temperament from father to son. When a predisposition to the gout has been derived from ancestors, less force in exciting causes will induce it than in those habits where this has not been the case. This predisposition sometimes passes by children, and appears in grand-children. There are instances likewise in which it has passed by the males, and appeared only in the females of a family. It even appears in the descendants of families who have been reduced to poverty, but not often where they have been obliged to labour for a subsistence. It generally passes by those children who are born before the gout makes its appearance in a father. It is curious to observe how extensively the predisposition pervades some families. An English gentleman, who had been afflicted with the gout, married a young woman in Philadelphia many years ago, by whom he had one daughter. His wife dying three weeks after the birth of this child, he returned to England, where he married a second wife, by whom he had six children, all of whom except one died with the gout before they attained to the usual age of matrimony in Great Britain. One of them died in her 16th year. Finally the father and grandfather died with the same disease. The daughter whom this afflicted gentleman left in this city, passed her life subject to the gout, and finally died under my care in the year 1789, in the 68th year of her age. She left a family of children, two of whom had the gout. One of them, a lady, has suffered exquisitely from it.
5. The gout is always induced by general predisposing debility.
6. The remote causes of the gout which induce this debility, are, indolence, great bodily labour, long protracted bodily exercise, intemperance in eating, and in venery, acid aliments and drinks, strong tea and coffee, public and domestic vexation, the violent, or long continued exercise of the understanding, imagination, and passions in study, business, or pleasure, and, lastly, the use of ardent, and fermented liquors. The last are absolutely necessary to produce that form of gout which appears in the ligaments and muscles. I assert this, not only from my own observations, but from those of Dr. Cadogan, and Dr. Darwin, who say they never saw a case of gout in the limbs in any person who had not used spirits or wine in a greater or less quantity. Perhaps this may be another reason why women, who drink less of those liquors than men, are so rarely affected with this disease in the extreme parts of their bodies. Wines of all kinds are more disposed to produce this form of gout than spirits. The reason of this must be resolved into the less stimulus in the former, than in the latter liquors. Wine appears to resemble, in its action upon the body, the moderate stimulus of miasmata which produce a common remitting fever, or intermitting fever, while spirits resemble that violent action induced by miasmata which passes by the blood-vessels, ligaments, and muscles, and invades at once the liver, bowels, and brain. There is one symptom of the gout in the extremities which seems to be produced exclusively by ardent spirits, and that is a burning in the palms of the hands, and soles of the feet. This is so uniform, that I have sometimes been able to convict my patients of intemperance in the use of spirits, when no other mark of their having taken them in excess, appeared in the system.
I have enumerated among the remote causes of the gout, the use of strong tea. I infer its predisposing quality to that disease, from its frequency at Japan, where tea is used in large quantities, and from the gout being more common among that sex in our country who drink the most, and the strongest tea.
7. The exciting causes of the gout are frequently a greater degree, or a sudden application of its remote and predisposing causes. They act upon the accumulated excitability of the system, and by destroying its equilibrium of excitement, and regular order of actions, produce convulsion, or irregular morbid and local excitement. These exciting causes are either of a stimulating, or of a sedative nature. The former are violent exercise, of body or mind, night-watching, and even sitting up late at night, a hearty meal, a fit of drunkenness, a few glasses of claret or a draught of cyder, where those liquors have not been habitual to the patient, a sudden paroxysm of joy, anger, or terror, a dislocation of a bone, straining of a joint, particularly of the ankle, undue pressure upon the foot, or leg, from a tight shoe or boot, an irritated corn, and the usual remote causes of fever. The latter exciting causes are sudden inanition from bleeding, purging, vomiting, fasting, cold, a sudden stoppage of moisture on the feet, fear, grief, excess in venery, and the debility left upon the system by the crisis of a fever. All these causes act more certainly when they are aided by the additional debility induced upon the system in sleep. It is for this reason that the gout generally makes its first attack in the night, and in a part of the system most remote from the energy of the brain, and most debilitated by exercise, viz. in the great toe, or in some part of the foot. In ascribing a fit of the gout to a cause which is of a sedative nature, the reader will not suppose that I have departed from the simplicity and uniformity of a proposition I have elsewhere delivered, that disease is the effect of stimulus. The abstraction of a natural and habitual impression of any kind, by increasing the force of those which remain, renders the production of morbid and excessive actions in the system as much the effect of preternatural or disproportioned stimulus, as if they were induced by causes that are externally and evidently stimulating. It is thus in many other of the operations of nature, opposite causes produce the same effects.
8. The gout consists simply in morbid excitement, accompanied with irregular action, or the absence of all action from the force of stimulus. There is nothing specific in the morbid excitement and actions which take place in the gout different from what occur in fevers. It is to be lamented that a kind of metastasis of error has taken place in pathology. The rejection of a specific acrimony as the cause of each disease, has unfortunately been followed by a belief in as many specific actions as there are different forms and grades of disease, and thus perpetuated the evils of our ancient systems of medicine. However varied morbid actions may be by their causes, seats, and effects, they are all of the same nature, and the time will probably come when the whole nomenclature of morbid actions will be absorbed in the single name of disease.
I shall now briefly enumerate the symptoms of the gout, as they appear in the ligaments, the blood-vessels, the viscera, the nervous system, the alimentary canal, the lymphatics, the skin, and the bones of the human body, and here we shall find that it is an epitome of all disease.
I. The ligaments which connect the bones are the seats, of what is called a legitimate or true gout. They are affected with pain, swelling, and inflammation. The pain is sometimes so acute as to be compared to the gnawing of a dog. We perceive here the sameness of the gout with the rheumatism. Many pages, and indeed whole essays, have been composed by writers to distinguish them, but they are exactly the same disease while the morbid actions are confined to this part of the body. They are, it is true, produced by different remote causes, but this constitutes no more difference in their nature, than is produced in a coal of fire, whether it be inflamed by a candle, or by a spark of electricity. The morbid actions which are induced by the usual causes of rheumatism affect, though less frequently, the lungs, the trachea, the head, the bowels, and even the heart, as well as the gout. Those actions, moreover, are the means of a fluid being effused, which is changed into calcareous matter in the joints and other parts of the body, exactly like that which is produced by the gout. They likewise twist and dislocate the bones in common with the gout, in a manner to be described hereafter. The only difference between what are called gouty, and rheumatic actions, consists in their seats, and in the degrees of their force. The debility which predisposes to the gout, being greater, and more extensively diffused through the body than the debility which precedes rheumatism, the morbid actions, in the former case, pass more readily from external to internal parts, and produce in both more acute and more dangerous effects. A simile derived from the difference in the degrees of action produced in the system by marsh miasmata, made use of upon a former occasion, will serve me again to illustrate this part of our subject. A mild remittent, and a yellow fever, are different grades of the same disease. The former, like the rheumatism, affects the bones chiefly with pain, while the latter, like the gout, affects not only the bones, but the stomach, bowels, brain, nerves, lymphatics, and all the internal parts of the body.
II. In the arterial system the gout produces fever. This fever appears not only in the increased force or frequency of the pulse, but in morbid affections of all the viscera. It puts on all the different grades of fever, from the malignity of the plague, to the mildness of a common intermittent. It has moreover its regular exacerbations and remissions once in every four and twenty hours, and its crisis usually on the fourteenth day, in violent cases. In moderate attacks, it runs on from twenty to forty days in common with the typhus or slow chronic state of fever. It is common for those persons who consider the gout as a specific disease, when it appears in the above forms, to say, that it is complicated with fever; but this is an error, for there can exist but one morbid action in the blood-vessels at once, and the same laws are imposed upon the morbid actions excited in those parts of the body by the remote causes of the gout, as by the common causes of fever. I have seen two instances of this disease appearing in the form of a genuine hectic, and one in which it appeared to yield to lunar influence, in the manner described by Dr. Balfour. In the highly inflammatory state of the gout, the sensibility of the blood-vessels far exceeds what is seen in the same state of fever from more common causes. I have known an instance in which a translation of the gouty action to the eye produced such an exquisite degree of sensibility, that the patient was unable to bear the feeble light which was emitted from a few coals of fire in his room, at a time too when the coldness of the weather would have made a large fire agreeable to him. It is from the extreme sensibility which the gout imparts to the stomach, that the bark is so generally rejected by it. I knew a British officer who had nearly died from taking a spoonful of the infusion of that medicine, while his arterial system was in this state of morbid excitability, from a fit of the gout. It is remarkable that the gout is most disposed to assume a malignant character, during the prevalence of an inflammatory constitution of the atmosphere. This has been long ago remarked by Dr. Huxham. Several instances of it have occurred in this city since the year 1793.
III. The gout affects most of the viscera. In the brain it produces head-ach, vertigo, coma, apoplexy, and palsy. In the lungs it produces pneumonia vera, notha, asthma, hæmoptysis, pulmonary consumption, and a short hecking cough, first described by Dr. Sydenham. In the throat it produces inflammatory angina. In the uterus it produces hæmorrhagia uterina. It affects the kidneys with inflammation, strangury, diabetes, and calculi. The position of the body for weeks or months on the back, by favouring the compression of the kidneys by the bowels, is the principal reason why those parts suffer so much in gouty people. The strangury appears to be produced by the same kind of engorgement or choking of the vessels of the kidneys, which takes place in the small-pox and yellow fever. Four cases of it are described in the 3d volume of the Physical and Literary Essays of Edinburgh, by Dr. David Clerk. I have seen one instance of death in an old man from this cause. The catheter brought no water from his bladder. The late Mr. John Penn, formerly governor of Pennsylvania, I have been informed by one of his physicians, died from a similar affection in his kidneys from gout. The catheter was as ineffectual in giving him relief, as it was in the case of my patient. The neck of the bladder sometimes becomes the seat of the gout. It discovers itself by spasm, and a suppression of urine in some cases, and occasionally by a habitual discharge of mucus through the urethra. This disease has been called, by Lieutaud, “a catarrh of the bladder.” Dr. Stoll describes it, and calls it “hæmorrhoids of the bladder.” But of all the viscera, the liver suffers most from the gout. It produces in it inflammation, suppuration, melena, schirrus, gall-stones, jaundice, and a habitual increased secretion and excretion of bile. These affections of the liver appear most frequently in southern countries, and in female habits. They are substitutes for a gout in the ligaments, and in the extremities of the body. They appear likewise in drunkards from ardent spirits. It would seem that certain stimuli act specifically upon the liver, probably for the wise purpose of discharging such parts of the blood from the body, as are vitiated by the rapidity of its circulation. I shall, in another place[58], take notice of the action of marsh miasmata upon the livers of men and beasts. It has been observed that hogs that live near brewhouses, and feed upon the fermented grains of barley, always discover enlarged or diseased livers. But a determination of the blood to the liver, and an increased action of its vessels, are produced by other causes than marsh miasmata, and fermented and distilled liquors. They appear in the fever which accompanies madness and the malignant sore-throat, also in contusions of the brain, and in the excited state of the blood-vessels which is produced by anger and exercise. I have found an attention to these facts useful in prescribing for diseases of the liver, inasmuch as they have led me from considering them as idiopathic affections, but as the effects only of morbid actions excited in other parts of the body.
IV. The gout sometimes affects the arterial and nervous systems jointly, producing in the brain, coma, vertigo, apoplexy, palsy, loss of memory, and madness, and in the nerves, hysteria, hypochondriasis, and syncope. It is common to say the gout counterfeits all these diseases. But this is an inaccurate mode of speaking. All those diseases have but one cause, and they are exactly the same, however different the stimulus may be, from which they are derived. Sometimes the gout affects the brain and nerves exclusively, without producing the least morbid action in the blood-vessels. I once attended a gentleman from Barbadoes who suffered, from this affection of his brain and nerves, the most intolerable depression of spirits. It yielded to large doses of wine, but his relief was perfect, and more durable, when a pain was excited by nature or art, in his hands or feet.
The muscles are sometimes affected by the gout with spasm, with general and partial convulsions, and lastly with great pain. Dr. Stoll describes a case of opisthotonos from it. The angina pectoris, or a sudden inability to breathe after climbing a hill, or a pair of stairs, and after a long walk, is sometimes a symptom of the gout. There is a pain which suddenly pervades the head, breast, and limbs, which resembles an electric shock. I have known two instances of it in gouty patients, and have taken the liberty of calling it the “aura arthritica.” But the pain which affects the muscles is often of a more permanent nature. It is felt with most severity in the calves of the legs. Sometimes it affects the muscles of the head, breast, and limbs, exciting in them large and distressing swellings. But further; the gout in some cases seizes upon the tendons, and twists them in such a manner as to dislocate bones in the hands and feet. It even affects the cartilages. Of this I once saw an instance in colonel Adams, of the state of Maryland. The external parts of both his ears were so much inflamed in a fit of the gout, that he was unable to lie on either of his sides.
V. The gout affects the alimentary canal, from the stomach to its termination in the rectum. Flatulency, sickness, acidity, indigestion, pain, or vomiting, usually usher in a fit of the disease. The sick head-ach, also dyspepsia, with all its train of distressing evils, are frequently the effects of gout concentrated in the stomach. I have seen a case in which the gout, by retreating to this viscus, produced the same burning sensation which is felt in the yellow fever. The patient who was the subject of this symptom died two days afterwards with a black vomiting. It was Mr. Patterson, formerly collector of the port of Philadelphia, under the British government. I was not surprised at these two uncommon symptoms in the gout, for I had long been familiar with its disposition to affect the biliary secretion, and the actions of the stomach. The colic and dysentery are often produced by the gout in the bowels. In the southern states of America, it sometimes produces a chronic diarrhœa, which is known in some places by the name of the “downward consumption.” The piles are a common symptom of gout, and where they pour forth blood occasionally, render it a harmless disease. I have known an instance in which a gouty pain in the rectum produced involuntary stools in a gentleman in this city, and I have heard from a southern gentleman, who had been afflicted with gouty symptoms, that a similar pain was excited in the same part to such a degree, whenever he went into a crowded room lighted by candles, as to oblige him to leave it. In considering the effects of the gout upon this part, I am led to take notice of a troublesome itching in the anus which has been described by Dr. Lettsom, and justly attributed by him to this disease[59]. I have known several cases of it. They always occurred in gouty habits. A distressing collection of air in the rectum, which renders frequent retirement from company necessary to discharge it, is likewise a symptom of gout. It is accompanied with frequent, and small, but hard stools.
Of the above morbid affections of the nerves, stomach, and bowels, the hysteria, the sick head-ach, and the colic, appear much oftener in women than in men. I have said that dyspepsia is a symptom of gout. Out of more than 500 persons who were the patients of the Liverpool infirmary and dispensary, in one year, Dr. Currie informs us, “a great majority were females[60].”
VI. The gout affects the glands and lymphatics. It produced a salivation of a profuse nature in major Pearce Butler, which continued for two days. It produced a bubo in the groin in a citizen of Philadelphia. He had never been infected with the venereal disease, of course no suspicion was entertained by me of its being derived from that cause. I knew a lady who had periodical swellings in her breasts, at the same season of the year in which she had before been accustomed to have a regular fit of the gout. The scrophula and all the forms of dropsy are the effects in many cases of the disposition of the gout to attack the lymphatic system. There is a large hard swelling without pain, of one, or both the legs and thighs, which has been called a dropsy, but is very different from the common disease of that name. It comes on, and goes off suddenly. It has lately been called in England the dumb gout. In the spring of 1798 I attended colonel Innes, of Virginia, in consultation with my Edinburgh friend and fellow-student, Dr. Walter Jones, of the same state. The colonel had large anasarcous swellings in his thighs and legs, which we had reason to believe were the effects of an indolent gout. We made several punctures in his feet and ancles, and thereby discharged a large quantity of water from his legs and thighs. A day or two afterwards his ancles exhibited in pain and inflammation, the usual form of gout in those parts. In the year 1794 I attended Mrs. Lloyd Jones, who had a swelling of the same kind in her foot and leg. Her constitution, habits, and the sober manners of her ancestors, gave me no reason to suspect it to arise from the usual remote causes of gout. She was feverish, and her pulse was tense. I drew ten ounces of blood from her, and gave her a purge. The swelling subsided, but it was succeeded by an acute rheumatic pain in the part, which was cured in a few days. I mention these facts as an additional proof of the sameness of the gout and rheumatism, and to show that the vessels in a simple disease, as well as in malignant fevers, are often oppressed beyond that point in which they emit the sensation of pain.
Under this head I shall include an account of the mucous discharge from the urethra, which sometimes takes place in an attack of the gout, and which has ignorantly been ascribed to a venereal gonorrhæa. There is a description of this symptom of the gout in the 3d volume of the Physical and Literary Essays of Edinburgh, by Dr. Clark. It was first taken notice of by Sauvages by the name of “gonorrhæa podagrica,” in a work entitled Pathologia Methodica. I have known three instances of it in this city. In the visits which the gout pays to the genitals, it sometimes excites great pain in the testicles. Dr. Whytt mentions three cases of this kind. One of them was attended with a troublesome itching of the scrotum. I have seen one case in which the testicles were affected with great pain, and the penis with an obstinate priapism. They succeeded a sudden translation of the gout from the bowels.
From the occasional disposition of the gout to produce a mucous discharge from the urethra in men, it is easy to conceive that it is the frequent cause of the fluor albus in women, for in them, the gout which is restrained from the feet, by a cause formerly mentioned, is driven to other parts, and particularly to that part which, from its offices, is more disposed to invite disease to it, than any other. The fluor albus sometimes occurs in females, apparently of the most robust habits. In such persons, more especially if they have been descended from gouty ancestors, and have led indolent and luxurious lives, there can be no doubt but the disease is derived from the gout, and should be treated with remedies which act not only upon the affected part, but the whole system. An itching similar to that I formerly mentioned in the anus, sometimes occurs in the vagina of women. Dr. Lettsom has described it. In all the cases I have known of it, I believe it was derived from the usual causes of the gout.
VII. There are many records in the annals of medicine of the gout affecting the skin. The erysipelas, gangrene, and petechiæ are its acute, and tetters, and running sores are its usual chronic forms when it appears in this part of the body. I attended a patient with the late Dr. Hutchinson, in whom the whole calf of one leg was destroyed by a mortification which succeeded the gout. Dr. Alexander, of Baltimore, informed me that petechiæ were among the last symptoms of this disease in the Rev. Mr. Oliver, who died in the town of Baltimore, about two years ago. In the disposition of the gout to attack external parts, it sometimes affects the eyes and ears with the most acute and distressing inflammation and pain. I hesitate the less in ascribing them both to the gout, because they not only occur in gouty habits, but because they now and then effuse a calcareous matter of the same nature with that which is found in the ligaments of the joints.
VIII. Even the bones are not exempted from the ravages of this disease. I have before mentioned that the bones of the hands and feet are sometimes dislocated by it. I have heard of an instance in which it dislocated the thigh bone. It probably produced this effect by the effusion of that part of the blood which constitutes chalk-stones, or by an excrescence of flesh in the cavity of the joint. Two instances have occurred in this city of its dislodging the teeth, after having produced the most distressing pains in the jaws. The long protracted, and acute pain in the face, which has been so accurately described by Dr. Fothergill, probably arises wholly from the gout acting upon the bones of the part affected.
I have more than once hinted at the sameness of some of the states of the gout, and the yellow fever. Who can compare the symptoms and seats of both diseases, and not admit the unity of the remote and immediate causes of fever?
Thus have I enumerated proofs of the gout being a disease of the whole system. I have only to add under this proposition, that it affects different parts of the body in different people, according to the nature of their congenital or acquired temperaments, and that it often passes from one part of the body to another in the twinkling of an eye.
The morbid excitement, and actions of the gout, when seated in the ligaments, the blood-vessels, and viscera, and left to themselves, produce effects different in their nature, according to the parts in which they take place. In the viscera they produce congestions composed of all the component parts of the blood. From the blood-vessels which terminate in hollow cavities and in cellular membrane, they produce those effusions of serum which compose dropsies. From the same vessels proceed those effusions which produce on the skin erysipelas, tetters, and all the different kinds of eruptions. In the ligaments they produce an effusion of coagulable lymph, which by stagnation is changed into what are called chalk-stones. In the urinary organs they produce an effusion of particles of coagulable lymph or red blood, which, under certain circumstances, are changed into sand, gravel, and stone. All these observations are liable to some exceptions. There are instances in which chalk-stones have been found in the lungs, mouth, on the eye-lids, and in the passages of the ears, and a preternatural flux of water and blood has taken place from the kidneys. Pus has likewise been formed in the joints, and air has been found in the cavity of the belly, instead of water.
Sometimes the gout is said to combine with the fevers which arise from cold and miasmata. We are not to suppose from this circumstance, that the system is under a twofold stimulus. By no means. The symptoms which are ascribed to the gout, are the effects of morbid excitement excited by the cold, or miasmata acting upon parts previously debilitated by the usual remote causes of that disease.
A bilious diathesis in the air so often excites the peculiar symptoms of gout, in persons predisposed to it, that it has sometimes been said to be epidemic. This was the case, Dr. Stoll says, in Vienna, in the years 1782 and 1784. The same mixture of gouty and bilious symptoms was observed by Dr. Hillary, in the fevers of Barbadoes.
From a review of the symptoms of the gout, the impropriety of distinguishing it from its various seats, by specific names, must be obvious to the reader. As well might we talk of a yellow fever in the brain, in the nerves, or in the groin, when its symptoms affect those parts, as talk of misplaced or retrocedent gout. The great toe, and the joints of the hands and feet, are no more its exclusive seats, than the “stomach is the throne of the yellow fever.” In short, the gout may be compared to a monarch whose empire is unlimited. The whole body crouches before it.
It has been said as a reflection upon our profession, that physicians are always changing their opinions respecting chronic diseases. For a long while they were all classed under the heads of nervous, or bilious. These names for many years afforded a sanctuary for the protection of fraud and error in medicine. They have happily yielded of late years to the name of gout. If we mean by this disease a primary affection of the joints, we have gained nothing by assuming that name; but if we mean by it a disease which consists simply of morbid excitement, invited by debility, and disposed to invade every part of the body, we conform our ideas to facts, and thus simplify theory and practice in chronic diseases.
I proceed now to treat of the METHOD OF CURE.
Let not the reader startle when I mention curing the gout. It is not a sacred disease. There will be no profanity in handling it freely. It has been cured often, and I hope to deliver such directions under this head, as will reduce it as much under the power of medicine, as a pleurisy or an intermitting fever. Let not superstition say here, that the gout is the just punishment of folly, and vice, and that the justice of Heaven would be defeated by curing it. The venereal disease is more egregiously the effect of vice than the gout, and yet Heaven has kindly directed human reason to the discovery of a remedy which effectually eradicates it from the constitution. This opinion of the gout being a curable disease, is as humane as it is just. It is calculated to prompt to early application for medical aid, and to prevent that despair of relief which has contributed so much to its duration, and mortality.
But does not the gout prevent other diseases, and is it not improper upon this account to cure it? I answer, that it prevents other diseases, as the daily use of drams prevents the intermitting fever. In doing this, they bring on a hundred more incurable morbid affections. The yellow fever carried off many chronic diseases in the year 1793, and yet who would wish for, or admit such a remedy for a similar purpose? The practice of encouraging, and inviting what has been called a “friendly fit” of the gout as a cure for other diseases, resembles the practice of school boys who swallow the stones of cherries to assist their stomachs in digesting that delicate fruit. It is no more necessary to produce the gout in the feet, in order to cure it, than it is to wait for, or encourage abscesses or natural hæmorrhages, to cure a fever. The practice originated at a time when morbific matter was supposed to be the cause of the gout, but it has unfortunately continued under the influence of theories which have placed the seat of the disease in the solids.
The remedies for the gout naturally divide themselves into the following heads.
I. Such as are proper in its approaching, or forming state.
II. Such as are proper in violent morbid action in the blood-vessels and viscera.
III. Such as are proper in a feeble morbid action in the same parts of the body.
IV. Such as are proper to relieve certain local symptoms which are not accompanied by general morbid action. And
V. Such as are proper to prevent its recurrence, or, in other words, to eradicate it from the system.
I. The symptoms of an approaching fit of the gout are great languor, and dulness of body and mind, doziness, giddiness, wakefulness, or sleep disturbed by vivid dreams, a dryness, and sometimes a coldness, numbness, and prickling in the feet and legs, a disappearance of pimples in the face, occasional chills, acidity and flatulency in the stomach, with an increased, a weak, or a defect of appetite. These symptoms are not universal, but more or less of them usher in nearly every fit of the gout. The reader will see at once their sameness with the premonitory symptoms of fever from cold and miasmata, and assent from this proof, in addition to others formerly mentioned, to the propriety of considering a fit of the gout, as a paroxysm of fever.
The system, during the existence of these symptoms, is in a state of morbid depression. The disease is as yet unformed, and may easily be prevented by the loss of a few ounces of blood, or, if this remedy be objected to, by a gentle doze of physic, and afterwards by bathing the feet in warm water, by a few drops of the spirit of hartshorn in a little sage or camomile tea, by a draught of wine whey, or a common doze of liquid laudanum, and, according to a late Portuguese physician, by taking a few doses of bark.
It is worthy of notice, that if these remedies are omitted, all the premonitory symptoms that have been mentioned disappear as soon as the arthritic fever is formed, just as lassitude and chilliness yield to a paroxysm of fever from other causes.
II. Of the remedies that are proper in cases of great morbid action in the blood-vessels and viscera.
I shall begin this head by repudiating the notion of a specific cure for the gout existing in any single article of the materia medica. Every attempt to cure it by elixirs, diet-drinks, pills, or boluses, which were intended to act singly on the system, has been as unsuccessful as the attempts to cure the whooping cough by spells, or tricks of legerdemain.
The first remedy that I shall mention for reducing great morbid action in the blood-vessels and viscera, is blood-letting. I was first taught the safety of this remedy in the gout by reading the works of Dr. Lister, above thirty years ago, and I have used it ever since with great advantage. It has the sanction of Dr. Hoffman, Dr. Cullen, and many others of the first names in medicine in its favour.
The usual objections to bleeding as a remedy, have been urged with more success in the gout, than in any other disease. It has been forbidden, because the gout is said to be a disease of debility. This is an error. Debility is not a disease. It is only its predisposing cause. Disease is preternatural strength in the state of the system now under consideration, occasioned by the abstraction of excitement from one part, and the accumulation of it in another part of the body. Every argument in favour of bleeding in a pleurisy applies in the present instance, for they both depend upon the same kind of morbid action in the blood-vessels. Bleeding acts moreover alike in both cases by abstracting the excess of excitement from the blood-vessels, and restoring its natural and healthy equality to every part of the system.
It has been further said, that bleeding disposes to more frequent returns of the gout. This objection to the lancet has been urged by Dr. Sydenham, who was misled in his opinion of it, by his theory of the disease being the offspring of morbific matter. The assertion is unfounded, for bleeding in a fit of the gout has no such effect, provided the remedies to be mentioned hereafter are used to prevent it. But a fit of the gout is not singular in its disposition to recur after being once cured. The rheumatism, the pleurisy, and the intermitting fever are all equally disposed to return when persons are exposed to their remote and exciting causes, and yet we do not upon this account consider them as incurable diseases, nor do we abstain from the usual remedies which cure them.
The inflammatory or violent state of the gout is said most commonly to affect the limbs. But this is far from being the case. It frequently makes its first attack upon the head, lungs, kidneys, stomach, and bowels. The remedies for expelling it from the stomach and bowels are generally of a stimulating nature. They are as improper in full habits, and in the recent state of the disease, as cordials are to drive the small-pox from the vitals to the skin. Hundreds have been destroyed by them. Bleeding in these cases affords the same speedy and certain relief that it does in removing pain from the stomach and bowels in the first stage of the yellow fever. Colonel Miles owes his life to the loss of 60 ounces of blood in an attack of the gout in his bowels, in the winter of 1795, and major Butler derived the same benefit from the loss of near 30 ounces, in an attack of the gout in his stomach in the spring of 1798.
I could add many more instances of the efficacy of the lancet in the gout when it affects the viscera, from my own experience, but I prefer mentioning one only from sir John Floyer, which is more striking than any I have met with in its favour. He tells us, sir Henry Coningsby was much disposed to the palsy from the gout when he was 30 years old. By frequent bleedings, and the use of the cold bath, he recovered, and lived to be 88. During his old age, he was bled every three months.
I have said, in the history of the symptoms of the gout, that it sometimes appeared in the form of a hectic fever. I have prescribed occasional bleedings in a case of this kind accompanied with a tense pulse, with the happiest effects. It confined the disease for several years wholly to the blood-vessels, and it bid fair in time to eradicate it from the system.
The state of the pulse, as described in another place[61], should govern the use of the lancet in this disease. Bleeding is required as much in its depressed, as in its full and chorded state. Colonel Miles's pulse, at the time he suffered from the gout in his bowels, was scarcely perceptible. It did not rise till after a second or third bleeding.
Some advantage may be derived from examining the blood. I have once known it to be dissolved; but for the most part I have observed it, with Dr. Lister, to be covered with the buffy coat of common inflammation.
The arguments made use of in favour of bleeding in the diseases of old people in a former volume, apply with equal force to its use in the gout. The inflammatory state of this disease frequently occurs in the decline of life, and bleeding is as much indicated in such cases as in any other inflammatory fever. The late Dr. Chovet died with an inflammation in his liver from gout, in the 86th year of his age. He was twice bled, and his blood each time was covered with a buffy coat.
Where the gout affects the head with obstinate pain, and appears to be seated in the muscles, cupping and leeches give great relief. This mode of bleeding should be trusted in those cases only in which the morbid action is confined chiefly to the head, and appears in a feeble state in the rest of the arterial system.
The advantages of bleeding in the gout, when performed under all the circumstances that have been mentioned, are as follow:
1. It removes or lessens pain.
2. It prevents those congestions and effusions which produce apoplexy, palsy, pneumonia notha, calculi in the kidneys and bladder, and chalk-stones in the hands and feet. The gravel and stone are nine times in ten, I believe, the effects of an effusion of lymph or blood from previous morbid action in the kidneys. If this disease were narrowly watched, and cured as often as it occurs, by the loss of blood, we should have but little gravel or stone among gouty people. A citizen of Philadelphia died a few years ago, in the 96th year of his age, who had been subject to the strangury the greatest part of his life. His only remedy for it was bleeding. He lived free from the gravel and stone; and died, or rather appeared to fall asleep in death, from old age. Dr. Haller mentions a similar case in his Bibliotheca Medicinæ, in which bleeding had the same happy effects.
3. It prevents the system from wearing itself down by fruitless pain and sickness, and thereby inducing a predisposition to frequent returns of the disease.
4. It shortens the duration of a fit of gout, by throwing it, not into the feet, but out of the system, and thus prevents a patient's lying upon his back for two or three months with a writhing face, scolding a wife and family of children, and sometimes cursing every servant that comes near enough to endanger the touch of an inflamed limb. Besides preventing all this parade of pain and peevishness, it frequently, when assisted with other remedies to be mentioned presently, restores a man to his business and society in two or three days: a circumstance this of great importance in the public as well as private pursuits of men; for who has not read of the most interesting affairs of nations being neglected or protracted, by the principal agents in them being suddenly confined to their beds, or chairs, for weeks or months, by a fit of the gout?
2. A second remedy in the state of the gout which has been mentioned, is purging. Sulphur is generally preferred for this purpose, but castor oil, cream of tartar, sena, jalap, rhubarb, and calomel, may all be used with equal safety and advantage. The stomach and habits of the patient should determine the choice of a suitable purge in every case. Salts are generally offensive to the stomach. They once brought on a fit of the gout in Dr. Brown.
3. Vomits may be given in all those cases where bleeding is objected to, or where the pulse is only moderately active. Mr. Small, in an excellent paper upon the gout, in the 6th volume of the Medical Observations and Inquiries, p. 205, containing the history of his own case, tells us that he always took a vomit upon the first attack of the gout, and that it never failed of relieving all its symptoms. The matter discharged by this vomit indicated a morbid state of the liver, for it was always a dark greenish bile, which was insoluble in water. A British lieutenant, whose misfortunes reduced him to the necessity of accepting a bed in the poor-house of this city, informed the late Dr. Stuben, that he had once been much afflicted with the gout, and that he had upon many occasions strangled a fit of it by the early use of an emetic. Dr. Pye adds his testimony to those which have been given in favour of vomits, and says further, that they do most service when they discharge an acid humour from the stomach. They appear to act in part by equalizing the divided excitement of the system, and in part by discharging the contents of the gall-bladder and stomach, vitiated by the previous debility of those organs. Care should be taken not to exhibit this remedy where the gout attacks the stomach with symptoms of inflammation, or where it has a tendency to fix itself upon the brain.
4. Nitre may be given with advantage in cases of inflammatory action, where the stomach is not affected.
5. A fifth remedy is cool or cold air. This is as safe and useful in the gout as in any other inflammatory state of fever. The affected limbs should be kept out of bed, uncovered. In this way Mr. Small says he moderated the pains of the gout in his hands and feet[62]. I have directed the same practice with great comfort, as well as advantage to my patients. Even cold water has been applied with good effects to a limb inflamed by the gout. Mr. Blair M'Clenachan taught me the safety and benefit of this remedy, by using it upon himself without the advice of a physician. It instantly removed his pain, nor was the gout translated by it to any other part of his body. It was removed in the same manner, Dr. Heberden tells us, by the celebrated Dr. Harvey from his own feet. Perhaps it would be best in most cases to prefer cool, or cold air, to cold water. The safety and advantages of both these modes of applying cold to the affected limbs, show the impropriety of the common practice of wrapping them in flannel.
6. Diluting liquors, such as are prescribed in common inflammatory fevers, should be given in such quantities as to dispose to a gentle perspiration.
7. Abstinence from wine, spirits, and malt liquors, also from such aliments as afford much nourishment or stimulus, should be carefully enjoined. Sago, panada, tapioca, diluted milk with bread, and the pulp of apples, summer fruits, tea, coffee, weak chocolate, and bread soaked in chicken water or beef tea, should constitute the principal diet of patients in this state of the gout.
8. Blisters are an invaluable remedy in this disease, when used at a proper time, that is, after the reduction of the morbid actions in the system by evacuations. They should be applied to the joints of the feet and wrists in general gout, and to the neck and sides, when it attacks the head or breast. A strangury from the gout is no objection to their use. So far from increasing this complaint, Dr. Clark and Dr. Whytt inform us, that they remove it[63]. But the principal advantage of blisters is derived from their collecting and concentrating scattered and painful sensations, and conveying them out of the system, and thus becoming excellent substitutes for a tedious fit of the gout.
9. Fear and terror have in some instances cured a paroxysm of this disease. A captain of a British ship of war, who had been confined for several weeks to his cabin, by a severe fit of the gout in his feet, was suddenly cured by hearing the cry of fire on board his ship. This fact was communicated to me by a gentleman who was a witness of it. Many similar cases are upon record in books of medicine. I shall in another place insert an account of one in which the cure effected by a fright, eradicated the disease from the system so completely, as ever afterwards to prevent its return.
Thus have I enumerated the remedies which are proper in the gout when it affects the blood-vessels and viscera with great morbid action. Most of those remedies are alike proper when the morbid actions are seated in the muscular fibres, whether of the bowels or limbs, and whether they produce local pain, or general convulsion, provided they are of a violent nature.
There are some remedies under this head of a doubtful nature, on which I shall make a few observations.
Sweating has been recommended in this state of the gout. All the objections to it in preference to other modes of depletion, mentioned in another place[64], apply against its use in the inflammatory state of the gout. It is not only less safe than bleeding, purging, and abstinence, but it is often an impracticable remedy. The only sudorific medicine to be trusted in this state of the disease is the Seneka snake-root. It promotes all the secretions and excretions, and exerts but a feeble stimulus upon the arterial system.
Many different preparations of opium have been advised in this state of the gout. They are all hurtful if given before the morbid action of the system is nearly reduced. It should then be given in small doses accommodated to the excitability of the system.
Applications of various kinds to the affected limbs have been used in a fit of the gout, and some of them with success. The late Dr. Chalmers of South-Carolina used to meet the pain of the gout as soon as it fixed in any of his limbs, with a blister, and generally removed it by that means in two or three days. I have imitated this practice in several cases, and always with success, nor have I ever seen the gout thrown upon any of the viscera by means of this remedy. Caustics have sometimes been applied to gouty limbs with advantage. The moxa described and used by sir William Temple, which is nothing but culinary fire, has often not only given relief to a pained limb, but carried off a fit of the gout in a few hours. These powerful applications may be used with equal advantage in those cases in which the gout by falling upon the head produces coma, or symptoms of apoplexy. A large caustic to the neck roused Mr. John M. Nesbit from a coma in which he had lain for three days, and thereby appeared to save his life. Blisters, and cataplasms of mustard, had been previously used to different parts of his body, but without the least effect. In cases of moderate pain, where a blister has been objected to, I have seen a cabbage leaf afford considerable relief. It produces a moisture upon the part affected, without exciting any pain. An old sea captain taught me to apply molasses to a limb inflamed or pained by the gout. I have frequently advised it, and generally with advantage. All volatile and stimulating liniments are improper, for they not only endanger a translation of the morbid excitement to the viscera, but where they have not this effect, they increase the pain and inflammation of the part affected.
The sooner a patient exercises his lower limbs by walking, after a fit of the gout, the better. “I made it a constant rule (says Mr. Small) to walk abroad as soon as the inflammatory state of the gout was past, and though by so doing, I often suffered great pain, I am well convinced that the free use I now enjoy of my limbs is chiefly owing to my determined perseverance in the use of that exercise; nor am I less persuaded that nine in ten of gouty cripples owe their lameness more to indolence, and fear of pain, than to the genuine effects of the gout[65].” Sir William Temple confirms the propriety of Mr. Small's opinion and practice, by an account of an old man who obviated a fit of the gout as often as he felt it coming in his feet, by walking in the open air, and afterwards by going into a warm bed, and having the parts well rubbed where the pain began. “By following this course (he says) he was never laid up with the gout, and before his death recommended the same course to his son if ever he should fall into that accident.” Under a conviction of the safety of this practice the same author concludes the history of his own case in the following words: “I favoured it [viz. the swelling in my feet] all this while more than I needed, upon the common opinion, that walking too much might draw down the humour, which I have since had reason to conclude is a great mistake, and that if I had walked as much as I could from the first day the pain left me, the swelling might have left me too in a much less time[66].”
III. I come now to mention the remedies which are proper in that state of the gout in which a feeble morbid action takes place in the blood-vessels and viscera.
I shall begin this head, by remarking, that this state of the gout is often created, like the typhus state of fever, by the neglect, or too scanty use of evacuations in its first stage. When the prejudices which now prevent the adoption of those remedies in their proper time, are removed, we shall hear but little of the low state of the arthritic fever, nor of the numerous diseases from obstruction which are produced by the blood-vessels disorganizing the viscera, by repeated and violent attacks of the disease.
To determine the character of a paroxysm of gout and the remedies proper to relieve it, the climate, the season of the year, the constitution of the atmosphere, and the nature of the prevailing epidemic, should be carefully attended to by a physician. But his principal dependence should be placed upon the state of the pulse. If it do not discover the marks which indicate bleeding formerly referred to, but is weak, quick, and soft, the remedies should be such as are calculated to produce a more vigorous, and equable action in the blood-vessels and viscera. They are,
1. Opium. It should at first be given in small doses, and afterwards increased, as circumstances may require.
2. Madeira or Sherry wine alone, or diluted with water, or in the form of whey, or rendered more cordial by having any agreeable spice infused in it. It may be given cold or warm, according to the taste of the patient, or the state of his stomach. If this medicine be rejected in all the above forms,
3. Porter should be given. It is often retained when no other liquor will lie upon the stomach. I think I once saved the life of Mr. Nesbit by this medicine. It checked a vomiting, from the gout, which seemed to be the last symptom of his departing life. If porter fail of giving relief,
4. Ardent spirits should be given, either alone, or in the form of grog, or toddy. Cases have occurred in which a pint of brandy has been taken in the course of an hour with advantage. Great benefit has sometimes been found from Dr. Warner's tincture, in this state of the gout. As these observations may fall into the hands of persons who may not have access to Dr. Warner's book, I shall here insert the receipt for preparing it.
Of raisins, sliced and stoned, half a pound.
Rhubarb, one ounce.
Sena, two drachms.
Coriander and fennel seeds, of each one drachm.
Cochineal, saffron, and liquorice root, each half a drachm.
Infuse them for ten days in a quart of French brandy, then strain it, and add a pint more of brandy to the ingredients, afterwards strain it, and mix both tinctures together. Four table spoons full of this cordial are to be taken every hour, mixed with an equal quantity of water, until relief be obtained.
Ten drops of laudanum may be added to each dose in those cases in which the cordial does not produce its intended effects, in two or three hours. If all the different forms of ardent spirits which have been mentioned fail of giving relief,
5. From 30 drops to a tea spoonful of æther should be given in any agreeable vehicle. Also,
6. Volatile alkali. From five to ten grains of this medicine should be given every two hours.
7. Aromatic substances, such as alspice, ginger, Virginia snake-root, cloves, and mace in the form of teas, have all been useful in this state of the gout.
All these remedies are indicated in a more especial manner when the gout affects the stomach. They are likewise proper when it affects the bowels. The laudanum in this case should be given by way of glyster. After the vomiting was checked in Mr. Nesbit by means of porter, he was afflicted with a dull and distressing pain in his bowels, which was finally removed by two anodyne glysters injected daily for two or three weeks.
8. Where the gout produces spasmodic or convulsive motions, the oil of amber may be given with advantage. I once saw it remove for a while a convulsive cough from the gout.
9. In cases where the stomach will bear the bark, it should be given in large and frequent doses. It does the same service in this state of gout, that it does in the slow, or low states of fever from any other cause. Where the gout appears in the form of an intermittent, the bark affords the same relief that it does in the same disease from autumnal exhalations. Mr. Small found great benefit from it after discharging the contents of his stomach and bowels by a dose of tartar emetic. “I do not call (says this gentleman) a fit of the gout a paroxysm, for there are several paroxysms in the fit, each of which is ushered in with a rigour, sickness at stomach, and subsequent heat. In this the gout bears a resemblance to an irregular intermittent, at least to a remitting fever, and hence perhaps the efficacy of the bark in removing the gout[67].”
10. The warm bath is a powerful remedy in exciting a regular and healthy action in the sanguiferous system. Where the patient is too weak to be taken out of bed, and put into a bathing tub, his limbs and body should be wrapped in flannels dipped in warm water. In case of a failure of all the above remedies,
11. A salivation should be excited as speedily as possible, by means of mercury. Dr. Cheyne commends it in high terms. I have once used it with success. The mercury, when used in this way, brings into action an immense mass of latent excitement, and afterwards diffuses it equally through every part of the body.
12. Besides these internal remedies, frictions with brandy, and volatile liniment, should be used to the stomach and bowels. Blisters should be applied to parts in which congestion or pain is seated, and stimulating cataplasms should be applied to the lower limbs. The flour of mustard has been justly preferred for this purpose. It should be applied to the upper part of the foot.
The reader will perceive, in the account I have given of the remedies proper in the feeble state of chronic fever, that they are the same which are used in the common typhus, or what is called nervous fever. There is no reason why they should not be the same, for the supposed two morbid states of the system are but one disease.
It is agreeable in medical researches to be under the direction of principles. They render unnecessary, in many instances, the slow and expensive operations of experience, and thus multiply knowledge, by lessening labour. The science of navigation has rested upon this basis, since the discovery of the loadstone. A mariner who has navigated a ship to one distant port, is capable of conducting her to every port on the globe. In like manner, the physician who can cure one disease by a knowledge of its principles, may by the same means cure all the diseases of the human body, for their causes are the same. Judgment is required, only in accommodating the force of remedies to the force of each disease. The difference in diseases which arises from their seats, from age, sex, habit, season, and climate, may be known in a short time, and is within the compass of very moderate talents.
IV. Were I to enumerate all the local symptoms of gout which occur without fever, and the remedies that are proper to relieve them, I should be led into a tedious digression. The reader must consult practical books for an account of them. I shall only mention the remedies for a few of them.
The theory of the gout which has been delivered, will enable us to understand the reason why a disease which properly belongs to the whole system, should at any time be accompanied only with local morbid affection. The whole body is a unit, and hence morbid impressions which are resisted by sound parts are propagated to such as are weak, where they excite those morbid actions we call disease.
The head-ach is a distressing symptom of the gout. It yields to depleting or tonic remedies, according to the degree of morbid action which accompanies it. I have heard an instance of an old man, who was cured of an obstinate head-ach by throwing aside his nightcap, and sleeping with his bare head exposed to the night air. The disease in this case was probably attended with great morbid action. In this state of the vessels of the brain, cupping, cold applications to the head, purges, a temperate diet, and blisters behind the ears, are all proper remedies, and should be used together, or in succession, as the nature of the disease may require. Many persons have been cured of the same complaint by sleeping in woollen nightcaps. The morbid action in these cases is always of a feeble nature. With this remedy, tonics, particularly the bark and cold bath, will be proper. I have once known a chronic gouty pain in the head cured by an issue in the arm, after pounds of bark, and many other tonic remedies, had been taken to no purpose.
The ophthalmia from gout should be treated with the usual remedies for that disease when it arises from other causes, with the addition of such local applications to other and distant parts of the body, as may abstract the gouty action from the eyes.
Dull but constant pains in the limbs yield to frictions, volatile liniments, muslin and woollen worn next to the skin, electricity, a salivation, and the warm and cold bath. A gentleman who was afflicted with a pain of this kind for three years and a half in one of his arms, informed me, that he had been cured by wearing a woollen stocking that had been boiled with sulphur in water, for two weeks upon the affected limb. He had previously worn flannel upon it, but without receiving any benefit from it. I have known wool and cotton, finely carded, and made into small mats, worn upon the hips, when affected by gout, with great advantage. In obstinate sciatic pains, without fever or inflammation, Dr. Pitcairn's remedy, published by Dr. Cheyne, has performed many cures. It consists in taking from one to four tea-spoons full of the fine spirit of turpentine every morning, for a week or ten days, in three times the quantity of honey, and afterwards in drinking a large quantity of sack whey, to settle it on the stomach, and carry it into the blood. An anodyne should be taken every night after taking this medicine.
A gouty diarrhœa should be treated with the usual astringent medicines of the shops. Blisters to the wrists and ankles, also a salivation, have often cured it. I have heard of its being checked, after continuing for many years, by the patient eating large quantities of alspice, which he carried loose in his pocket for that purpose.
The angina pectoris, which I have said is a symptom of the gout, generally comes on with fulness and tension in the pulse. After these are reduced by two or three bleedings, mineral tonics seldom fail of giving relief.
Spasms in the stomach, and pains in the bowels, often seize gouty people in the midst of business or pleasure, or in the middle of the night. My constant prescription for these complaints is ten drops of laudanum every half hour, till relief be obtained. If this medicine be taken in the forming state of these pains, a single dose generally removes the disease. It is preferable to spiced wine and spirits, inasmuch as it acts quicker, and leaves no disposition to contract a love for it when it is not required to ease pain.
The pain in the rectum which has been described, yields to the common remedies for the piles. Cold water applied to the part, generally gives immediate relief.
For a preternatural secretion and excretion of bile, gentle laxatives, and abstinence from oily food, full meals, and all violent exercises of the body and mind, are proper.
The itching in the anus, which I have supposed to be a symptom of gout, has yielded in one instance that has come within my knowledge to mercurial ointment applied to the part affected. Dr. Lettsom recommends fomenting the part with a decoction of poppy heads and hemlock, and advises lenient purges and a vegetable diet as a radical cure for the disease[68].
For the itching in the vagina I have found a solution of the sugar of lead in water to be an excellent palliative application. Dr. Lettsom recommends as a cure for it, the use of bark in delicate habits, and occasional bleeding, with a light and moderate diet, if it occur about the time of the cessation of the menses.
Obstinate cutaneous eruptions, which are the effects of gout, have been cured by gentle physic, a suitable diet, issues, and applications of the unguentum citrinum to the parts affected.
The arthritic gonorrhœa should be treated with the same remedies as a gonorrhœa from any other cause.
In the treatment of all the local symptoms that have been enumerated, it will be of great consequence to inquire, before we attempt to cure them, whether they have not succeeded general gout, and thereby relieved the system from its effects in parts essential to life. If this have been the case, the cure of them should be undertaken with caution, and the danger of a local disease being exchanged for a general one, should be obviated by remedies that are calculated to eradicate the gouty diathesis altogether from the system. The means for this purpose, agreeably to our order, come next under our consideration. Before I enter upon this head, I shall premise, that I do not admit of the seeds of the gout remaining in the body to be eliminated by art after a complete termination of one of its paroxysms, any more than I admit of the seeds of a pleurisy or intermitting fever remaining in the body, after they have been cured by blood-letting or bark. A predisposition only remains in the system to a return of the gout, from its usual remote and exciting causes. The contrary idea took its rise in those ages of medicine in which morbific matter was supposed to be the proximate cause of the gout, but it has unfortunately continued since the rejection of that theory. Thus in many cases we see wrong habits continue long after the principles have been discarded, from which they were derived.
I have known several instances in which art, and I have heard and read of others in which accidental suffering from abstinence, pain, and terror have been the happy means of overcoming a predisposition to the gout. A gentleman from one of the West-India islands, who had been for many years afflicted with the gout, was perfectly cured of it by living a year or two upon the temperate diet of the jail in this city, into which he was thrown for debt by one of his creditors. A large hæmorrhage from the foot, inflamed and swelled by the gout, accidentally produced by a penknife which fell upon it, effected in an Irish gentleman a lasting cure of the disease. Hildanus mentions the history of a gentleman, whom he knew intimately, who was radically cured of a gout with which he had been long afflicted, by the extreme bodily pain he suffered innocently from torture in the canton of Berne. He lived to be an old man, and ever afterwards enjoyed good health[69]. The following letter from my brother contains the history of a case in which terror suddenly eradicated the gout from the system.
“Reading, July 27th, 1797.
“DEAR BROTHER,
“WHEN I had the pleasure of seeing you last week, I mentioned an extraordinary cure of the gout in this town, by means of a fright. In compliance with your request, I now send an exact narration of the facts.
“Peter Fether, the person cured, is now alive, a householder in Reading, seventy-three years of age, a native of Germany, and a very hearty man. The first fit of the gout he ever had, was about the year 1773; and from that time till 1785, he had a regular attack in the spring of every year. His feet, hands, and elbows were much swollen and inflamed; the fits lasted long, and were excruciating. In particular, the last fit in 1785 was so severe, as to induce an apprehension, that it would inevitably carry him off, when he was suddenly relieved by the following accident.
“As he lay in a small back room adjoining the yard, it happened that one of his sons, in turning a waggon and horses, drove the tongue of the waggon with such force against the window, near which the old man lay stretched on a bed, as to beat in the sash of the window, and to scatter the pieces of broken glass all about him. To such a degree was he alarmed by the noise and violence, that he instantly leaped out of bed, forgot that he had ever used crutches, and eagerly inquired what was the matter. His wife, hearing the uproar, ran into the room, where, to her astonishment, she found her husband on his feet, bawling against the author of the mischief, with the most passionate vehemence. From that moment, he has been entirely exempt from the gout, has never had the slightest touch of it, and now enjoys perfect health, has a good appetite, and says he was never heartier in his life. This is probably the more remarkable, when I add, that he has always been used to the hard work of a farm, and since the year 1785 has frequently mowed in his own meadow, which I understand is low and wet. I am well informed, in his mode of living, he has been temperate, occasionally indulging in a glass of wine, after the manner of the German farmers, but not to excess.
“To you, who have been long accustomed to explore diseases, I leave the task of developing the principles, on which this mysterious restoration from the lowest decrepitude and bodily wretchedness, to a state of perfect health, has been accomplished. I well know that tooth-achs, head-achs, hiccoughs, [**AMP]c. are often removed by the sudden impression of fear, and that they return again. But to see a debilitated gouty frame instantly restored to vigour; to see the whole system in a moment, as it were, undergo a perfect and entire change, and the most inveterate and incurable disease radically expelled, is surely a different thing, and must be acknowledged a very singular and marvellous event. If an old man, languishing under disease and infirmity, had died of mere fright, nobody would have been surprised at it; but that he should be absolutely cured, and his constitution renovated by it, is a most extraordinary fact, which, while I am compelled to believe by unexceptionable evidence, I am totally at a loss to account for.
I am your sincerely
affectionate brother,
JACOB RUSH.”
These facts, and many similar ones which might be mentioned, afford ample encouragement to proceed in enumerating the means which are proper to prevent the recurrence of the gout, or, in other words, to eradicate it from the system.
V. I shall first mention the means of preventing the return of that state of the disease which is accompanied with violent action, and afterwards take notice of the means of preventing the return of that state of it, in which a feeble morbid action takes place in the blood-vessels. The means for this purpose consist in avoiding all the remote, exciting, and predisposing causes of the gout which have been mentioned. I shall say a few words upon the most important of them, in the order that has been proposed.
I. The first remedy for obviating the violent state of gout is,
1. Temperance. This should be regulated in its degrees by the age, habits, and constitution of the patient. A diet consisting wholly of milk, vegetables, and simple water, has been found necessary to prevent the recurrence of the gout in some cases. But, in general, fish, eggs, the white meats and weak broths may be taken in small quantities once a day, with milk and vegetables at other times. A little salted meat, which affords less nourishment than fresh, may be eaten occasionally. It imparts vigour to the stomach, and prevents dyspepsia from a diet consisting chiefly of vegetables. The low and acid wines should be avoided, but weak Madeira or sherry wine and water, or small beer, may be drunken at meals. The latter liquor was the favourite drink of Dr. Sydenham in his fits of the gout. Strong tea and coffee should not be tasted, where there is reason to believe the habitual use of them has contributed to bring on the disease.
From the disposition of the gout to return in the spring and autumn, greater degrees of abstinence in eating and drinking will be necessary at those seasons than at any other time. With this diminution of aliment, gentle purges should be taken, to obviate an attack of the gout. In persons above fifty years of age, an abstemious mode of living should be commenced with great caution. It has sometimes, when entered upon suddenly, and carried to its utmost extent, induced fits of the gout, and precipitated death. In such persons, the abstractions from their usual diet should be small, and our dependence should be placed upon other means to prevent a return of the disease.
2. Moderate labour and gentle exercise have frequently removed that debility and vibratility in the blood-vessels, on which a predisposition to the gout depends. Hundreds of persons who have been reduced by misfortunes to the necessity of working for their daily bread, have thrown off a gouty diathesis derived from their patents, or acquired by personal acts of folly and intemperance. The employments of agriculture afford the most wholesome labour, and walking, the most salutary exercise. To be useful, they should be moderate. The extremes of indolence and bodily activity meet in a point. They both induce debility, which predisposes to a recurrence of a fit of the gout. Riding in a carriage, and on horseback, are less proper as a means of preventing the disease than walking. Their action upon the body is partial. The lower limbs derive no benefit from it, and on these the violent state of gout generally makes its first attack. In England, many domestic exercises have been contrived for gouty people, such as shuttle-cock, bullets, the chamber-horse, and the like, but they are all trifling in their effects, compared with labour, and exercise in the open air. The efficacy of the former of those prophylactic remedies will appear in a strong point of light, when we consider, how much the operation of the remote and exciting causes of the gout which act more or less upon persons in the humblest ranks of society, are constantly counteracted in their effects, by the daily labour which is necessary for their subsistence.
3. To prevent the recurrence of the gout, cold should be carefully avoided, more especially when it is combined with moisture. Flannel should be worn next to the skin in winter, and muslin in summer, in order to keep up a steady and uniform perspiration. Fleecy hosiery should be worn in cold weather upon the breast and knees, and the feet should be kept constantly warm and dry by means of socks and cork-soaled shoes. It was by wetting his feet, by standing two or three hours upon the damp ground, that colonel Miles produced the gout in his stomach and bowels which had nearly destroyed him in the year 1795.
4. Great moderation should be used by persons who are subject to the gout in the exercise of their understandings and passions. Intense study, fear, terror, anger, and even joy, have often excited the disease into action. It has been observed, that the political and military passions act with more force upon the system, than those which are of a social and domestic nature; hence generals and statesmen are so often afflicted with the gout, and that too, as was hinted in another place, in moments the most critical and important to the welfare of a nation. The combination of the exercises of the understanding, and the passion of avarice in gaming, have often produced an attack of this disease.
These facts show the necessity of gouty people subjecting their minds, with all their operations, to the government of reason and religion. The understanding should be exercised only upon light and pleasant subjects. No study should ever be pursued till it brings on fatigue; and, above all things, midnight, and even late studies should be strictly avoided. A gouty man should always be in bed at an early hour. This advice has the sanction of Dr. Sydenham's name, and experience proves its efficacy in all chronic diseases.
5. The venereal appetite should be indulged with moderation. And,
6. Costiveness should be prevented by all persons who wish to escape a return of violent fits of the gout. Sulphur is an excellent remedy for this purpose. Dr. Cheyne commends it in high terms. His words are, “Sulphur is one of the best remedies in the intervals of the gout. In the whole extent of the materia medica, I know not a more safe and active medicine[70].” Two cases have come within my knowledge, in which it has kept off fits of the gout for several years, in persons who had been accustomed to have them once or twice a year. Rhubarb in small quantities chewed, or in the form of pills, may be taken to obviate costiveness, by persons who object to the habitual use of sulphur. Dr. Cheyne, who is lavish in his praises of that medicine as a gentle laxative, says, he “knew a noble lord of great worth and much gout, who, by taking from the hands of a quack a drachm of rhubarb, tinged with cochineal to disguise it, every morning for six weeks, lived in health, for four years after, without any symptom of it[71].”
I have said that abstinence should be enjoined with more strictness in the spring and autumn, than at any other time, to prevent a return of the gout. From the influence of the weather at those seasons in exciting febrile actions in the system, the loss of a pint of blood will be useful in some cases for the same purpose. It will be the more necessary if the gout has not paid its habitual visits to the system. The late Dr. Gregory had been accustomed to an attack of the gout every spring. Two seasons passed away without his feeling any symptoms of it. He began to flatter himself with a hope that the predisposition to the disease had left him. Soon afterwards he died suddenly of an apoplexy. The loss of a few ounces of blood at the usual time in which the gout affected him, would probably have protracted his life for many years. In the year 1796, in visiting a patient, I was accidentally introduced into a room where a gentleman from the Delaware state had been lying on his back for near six weeks with an acute fit of the gout. He gave me a history of his sufferings. His pulse was full and tense, and his whole body was covered with sweat from the intensity of his pain. He had not had his bowels opened for ten days. I advised purging and bleeding in his case. The very names of those remedies startled him, for he had adopted the opinion of the salutary nature of a fit of the gout, and therefore hugged his chains. After explaining the reason of my prescriptions, he informed me, in support of them, that he had escaped the gout but two years in twenty, and that in one of these two years he had been bled for a fall from his horse, and, in the other, his body had been reduced by a chronic fever, previously to the time of the annual visit of his gout.
As a proof of the efficacy of active, or passive depletion, in preventing the gout, it has been found that persons who sweat freely, either generally or partially, or who make a great deal of water, are rarely affected by it.
An epitome of all that has been said upon the means of preventing a return of the gout, may be delivered in a few words. A man who has had one fit of it, should consider himself in the same state as a man who has received the seeds of a malignant fever into his blood. He should treat his body as if it were a Florence flask. By this means he will probably prevent, during his life, the re-excitement of the disease.
Are issues proper to prevent the return of the violent state of gout? I have heard of an instance of an issue in the leg having been effectual for this purpose; but if the remedies before-mentioned be used in the manner that has been directed, so unpleasant a remedy can seldom be necessary.
Are bitters proper to prevent a return of this state of gout? It will be a sufficient answer to this question to mention, that the duke of Portland's powder, which is composed of bitter ingredients, excited a fatal gout in many people who used it for that purpose. I should as soon expect to see gold produced by the operations of fire upon copper or lead, as expect to see the gout prevented or cured by any medicine that acted upon the system, without the aid of more or less of the remedies that have been mentioned.
II. We come now, in the last place, to mention the remedies which are proper to prevent a return of that state of gout which is attended with a feeble morbid action in the blood-vessels and viscera.
This state of gout generally occurs in the evening of life, and in persons of delicate habits, or in such as have had their constitutions worn down by repeated attacks of the disease.
The remedies to prevent it are,
1. A gently stimulating diet, consisting of animal food well cooked, with sound old Madeira or sherry wine, or weak spirit and water. Salted, and even smoked meat may be taken, in this state of the system, with advantage. It is an agreeable tonic, and is less disposed to create plethora than fresh meat. Pickles and vinegar should seldom be tasted. They dispose to gouty spasms in the stomach and bowels. Long intervals between meals should be carefully avoided. The stomach, when overstretched or empty, is always alike predisposed to disease. There are cases in which the evils of inanition in the stomach will be prevented, by a gouty patient eating in the middle of the night.
2. The use of chalybeate medicines. These are more safe when used habitually, than bitters. I have long been in the practice of giving the different preparations of iron in large doses, in chronic diseases, and in that state of debility which disposes to them. A lady of a weak constitution informed Dr. Cheyne, that she once asked Dr. Sydenham how long she might safely take steel. His answer was, that “she might take it for thirty years, and then begin again if she continued ill[72].”
Water impregnated with iron, either by nature or art, may be taken instead of the solid forms of the metal. It will be more useful if it be drunken in a place where patients will have the benefit of country air.
3. The habitual use of the volatile tincture of gum guiacum, and of other cordial and gently stimulating medicines. A clove of garlic taken once or twice a day, has been found useful in debilitated habits predisposed to the gout. It possesses a wonderful power in bringing latent excitement into action. It moreover acts agreeably upon the nervous system.
Mr. Small found great benefit from breakfasting upon a tea made of half a drachm of ginger cut into small slices, in preventing occasional attacks of the gout in his stomach. Sir Joseph Banks was much relieved by a diet of milk, with ginger boiled in it. The root of the sassafras of our country might probably be used with advantage for the same purpose. Aurelian speaks of certain remedies for the gout which he calls “annalia[73].” The above medicines belong to this class. To be effectual, they should be persisted in, not for one year only, but for many years.
4. Warmth, uniformly applied, by means of suitable dresses, and sitting rooms, to every part of the body.
5. The warm bath in winter, and the temperate, or cold bath in summer.
6. Exercise. This may be in a carriage, or on horseback. The viscera being debilitated in this state of predisposition to the gout, are strengthened in a peculiar manner by the gentle motion of a horse. Where this or other modes of passive exercise cannot be had, frictions to the limbs and body should be used every day.
7. Costiveness should be avoided by taking occasionally one or two table spoons full of Dr. Warner's purging tincture prepared by infusing rhubarb, orange peel, and caraway seeds, of each an ounce, for three days in a quart of Madeira, or any other white wine. If this medicine be ineffectual for opening the bowels, rhubarb may be taken in the manner formerly mentioned.
8. The understanding and passions should be constantly employed in agreeable studies and pursuits. Fatigue of mind and body should be carefully avoided.
9. A warm climate often protracts life in persons subject to this state of gout. The citizens of Rome who had worn down their constitutions by intemperance, added many years to their lives, by migrating to Naples, and enjoying there, in a warmer sun, the pure air of the Mediterranean, and sir William Temple says the Portuguese obtain the same benefit by transporting themselves to the Brazils, after medicine and diet cease to impart vigour to their constitutions in their native country.
Thus have I enumerated the principal remedies for curing and preventing the gout. Most of them are to be met with in books of medicine, but they have been administered by physicians, or taken by patients with so little regard to the different states of the system, that they have in many instances done more harm than good. Solomon places all wisdom, in the management of human affairs, in finding out the proper times for performing certain actions. Skill in medicine, consists in an eminent degree in timing remedies. There is a time to bleed, and a time to withhold the lancet. There is a time to give physic, and a time to trust to the operations of nature. There is a time to eat meat, and there is a time to abstain from it. There is a time to give tonic medicines, and a time to refrain from them. In a word, the cure of the gout depends wholly upon two things, viz. proper remedies, in their proper times, and places.
I shall take leave of this disease, by comparing it to a deep and dreary cave in a new country, in which ferocious beasts and venomous reptiles, with numerous ghosts and hobgoblins, are said to reside. The neighbours point at the entrance of this cave with horror, and tell of the many ravages that have been committed upon their domestic animals, by the cruel tenants which inhabit it. At length a school-boy, careless of his safety, ventures to enter this subterraneous cavern, when! to his great delight, he finds nothing in it but the same kind of stones and water he left behind him upon the surface of the earth. In like manner, I have found no other principles necessary to explain the cause of the gout, and no other remedies necessary to cure it, than such as are admitted in explaining the causes, and in prescribing for the most simple and common diseases.
Footnotes:
[59] Medical Memoirs, vol. III.
[60] Medical Reports on the Effects of Hot and Cold Water, p. 215.
[61] Defence of Blood-letting, vol. IV.
[62] Medical Observations and Inquiries, vol VI. p. 201.
[63] Physical and Literary Essays, vol. III. p. 469.
[64] Defence of Blood-letting.
[65] Medical Observations and Inquiries, vol. vi. p. 220.
[66] Essay upon the Cure of the Gout by Moxa, vol. i. folio edition, p. 143 and 141.
[67] Medical Observations and Inquiries, vol. vi. p. 220.
[68] Medical Memoirs, vol. III.
[69] Observat. Chirurg. Cent. 1. Obs. 79.
[70] Essay on the Nature and True Method of Treating the Gout, p. 36.
[72] Essay on the Nature, and True Method of Treating the Gout, p. 69.
[73] Morborum Chronicorum. Lib. v. Cap. 2.
OBSERVATIONS
UPON
THE NATURE AND CURE
OF THE
HYDROPHOBIA.
In entering upon the consideration of this formidable disease, I feel myself under an involuntary impression, somewhat like that which was produced by the order the king of Syria gave to his captains when he was conducting them to battle: “Fight not with small or great, save only with the king of Israel[74].” In whatever light we contemplate the hydrophobia, it may be considered as pre-eminent in power and mortality, over all other diseases.
It is now many years since the distress and horror excited by it, both in patients and their friends, led me with great solicitude to investigate its nature. I have at length satisfied myself with a theory of it, which, I hope, will lead to a rational and successful mode of treating it.
For a history of the symptoms of the disease, and many interesting facts connected with it, I beg leave to refer the reader to Dr. Mease's learned and ingenious inaugural dissertation, published in the year 1792.
The remote and exciting causes of the hydrophobia are as follow:
1. The bite of a rabid animal. Wolves, foxes, cats, as well as dogs, impart the disease. It has been said that blood must be drawn in order to produce it, but I have heard of a case in Lancaster county, in Pennsylvania, in which a severe contusion, by the teeth of the rabid animal, without the effusion of a drop of red blood, excited the disease. Happily for mankind, it cannot be communicated by blood, or saliva falling upon sound parts of the body. In Maryland, the negroes eat with safety the flesh of hogs that have perished from the bite of mad dogs; and I have heard of the milk of a cow, at Chestertown, in the same state, having been used without any inconvenience by a whole family, on the very day in which she was affected by this disease, and which killed her in a few hours. Dr. Baumgarten confirms these facts by saying, that “the flesh and milk of rabid animals have been eaten with perfect impunity[75].”
In the following observations I shall confine myself chiefly to the treatment of the hydrophobia which arises from the bite of a rabid animal, but I shall add in this place a short account of all its other causes.
2. Cold night air. Dr. Arthaud, late president of the society of Philadelphians in St. Domingo, has published several cases in which it was produced in negroes by sleeping all night in the open air.
3. A wound in a tendinous part.
4. Putrid and impure animal food.
5. Worms.
6. Eating beech nuts.
7. Great thirst.
8. Exposure to intense heat.
9. Drinking cold water when the body was very much heated.
10. A fall.
11. Fear.
12. Hysteria.
13. Epilepsy.
14. Tetanus.
15. Hydrocephalus. Of the presence of hydrophobia in the hydrocephalic state of fever, there have been several instances in Philadelphia.
16. An inflammation of the stomach.
17. The dysentery.
18. The typhus fever. Dr. Trotter mentions the hydrophobia as a symptom which frequently occurred in the typhus state of fever in the British navy[76].
19. It is taken notice of likewise in a putrid fever by Dr. Coste[77]; and Dr. Griffitts observed it in a high degree in a young lady who died of the yellow fever, in 1793.
20. The bite of an angry, but not a diseased animal.
21. An involuntary association of ideas.
Cases of spontaneous hydrophobia from all the above causes are to be met with in practical writers, and of most of them in M. Audry's learned work, entitled, “Recherches sur la Rage.”
The dread of water, from which this disease derives its name, has five distinct grades. 1. It cannot be drunken. 2. It cannot be touched. 3. The sound of it pouring from one vessel to another, 4. the sight of it, and 5. even the naming of it, cannot be borne, without exciting convulsions. But this symptom is not a universal one. Dr. Mead mentions three cases in which there was no dread of water, in persons who received the disease from the bite of a rabid animal. It is unfortunate for this disease, as well as many others, that a single symptom should impose names upon them. In the present instance it has done great harm, by fixing the attention of physicians so exclusively upon the dread of water which occurs in it, that they have in a great measure overlooked every other circumstance which belongs to the disease. The theory of the hydrophobia, which an examination of its causes, symptoms, and accidental cures, with all the industry I was capable of, has led me to adopt, is, that it is a malignant state of fever. My reasons for this opinion are as follow:
1. The disease in all rabid animals is a fever. This is obvious in dogs who are most subject to it. It is induced in them by the usual causes of fever, such as scanty or putrid aliment[78], extreme cold, and the sudden action of heat upon their bodies. Proofs of its being derived from each of the above causes are to be met with in most of the authors who have written upon it. The animal matters which are rendered morbid by the action of the above causes upon them, are determined to the saliva, in which a change seems to be induced, similar to that which takes place in the perspirable matter of the human species from the operation of similar causes upon it. This matter, it is well known, is the remote cause of the jail fever. No wonder the saliva of a dog should produce a disease of the same kind, after being vitiated by the same causes, and thereby disposed to produce the same effects.
2. The disease called canine madness, prevails occasionally among dogs at those times in which malignant fevers are epidemic. This will not surprise those persons who have been accustomed to observe the prevalence of the influenza and bilious fevers among other domestic animals at a time when they are epidemic among the human species.
3. Dogs, when they are said to be mad, exhibit the usual symptoms of fever, such as a want of appetite, great heat, a dull, fierce, red, or watery eye, indisposition to motion, sleepiness, delirium, and madness. The symptom of madness is far from being universal, and hence many dogs are diseased and die with this malignant fever, that are inoffensive, and instead of biting, continue to fawn upon their masters. Nor is the disposition of the fever to communicate itself by infection universal among dogs any more than the same fever in the human species, and this I suppose to be one reason why many people are bitten by what are called mad dogs, who never suffer any inconvenience from it.
4. A dissection of a dog, by Dr. Cooper, that died with this fever, exhibited all the usual marks of inflammation and effusion which take place in common malignant fevers. I shall in another place mention a fifth argument in favour of the disease in dogs being a malignant fever, from the efficacy of one of the most powerful remedies in that state of fever, having cured it in two instances.
II. The disease produced in the human species by the bite of a rabid animal, is a malignant fever. This appears first from its symptoms. These, as recorded by Aurelian, Mead, Fothergill, Plummer, Arnold, Baumgarten, and Morgagni, are chills, great heat, thirst, nausea, a burning sensation in the stomach, vomiting, costiveness; a small, quick, tense, irregular, intermitting, natural, or slow pulse; a cool skin, great sensibility to cold air, partial cold and clammy sweats on the hands, or sweats accompanied with a warm skin diffused all over the body, difficulty of breathing, sighing, restlessness, hiccup, giddiness, head-ach, delirium, coma, false vision, dilatation of the pupils, dulness of sight, blindness, glandular swellings, heat of urine, priapism, palpitation of the heart, and convulsions. I know that there are cases of hydrophobia upon record, in which there is said to be a total absence of fever. The same thing has been said of the plague. In both cases the supposed absence of fever is the effect of stimulus acting upon the blood-vessels with so much force as to suspend morbid action in them. By abstracting a part of this stimulus, a fever is excited, which soon discovers itself in the pulse and on the skin, and frequently in pains in every part of the body. The dread of water, and the great sensibility of the system to cold air, are said to give a specific character to the hydrophobia; but the former symptom, it has been often seen, occurs in diseases from other causes, and the latter has been frequently observed in the yellow fever. It is no more extraordinary that a fever excited by the bite of a rabid animal should excite a dread of water, than that fevers from other causes should produce aversion from certain aliments, from light, and from sounds of all kinds; nor is it any more a departure from the known laws of stimulants, that the saliva of a mad dog should affect the fauces, than that mercury should affect the salivary glands. Both stimuli appear to act in a specific manner.
2. The hydrophobia partakes of the character of a malignant fever, in appearing at different intervals from the time in which the infection is received into the body. These intervals are from one day to five or six months. The small-pox shows itself in intervals from eight to twenty days, and the plague and yellow fever from the moment in which the miasmata are inhaled, to nearly the same distance of time. This latitude in the periods at which infectious and contagious matters are brought into action in the body, must be resolved into the influence which the season of the year, the habits of the patients, and the passion of fear have upon them.
Where the interval between the time of being bitten, and the appearance of a dread of water, exceeds five or six months, it is probable it may be occasioned by a disease derived from another cause. Such a person is predisposed in common with other people to all the diseases of which the hydrophobia is a symptom. The recollection of the poisonous wound he has received, and its usual consequences, is seldom absent from his mind for months or years. A fever, or an affection of his nerves from their most common causes, cannot fail of exciting in him apprehensions of the disease which usually follows the accident to which he has been exposed. His fears are then let loose upon his system, and produce in a short time a dread of water which appears to be wholly unconnected with the bite of a rabid animal. Similar instances of the effects of fear upon the human body are to be met with in books of medicine. The pains produced by fear acting upon the imagination in supposed venereal infections, are as real and severe as they are in the worst state of that disease.
3. Blood drawn in the hydrophobia exhibits the same appearances which have been remarked in malignant fevers. In Mr. Bellamy, the gentleman whose case is so minutely related by Dr. Fothergill, the blood discovered with “slight traces of size, serum remarkably yellow.” It was uncommonly sizy in a boy of Mr. George Oakley whom I saw, and bled for the first time, on the fourth day of his disease, in the beginning of the year 1797. His pulse imparted to the fingers the same kind of quick and tense stroke which is common in an acute inflammatory fever. He died in convulsions the next day. He had been bitten by a mad dog on one of his temples, three weeks before he discovered any signs of indisposition. There are several other cases upon record, of the blood exhibiting, in this disease, the same appearances as in common malignant and inflammatory fevers.
4. The hydrophobia accords exactly with malignant fevers in its duration. It generally terminates in death, according to its violence, and the habit of the patient, in the first, second, third, fourth, or fifth day, from the time of its attack, and with the same symptoms which attend the last stage of malignant fevers.
5. The body, after death from the hydrophobia, putrifies with the same rapidity that it does after death from a malignant fever in which no depletion has been used.
6. Dissections of bodies which have died of the hydrophobia, exhibit the same appearances which are observed in the bodies of persons who have perished of malignant fevers. These appearances, according to Morgagni and Tauvry[79], are marks of inflammation in the throat, œsophagus, trachea, brain, stomach, liver, and bowels. Effusions of water, and congestions of blood in the brain, large quantities of dark-coloured or black bile in the gall-bladder and stomach, mortifications in the bowels and bladder, livid spots on the surface of the body, and, above all, the arteries filled with fluid blood, and the veins nearly empty. I am aware, that two cases of death from hydrophobia are related by Dr. Vaughan, in which no appearance of disease was discovered by dissection in any part of the body. Similar appearances have occasionally been met with in persons who have died of malignant fevers. In another place I hope to prove, that we err in placing disease in inflammation, for it is one of its primary effects only, and hence, as was before remarked, it does not take place in many instances in malignant fevers, until the arteries are so far relaxed by two or three bleedings, as to be able to relieve themselves by effusing red blood into serous vessels, and thus to produce that error loci which I shall say hereafter is essential to inflammation[80]. The existence of this grade of action in the arteries may always be known by the presence of sizy blood, and by the more obvious and common symptoms of fever.
The remedies for hydrophobia, according to the principles I have endeavoured to establish, divide themselves naturally into two kinds.
I. Such as are proper to prevent the disease, after the infection of the rabid animal is received into the body.
II. Such as are proper to cure it when formed.
The first remedy under the first general head is, abstracting or destroying the virus, by cutting or burning out the wounded part, or by long and frequent effusions of water upon it, agreeably to the advice of Dr. Haygarth, in order to wash the saliva from it. The small-pox has been prevented, by cutting out the part in which the puncture was made in the arm with variolous matter. There is no reason why the same practice should not succeed, if used in time, in the hydrophobia. Where it has failed of success, it has probably been used after the poison has contaminated the blood. The wound should be kept open and running for several months. In this way a servant girl, who was bitten by the same cat that bit Mr. Bellamy, is supposed by Dr. Fothergill to have escaped the disease. Dr. Weston of Jamaica believes that he prevented the disease by the same means, in two instances. Perhaps an advantage would arise from exciting a good deal of inflammation in the wound. We observe after inoculation, that the more inflamed the puncture becomes, and the greater the discharge from it, the less fever and eruption follow in the small-pox.
A second preventive is a low diet, such as has been often used with success to mitigate the plague and yellow fever. The system, in this case, bends beneath the stimulus of the morbid saliva, and thus obviates or lessens its effects at a future day.
During the use of these means to prevent the disease, the utmost care should be taken to keep up our patient's spirits, by inspiring confidence in the remedies prescribed for him.
Mercury has been used in order to prevent the disease. There are many well-attested cases upon record, of persons who have been salivated after being bitten by mad animals, in whom the disease did not show itself, but there are an equal number of cases to be met with, in which a salivation did not prevent it. From this it would seem probable, that the saliva did not infect in the cases in which the disease was supposed to have been prevented by the mercury. At the time calomel was used to prepare the body for the small-pox, a salivation was often induced by it. The affection of the salivary glands in many instances lessened the number of pock, but I believe in no instance prevented the eruptive fever.
I shall say nothing here of the many other medicines which have been used to prevent the disease. No one of them has, I believe, done any more good, than the boasted specifics which have been used to eradicate the gout, or to procure old age. They appear to have derived their credit from some of the following circumstances accompanying the bite of the animal.
1. The animal may have been angry, but not diseased with a malignant fever such as I have described.
2. He may have been diseased, but not to such a degree as to have rendered his saliva infectious.
3. The saliva, when infectious, may have been so washed off in passing through the patient's clothes, as not to have entered the wound made in the flesh. And
4. There may have been no predisposition in the patient to receive the fever. This is often observed in persons exposed to the plague, yellow fever, small-pox, and to the infection of the itch, and the venereal disease.
The hydrophobia, like the small-pox, generally comes on with some pain, and inflammation in the part in which the infection was infused into the body, but to this remark, as in the small-pox, there are some exceptions. As soon as the disease discovers itself, whether by pain or inflammation in the wounded part, or by any of the symptoms formerly mentioned, the first remedy indicated is blood-letting. All the facts which have been mentioned, relative to its cause, symptoms, and the appearances of the body after death, concur to enforce the use of the lancet in this disease. Its affinity to the plague and yellow fever in its force, is an additional argument in favour of that remedy. To be effectual, it should be used in the most liberal manner. The loss of 100 to 200 ounces of blood will probably be necessary in most cases to effect a cure. The pulse should govern the use of the lancet as in other states of fever, taking care not to be imposed upon by the absence of frequency in it, in the supposed absence of fever, and of tension in affections of the stomach, bowels, and brain. This practice, in the extent I have recommended it, is justified not only by the theory of the disease, but by its having been used with success in the following cases.
Dr. Nugent cured a woman by two copious bleedings, and afterwards by the use of sweating and cordial medicines.
Mr. Wrightson was encouraged by Dr. Nugent's success to use the same remedies with the same happy issue in a boy of 15 years of age[81].
Mr. Falconer cured a young woman of the name of Hannah Moore, by “a copious bleeding,” and another depleting remedy to be mentioned hereafter[82]
Mr. Poupart cured a woman by bleeding until she fainted, and Mr. Berger gives an account of a number of persons being bitten by a rabid animal, all of whom died, except two who were saved by bleeding[83].
In the 40th volume of the Transactions of the Royal Society of London, there is an account of a man being cured of hydrophobia by Dr. Hartley, by the loss of 120 ounces of blood.
Dr. Tilton cured this disease in a woman in the Delaware state by very copious bleeding. The remedy was suggested to the doctor by an account taken from a London magazine of a dreadful hydrophobia being cured by an accidental and profuse hæmorrhage from the temporal artery[84].
A case is related by Dr. Innes[85], of the loss of 116 ounces of blood in seven days having cured this disease. In the patient who was the subject of this cure, the bleeding was used in the most depressed, and apparently weak state of the pulse. It rose constantly with the loss of blood.
The cases related by Dr. Tilton and Dr. Innes were said to be of a spontaneous nature, but the morbid actions were exactly the same in both patients with those which are derived from the bite of a rabid animal. There is but one remote cause of disease, and that is stimulus, and it is of no consequence in the disease now under consideration, whether the dread of water be the effect of the saliva of a rabid animal acting upon the fauces, or of a morbid excitement determined to those parts by any other stimulus. The inflammation of the stomach depends upon the same kind of morbid action, whether it be produced by the miasmata of the yellow fever, or the usual remote and exciting causes of the gout. An apoplexy is the same disease when it arises from a contusion by external violence, that it is when it arises spontaneously from the congestion of blood or water in the brain. A dropsy from obstructions in the liver induced by strong drink, does not differ in its proximate cause from the dropsy brought on by the obstructions in the same viscus which are left by a neglected, or half cured bilious fever. These remarks are of extensive application, and, if duly attended to, would deliver us from a mass of error which has been accumulating for ages in medicine: I mean the nomenclature of diseases from their remote causes. It is the most offensive and injurious part of the rubbish of our science.
I grant that bleeding has been used in some instances in hydrophobia without effect, but in all such cases it was probably used out of time, or in too sparing a manner. The credit of this remedy has suffered in many other diseases from the same causes. I beg it may not be tried in this disease, by any physician who has not renounced our modern systems of nosology, and adopted, in their utmost extent, the principles and practice of Botallus and Sydenham in the treatment of malignant fevers.
Before I quit the subject of blood-letting in hydrophobia, I have to add, that it has been used with success in two instances in dogs that had exhibited all the usual symptoms of what has been called madness. In one case, blood was drawn by cutting off the tail, in the other, by cutting off the ears of the diseased animal. I mention these facts with pleasure, not only because they serve to support the theory and practice which I have endeavoured to establish in this disease, but because they will render it unnecessary to destroy the life of a useful and affectionate animal in order to prevent his spreading it. By curing it in a dog by means of bleeding, we moreover beget confidence in the same remedy in persons who have been bitten by him, and thus lessen the force of the disease, by preventing the operation of fear upon the system.
2. Purges and glysters have been found useful in the hydrophobia. They discharge bile which is frequently vitiated, and reduce morbid action in the stomach and blood-vessels. Dr. Coste ascribes the cure of a young woman in a convent wholly to glysters given five or six times every day.
3. Sweating after bleeding completed the cure of the boy whose case is mentioned by Mr. Wrightson. Dr. Baumgarten speaks highly of this mode of depleting, and says further, that it has never been cured “but by evacuations of some kind.”
4. All the advantages which attend a salivation in common malignant fevers, are to be expected from it in the hydrophobia. It aided blood-letting in two persons who were cured by Mr. Falconer and Dr. Le Compt.
There are several cases upon record in which musk and opium have afforded evident relief in this disease.
A physician in Virginia cured it by large doses of bark and wine. I have no doubt of the efficacy of these remedies when the disease is attended with a moderate or feeble morbid action in the system, for I take it for granted, it resembles malignant fevers from other causes in appearing in different grades of force. In its more violent and common form, stimulants of all kinds must do harm, unless they are of such a nature, and exhibited in such quantities, as to exceed in their force the stimulus of the disease; but this is not to be expected, more especially as the stomach is for the most part so irritable as sometimes to reject the mildest aliments as well as the most gentle medicines.
After the morbid actions in the system have been weakened, tonic remedies would probably be useful in accelerating the cure.
Blisters and stimulating cataplasms, applied to the feet, might probably be used with the same advantage in the declining state of the disease, that they have been used in the same stage of other malignant fevers.
The cold bath, also long immersion in cold water, have been frequently used in this disease. The former aided the lancet, in the cure of the man whose case is related by Dr. Hartley. There can be no objection to the cold water in either of the above forms, provided no dread is excited by it in the mind of the patient.
The reader will perceive here that I have deserted an opinion which I formerly held upon the cause and cure of the tetanus. I supposed the hydrophobia to depend upon debility. This debility I have since been led to consider as partial, depending upon abstraction of excitement from some, and a morbid accumulation of it in other parts of the body. The preternatural excitement predominates so far, in most cases of hydrophobia, over debility, that depleting remedies promise more speedily and safely to equalize, and render it natural, than medicines of an opposite character.
In the treatment of those cases of hydrophobia which are not derived from the bite of a rabid animal, regard should always be had to its remote and exciting causes, so as to accommodate the remedies to them.
The imperfection of the present nomenclature of medicine has become the subject of general complaint. The mortality of the disease from the bite of a rabid animal, has been increased by its name. The terms hydrophobia and canine madness, convey ideas of the symptoms of the disease only, and of such of them too as are by no means universal. If the theory I have delivered, and the practice I have recommended, be just, it ought to be called the hydrophobic state of fever. This name associates it at once with all the other states of fever, and leads us to treat it with the remedies which are proper in its kindred diseases, and to vary them constantly with the varying state of the system.
In reviewing what has been said of this disease, I dare not say that I have not been misled by the principles of fever which I have adopted; but if I have, I hope the reader will not be discouraged by my errors from using his reason in medicine. By contemplating those errors, he may perhaps avoid the shoals upon which I have been wrecked. In all his researches, let him ever remember that there is the same difference between the knowledge of a physician who prescribes for diseases as limited by genera and species, and of one who prescribes under the direction of just principles, that there is between the knowledge we obtain of the nature and extent of the sky, by viewing a few feet of it from the bottom of a well, and viewing from the top of a mountain the whole canopy of heaven.
Since the first edition of the foregoing observations, I have seen a communication to the editors of the Medical Repository[86], by Dr. Physick, which has thrown new light upon this obscure disease, and which, I hope, will aid the remedies that have been proposed, in rendering them more effectual for its cure. The doctor supposes death from hydrophobia to be the effect of a sudden and spasmodic constriction of the glottis, inducing suffocation, and that it might be prevented by creating an artificial passage for air into the lungs, whereby life might be continued long enough to admit of the disease being cured by other remedies. The following account of a dissection is intended to show the probability of the doctor's proposal being attended with success.
On the 13th of September, 1802, I was called, with Dr. Physick, to visit, in consultation with Dr. Griffitts, the son of William Todd, Esq. aged five years, who was ill with the disease called hydrophobia, brought on by the bite of a mad dog, on the 6th of the preceding month. The wound was small, and on his cheek, near his mouth, two circumstances which are said at all times to increase the danger of wounds from rabid animals. From the time he was bitten, he used the cold bath daily, and took the infusion, powder, and seeds of the anagallis, in succession, until the 9th of September, when he was seized with a fever which at first resembled the remittent of the season. Bleeding, purging, blisters, and the warm bath were prescribed for him, but without success. The last named remedy appeared to afford him some relief, which he manifested by paddling and playing in the water. At the time I saw him he was much agitated, had frequent twitchings, laughed often; but, with this uncommon excitement in his muscles and nerves, his mind was unusually correct in all its operations.
He discovered no dread of water, except in one instance, when he turned from it with horror. He swallowed occasionally about a spoon full of it at a time, holding the cup in his own hand, as if to prevent too great a quantity being poured at once into his throat. The quick manner of his swallowing, and the intervals between each time of doing so, were such as we sometimes observe in persons in the act of dying of acute diseases. Immediately after swallowing water, he looked pale, and panted for breath. He spoke rapidly, and with much difficulty. This was more remarkably the case when he attempted to pronounce the words carriage, water, and river. After speaking he panted for breath in the same manner that he did after drinking. He coughed and breathed as patients do in the moderate grade of the cynanche trachealis. The dog that had bitten him, Mr. Todd informed me, made a similar noise in attempting to bark, a day or two before he was killed. We proposed making an opening into his windpipe. To this his parents readily consented; but while we were preparing for the operation, such a change for the worse took place, that we concluded not to perform it. A cold sweat, with a feeble and quick pulse, came on; and he died suddenly, at 12 o'clock at night, about six hours after I first saw him. He retained his reason, and a playful humour, till the last minute of his life. An instance of the latter appeared in his throwing his handkerchief at his father just before he expired. The parents consented to our united request to examine his body. Dr. Griffitts being obliged to go into the country, and Dr. Physick being indisposed, I undertook this business the next morning; and, in the presence of Dr. John Dorsey (to whom I gave the dissecting knife), and my pupil Mr. Murduck, I discovered the following appearances. All the muscles of the neck had a livid colour, such as we sometimes observe, after death, in persons who have died of the sore throat. The muscles employed in deglutition and speech were suffused with blood. The epiglottis was inflamed, and the glottis so thickened and contracted, as barely to admit a probe of the common size. The trachea below it was likewise inflamed and thickened, and contained a quantity of mucus in it, such as we observe, now and then, after death from cynanche trachealis. The œsophagus exhibited no marks of disease; but the stomach had several inflamed spots upon it, and contained a matter of a brown appearance, and which emitted an offensive odour.
From the history of this dissection, and of many others, in which much fewer marks appeared of violent disease, in parts whose actions are essential to life, it is highly probable death is not induced in the ordinary manner in which malignant fevers produce it, but by a sudden or gradual suffocation. It is the temporary closure of this aperture which produces the dread of swallowing liquids: hence the reason why they are swallowed suddenly, and with intervals, in the manner that has been described; for, should the glottis be closed during the time of two swallows, in the highly diseased state of the system which takes place in this disease, suffocation would be the immediate and certain consequence. The same difficulty and danger attend the swallowing saliva, and hence the symptom of spitting, which has been so often taken notice of in hydrophobia. Solids are swallowed more easily than fluids, only because they descend by intervals, and because a less closure of the glottis is sufficient to favour their passage into the stomach. This remark is confirmed by the frequent occurrence of death in the very act of swallowing, and that too with the common symptoms of suffocation. To account for death from this cause, and in the manner that has been described, it will be necessary to recollect, that fresh air is more necessary to the action of the lungs in a fever than in health, and much more so in a fever of a malignant character, such as the hydrophobia appears to be, than in fevers of a milder nature. An aversion from swallowing liquids is not peculiar to this disease. It occurs occasionally in the yellow fever. It occurs likewise in the disease which has prevailed among the cats, both in Europe and America, and probably, in both instances, from a dread of suffocation in consequence of the closure of the glottis, and sudden abstraction of fresh air.
The seat of the disease, and the cause of death, being, I hope, thus ascertained, the means of preventing death come next under our consideration. Tonic remedies, in all their forms, have been administered to no purpose. The theory of the disease would lead us to expect a remedy for it in blood-letting. But this, though now and then used with success, is not its cure, owing, as we now see, to the mortal seat of the disease being so far removed from the circulation, as not to be affected by the loss of blood in the most liberal quantity. As well might we expect the inflammation and pain of a paronychia, or what is called a felon on the finger, to be removed by the same remedy. Purging and sweating, though occasionally successful, have failed in many instances; and even a salivation, when excited (which is rarely the case), has not cured it. An artificial aperture into the windpipe alone bids fair to arrest its tendency to death, by removing the symptom which generally induces it, and thereby giving time for other remedies, which have hitherto been unsuccessful, to produce their usual salutary effects in similar diseases[87]. In removing faintness, in drawing off the water in ischuria, in composing convulsions, and in stopping hæmorrhages in malignant fever, we do not cure the disease, but we prevent death, and thereby gain time for the use of the remedies which are proper to cure it. Laryngotomy, according to Fourcroy's advice, in diseases of the throat which obstruct respiration, should be preferred to tracheotomy, and the incision should be made in the triangular space between the thyroid and cricoid cartilages. Should this operation be adopted, in order to save life, it will not offer near so much violence to humanity as many other operations. We cut through a large mass of flesh into the bladder in extracting a stone. We cut into the cavity of the thorax in the operation for the empyema. We perforate the bones of the head in trepanning; and we cut through the uterus, in performing the Cæsarian operation, in order to save life. The operation of laryngotomy is much less painful and dangerous than any of them; and besides permitting the patient to breathe and to swallow, it is calculated to serve the inferior purpose of lessening the disease of the glottis by means of local depletion. After an aperture has been thus made through the larynx, the remedies should be such as are indicated by the state of the system, particularly by the state of the pulse. In hot climates it is, I believe, generally a disease of feeble re-action, and requires tonic remedies; but in the middle and northern states of America it is more commonly attended with so much activity and excitement of the blood-vessels, as to require copious blood-letting and other depleting remedies.
Should this new mode of attacking this furious disease be adopted, and become generally successful, the discovery will place the ingenious gentleman who suggested it in the first rank of the medical benefactors of mankind.
I have only to add a fact upon this subject which may tend to increase confidence in a mode of preventing the disease which has been recommended by Dr. Haygarth, and used with success in several instances. The same dog which bit Mr. Todd's son, bit, at the same time, a cow, a pig, a dog, and a black servant of Mr. Todd's. The cow and pig died; the dog became mad, and was killed by his master. The black man, who was bitten on one of his fingers, exposed the wound for some time, immediately after he received it, to a stream of pump water, and washed it likewise with soap and water. He happily escaped the disease, and is now in good health. That his wound was poisoned is highly probable, from its having been made eight hours after the last of the above animals was bitten, in which time there can be but little doubt of such a fresh secretion of saliva having taken place as would have produced the hydrophobia, had it not been prevented by the above simple remedy. I am not, however, so much encouraged by its happy issue in this case as to advise it in preference to cutting out the wounded part. It should only be resorted to where the fears of a patient, or his distance from a surgeon render it impossible to use the knife.
Footnotes:
[74] II. Chron. xviii. 30.
[75] Medical Commentaries, Philadelphia edition, vol. 7. p. 409.
[76] Medicina Nautica, p. 301.
[77] Medical Commentaries, Dobson's edition, vol. II. p. 476.
[78] “Animal food, in a state of putridity, is amongst the most frequent causes of canine madness.”
“Canine madness chiefly arises from the excessive number of ill-kept and ill-fed dogs.”
Young's Annuals, vol. XVII. p. 561.
[79] Bibliotheque Choisie de Medecine, tome XV. p. 210.
[80] In the 6th volume of the Medical Observations and Inquiries, there is an account of a dissection of a person who had been destroyed by taking opium. “No morbid appearance (says Mr. Whateley, the surgeon who opened the body) was found in any part of the body, except that the villous coat of the stomach was very slightly inflamed.” The stimulus of the opium in this case either produced an action which transcended inflammation, or destroyed action altogether by its immense force, by which means the more common morbid appearances which follow disease in a dead body could not take place.
[81] Medical Transactions, vol. ii. p. 192.
[82] Ditto, p. 222.
[83] Bibliotheque Choisie de Medecine, tome xv. p. 212.
[84] Medical Essays of Edinburgh, vol. i. p. 226.
[85] Medical Commentaries, vol. iii. p. 496.
[86] Volume V.
[87] The hoarse barking, or the total inability of mad dogs to bark, favours still further the idea that the mortal seat of the disease is in the glottis, and that the remedy which has been proposed is a rational one.
AN ACCOUNT
OF
THE MEASLES,
AS THEY
APPEARED IN PHILADELPHIA,
IN THE SPRING OF 1789.
The weather in December, 1788, and in January, 1789, was variable, but seldom very cold. On the first of February, 1789, at six o'clock in the morning, the mercury in Fahrenheit's thermometer fell 5° below 0, in the city of Philadelphia. At twenty miles from the city, on the Schuylkill, it fell 12° below 0, at the same hour. On the 19th and 20th of this month, there fell a quantity of snow, the depth of which, upon an average, was supposed to be about eight or ten inches. On the 23d, 24th, 25th, and 27th, the weather was very cold. The mercury fluctuated during these days between 4° and 10° above 0.
In the intervals between these cold days, the weather frequently moderated, so that the Delaware was frozen and thawed not less than four times. It was not navigable till the 8th of March. There were in all, during the winter and month of March, sixteen distinct falls of snow.
In April and May there were a few warm days; but upon the whole, it was a very cold and backward spring. The peaches failed almost universally. There were no strawberries or cherries on the 24th of May, and every other vegetable product was equally backward. A country woman of 84 years of age informed me, that it was the coldest spring she had ever known. It was uncomfortable to sit without fire till the first of June.
The measles appeared first in the Northern Liberties, in December. They spread slowly in January, and were not universal in the city till February and March.
This disease, like many others, had its precursor. It was either a gum-boil, or a sore on the tongue. They were both very common, but not universal. They occurred, in some instances, several days before the fever, but in general they made their appearance during the eruptive fever, and were a sure mark of the approaching eruption of the measles. I was first led to observe this fact, from having read Dr. Quin's accurate account of the measles in Jamaica. I shall now proceed to mention the symptoms of the measles as they appeared in the different parts of the body.
1. In the head, they produced great pain, swelling of the eye-lids, so as to obstruct the eye-sight, tooth-ach, bleeding at the nose, tinnitus aurium, and deafness; also coma for two days, and convulsions. I saw the last symptom only in one instance. It was brought on by a stoppage of a running from the ear.
2. In the throat and lungs, they produced a soreness and hoarseness, acute or dull pains in the breast and sides, and a painful or distressing cough. In one case, this cough continued for two hours without any intermission, attended by copious expectoration. In two cases, I saw a constant involuntary discharge of phlegm and mucus from the mouth, without any cough. One of them terminated fatally. Spitting of blood occurred in several instances. The symptoms of pneumonia vera notha and typhoides were very common. I saw two fatal cases from pneumonia notha, in both of which the patients died with the trunk of the body in an erect posture. I met with two cases in which there was no cough till the eruption made its appearance on the fourth day, and one which was accompanied by all the usual symptoms of the cynanche trachealis.
3. In the stomach the measles produced, in many instances, sickness and vomiting. And
4. In the bowels, griping, diarrhœa, and, in some instances, bloody stools. The diarrhœa occurred in every stage of the disease, but it was bloody and most painful in its decline. I attended a black girl who discharged a great many worms, but without the least relief of any of her symptoms.
There was a great variety in this disease. 1. In the time of the attack of the fever, from the time of the reception of the contagion. In general the interval was fourteen days, but it frequently appeared before, and sometimes later than that period.
2. In the time of the eruption, from the beginning of the fever. It generally appeared on the third and fourth days. In one case, Dr. Waters informed me, it did not appear till the eighth day.
3. In the abatement or continuance of the fever after the eruption.
4. In the colour and figure of the eruption. In some it put on a pale red, in others a deep, and in a few a livid colour, resembling an incipient mortification. In some there appeared red blotches, in others an equally diffused redness, and in a few, eruptions like the small-pox, called by Dr. Cullen, rubiola varioloides.
5. In the duration of the eruption on the skin. It remained in most cases only three or four days; but in one, which came under my care, it remained nine days.
6. In the manner of its retrocession. I saw very few cases of its leaving the branny appearance so generally spoken of by authors on the skin.
7. In not affecting many persons, and even families who were exposed to it.
The symptoms which continued in many after the retrocession of the measles, were cough, hoarseness, or complete aphonia, which continued in two cases for two weeks; also diarrhœa, opthalmy, a bad taste in the mouth, a defect or excess of appetite, and a fever, which in some instances was of the intermitting kind, but which in more assumed the more dangerous form of the typhus mitior. Two cases of internal dropsy of the brain followed them. One was evidently excited by a fall. They both ended fatally.
During the prevalence of the disease I observed several persons (who had had the measles, and who were closely confined to the rooms of persons ill with them) to be affected with a slight cough, sore throat, and even sores in the mouth. I find a similar fact taken notice of by Dr. Quier.
But I observed further, many children to be affected by a fever, cough, and all the other symptoms of the measles which have been mentioned, except a general eruption, for in some there was a trifling efflorescence about the neck and breast. I observed the same thing in 1773 and 1783. In my note book I find the following account of the appearance of this disease in children in the year 1773. “The measles appeared in March; a catarrh (for by that name I then called it) appeared at the same time, and was often mistaken for them, the symptoms being nearly the same in both. In the catarrh there was in some instances a trifling eruption. A lax often attended it, and some who had it had an extremely sore mouth.”
I was the more struck with this disease, from finding it was taken notice of by Dr. Sydenham. He calls it a morbillous fever. I likewise find an account of it in the 2d article of the 5th volume of the Edinburgh Medical Essays. The words of the author, who is anonymous, are as follow. “During this measly season, several persons, who never had the measles, had all the symptoms of measles, which went off in a few days without any eruptions. The same persons had the measles months or years afterwards.” Is this disease a common fever, marked by the reigning epidemic, and produced in the same manner, and by the same causes, as the variolous fever described by Dr. Sydenham, which he says prevailed at the same time with the small-pox? I think it is not. My reasons for this opinion are as follow.
1. I never saw it affect any but children, in the degree that has been mentioned, and such only as had never had the measles.
2. It affected whole families at the same time. It proved fatal to one of three children whom it affected on the same day.
3. It terminated in a pulmonary consumption in a boy of ten years old, with all the symptoms which attend that disease when it follows the regular measles.
4. It affected a child in one family, on the same day that two other members of the same family were affected by the genuine measles.
5. It appeared on the usual days of the genuine measles, from the time the persons affected by it were exposed to its contagion. And,
6. It communicated the disease in one family, in the usual time in which the disease is taken from the genuine measles.
The measles, then, appear to follow the analogy of the small-pox, which affects so superficially as to be taken a second time, and which produce on persons who have had them what are called the nurse pock. They follow likewise the analogy of another disease, viz. the scarlatina anginosa. In the account of the epidemic for 1773, published in the third volume of the Edinburgh Medical Essays, we are told, that such patients as had previously had the scarlet fever without sore throats, took the sore throat, and had no eruption, while those who had previously had the sore throat had a scarlet eruption, but the throat remained free from the distemper. All other persons who were affected had both.
From these facts, I have taken the liberty of calling it the internal measles, to distinguish it from those which are external. I think the discovery of this new state of this disease of some application to practice.
1. It will lead us to be cautious in declaring any disease to be the external measles, in which there is not a general eruption. From my ignorance of this, I have been led to commit several mistakes, which were dishonourable to the profession. I was called, during the prevalence of the measles in the above-named season, to visit a girl of twelve years old, with an eruption on the skin. I called it the measles. The mother told me it was impossible, for that I had in 1783 attended her for the same disease. I suspect the anonymous author before-mentioned has fallen into the same error. He adds to the account before quoted the following words. “Others, who had undergone the measles formerly, had at this time a fever of the erysipelatous kind, with eruptions like to which nettles cause, and all the previous and concomitant symptoms of the measles, from the beginning to the end of the disease.”
2. If inoculation, or any other mode of lessening the violence of the disease, should be adopted, it will be of consequence to know what persons are secure from the attacks of it, and who are still exposed to it.
I shall now add a short account of my method of treating this disease.
Many hundred families came through the disease without the help of a physician. But in many cases it was attended with peculiar danger, and in some with death. I think it was much more fatal than in the years 1773 and 1783, probably owing to the variable weather in the winter, and the coldness and dampness of the succeeding spring. Dr. Huxham says, he once saw the measles attended with peculiar mortality, during a late cold and damp spring in England. It was much more fatal (cæteris paribus) to adults than to young people.
The remedies I used were,
1. Bleeding, in all cases where great pain and cough with a hard pulse attended. In some I found it necessary to repeat this remedy. But I met with many cases in which it was forbidden by the weakness of the pulse, and by other marks of a feeble action in the blood-vessels.
2. Vomits. These were very useful in removing a nausea; they likewise favoured the eruption of the measles.
3. Demulcent and diluting drinks. These were barley water, bran, and flaxseed tea, dried cherry and raw apple water, also beverage, and cyder and water. The last drink I found to be the most agreeable to my patients of any that have been mentioned.
4. Blisters to the neck, sides, and extremities, according to the symptoms. They were useful in every stage of the disease.
5. Opiates. These were given not only at night, but in small doses during the day, when a troublesome cough or diarrhœa attended.
6. Where a catarrhal fever ensued, I used bleeding and blisters. In those cases in which this fever terminated in an intermittent, or in a mild typhus fever, I gave the bark with evident advantage. In that case of measles, formerly mentioned, which was accompanied by symptoms of cynanche trachealis, I gave calomel with the happiest effects. In the admission of fresh air I observed a medium as to its temperature, and accommodated it to the degrees of action in the system. In different parts of the country, in Pennsylvania and New-Jersey, I heard with great pleasure of the cold air being used as freely and as successfully in this disease, as in the inflammatory small-pox. The same people who were so much benefited by cool air, I was informed, drank plentifully of cold water during every stage of the fever. One thing in favour of this country practice deserves to be mentioned, and that is, evident advantage arose in all the cases which I attended, from patients leaving their beds in the febrile state of this disease. But this was practised only by those in whom inflammatory diathesis prevailed, for these alone had strength enough to bear it.
The convalescent state of this disease required particular attention.
1. A diarrhœa often continued to be troublesome after other symptoms had abated. I relieved it by opiates and demulcent drinks. Bleeding has been recommended for it, but I did not find it necessary in a single case.
2. An opthalmia which sometimes attended, yielded to astringent collyria and blisters.
3. Where a cough or fever followed so slight as not to require bleeding, I advised a milk and vegetable diet, country air, and moderate warmth; for whatever might have been the relation of the lungs in the beginning of the disease to cold air, they were now evidently too much debilitated to bear it.
4. It is a common practice to prescribe purges after the measles. After the asthenic state of this disease they certainly do harm. In all cases, the effects of them may be better obviated by diet, full or low, suitable clothing, and gentle exercise, or country air. I omitted them in several cases, and no eruption or disease of any kind followed their disuse.
I shall only add to this account of the measles, that in several families, I saw evident advantages from preparing the body for the reception of the contagion, by means of a vegetable diet.
AN ACCOUNT
OF
THE INFLUENZA,
AS IT APPEARED
IN PHILADELPHIA,
IN THE AUTUMN OF 1789, IN THE SPRING OF 1790, AND IN THE WINTER OF 1791.
The latter end of the month of August, in the summer of 1789, was so very cool that fires became agreeable. The month of September was cool, dry, and pleasant. During the whole of this month, and for some days before it began, and after it ended, there had been no rain. In the beginning of October, a number of the members of the first congress, that had assembled in New-York, under the present national government, arrived in Philadelphia, much indisposed with colds. They ascribed them to the fatigue and night air to which they had been exposed in travelling in the public stages; but from the number of persons who were affected, from the uniformity of their complaints, and from the rapidity with which it spread through our city, it soon became evident that it was the disease so well known of late years by the name of the influenza.
The symptoms which ushered in the disease were generally a hoarseness, a sore throat, a sense of weariness, chills, and a fever. After the disease was formed, it affected more or less the following parts of the body. Many complained of acute pains in the head. These pains were frequently fixed between the eye-balls, and, in three cases which came under my notice, they were terminated by abscesses in the frontal sinus, which discharged themselves through the nose. The pain, in one of these cases, before the rupture of the abscess, was so exquisite, that my patient informed me, that he felt as if he should lose his reason. Many complained of a great itching in the eye-lids. In some, the eye-lids were swelled. In others, a copious effusion of water took place from the eyes; and in a few, there was a true ophthalmia. Many complained of great pains in one ear, and some of pains in both ears. In some, these pains terminated in abscesses, which discharged for some days a bloody or purulent matter. In others, there was a swelling behind each ear, without a suppuration.—Sneezing was a universal symptom. In some, it occurred not less than fifty times in a day. The matter discharged from the nose was so acrid as to inflame the nostrils and the upper lip, in such a manner as to bring on swellings, sores, and scabs in many people. In some, the nose discharged drops, and in a few, streams of blood, to the amount, in one case, of twenty ounces. In many cases, it was so much obstructed, as to render breathing through it difficult. In some, there was a total defect of taste. In others, there was a bad taste in the mouth, which frequently continued through the whole course of the disease. In some, there was a want of appetite. In others, it was perfectly natural. Some complained of a soreness in their mouths, as if they had been inflamed by holding pepper in them. Some had swelled jaws, and many complained of the tooth-ach. I saw only one case in which the disease produced a coma.
Many were affected with pains in the breast and sides. A difficulty of breathing attended in some, and a cough was universal. Sometimes this cough alternated with a pain in the head. Sometimes it preceded this pain, and sometimes it followed it. It was at all times distressing. In some instances, it resembled the chin-cough. One person expired in a fit of coughing, and many persons spat blood in consequence of its violence. I saw several patients in whom the disease affected the trachea chiefly, producing great difficulty of breathing, and, in one case, a suppression of the voice, and I heard of another in which the disease, by falling on the trachea, produced a cynanche trachealis. In most of the cases which terminated fatally, the patients died of pneumonia notha.
The stomach was sometimes affected by nausea and vomiting; but this was far from being a universal symptom.
I met with four cases in which the whole force of the disease fell upon the bowels, and went off in a diarrhœa; but in general the bowels were regular or costive.
The limbs were affected with such acute pains as to be mistaken for the rheumatism, or for the break-bone-fever of 1780. The pains were most acute in the back and thighs.
Profuse sweats appeared in many over the whole body in the beginning, but without affording any relief. It was in some instances accompanied by erysipelatous, and in four cases which came to my knowledge, it was followed by miliary eruptions.
The pulse was sometimes tense and quick, but seldom full. In a great majority of those whom I visited it was quick, weak, and soft.
There was no appearance in the urine different from what is common in all fevers.
The disease had evident remissions, and the fever seldom continued above three or four days; but the cough, and some other troublesome symptoms, sometimes continued two or three weeks.
In a few persons, the fever terminated in a tedious and dangerous typhus.
In several pregnant women it produced uterine hæmorrhages and abortions.
It affected adults of both sexes alike. A few old people escaped it. It passed by children under eight years old with a few exceptions. Out of five and thirty maniacs in the Pennsylvania hospital, but three were affected by it. No profession or occupation escaped it. The smell of tar and tobacco did not preserve the persons who worked in them from the disease, nor did the use of tobacco, in snuff, smoking, or chewing, afford a security against it.[88]
Even previous and existing diseases did not protect patients from it. It insinuated into sick chambers, and blended itself with every species of chronic complaint.
It was remarkable that persons who worked in the open air, such as sailors, and 'long-shore-men, (to use a mercantile epithet) had it much worse than tradesmen who worked within doors. A body of surveyors, in the eastern woods of Pennsylvania, suffered extremely from it. Even the vigour of constitution which is imparted by the savage life did not mitigate its violence. Mr. Andrew Ellicott, the geographer of the United States, informed me that he was a witness of its affecting the Indians in the neighbourhood of Niagara with peculiar force. The cough which attended this disease was so new and so irritating a complaint among them, that they ascribed it to witchcraft.
It proved most fatal on the sea-shore of the United States.
Many people who had recovered, were affected a second time with all the symptoms of the disease. I met with a woman, who, after recovering from it in Philadelphia, took it a second time in New-York, and a third time upon her return to Philadelphia.
Many thousand people had the disease who were not confined to their houses, but transacted business as usual out of doors. A perpetual coughing was heard in every street of the city. Buying and selling were rendered tedious by the coughing of the farmer and the citizen who met in market places. It even rendered divine service scarcely intelligible in the churches.
A few persons who were exposed to the disease escaped it, and some had it so lightly as scarcely to be sensible of it. Of the persons who were confined to their houses, not a fourth part of them kept their beds.
It proved fatal (with few exceptions) only to old people, and to persons who had been previously debilitated by consumptive complaints. It likewise carried of several hard drinkers. It terminated in asthma in three persons whose cases came under my notice, and in pulmonary consumption, in many more. I met with an instance in a lady, who was much relieved of a chronic complaint in her liver; and I heard of another instance of a clergyman whose general health was much improved by a severe attack of this disease.
It was not wholly confined to the human species. It affected two cats, two house-dogs, and one horse, within the sphere of my observations. One of the dogs disturbed his mistress so much by coughing at night, that she gave him ten drops of laudanum for several nights, which perfectly composed him. One of the cats had a vomiting with her cough. The horse breathed as if he had been affected by the cynanche trachealis.
The scarlatina anginosa, which prevailed during the summer, disappeared after the first of October; but appeared again after the influenza left the city. Nor was the remitting fever seen during the prevalence of the reigning epidemic.
I inoculated about twenty children for the small-pox during this prevalence of the influenza, and never saw that disease exhibit a more favourable appearance.
In the treatment of the influenza I was governed by the state of the system. Where inflammatory diathesis discovered itself by a full or tense pulse, or where great difficulty of breathing occurred, and the pulse was low and weak in the beginning of the disease, I ordered moderate bleeding. In a few cases in which the symptoms of pneumony attended, I bled a second time with advantage. In all these instances of inflammatory affection, I gave the usual antiphlogistic medicines. I found that vomits did not terminate the disease, as they often do a common catarrh, in the course of a day, or of a few hours.
In cases where no inflammatory action appeared in the system, I prescribed cordial drinks and diet, and forbad every kind of evacuation. I saw several instances of persons who had languished for a week or two with the disease, who were suddenly cured by eating a hearty meal, or by drinking half a pint of wine, or a pint of warm punch. In all these cases of weak action in the blood-vessels, liquid laudanum gave great relief, not only by suspending the cough, but by easing the pains in the bones.
I met with a case of an old lady who was suddenly and perfectly cured of her cough by a fright.
The duration of this epidemic in our city was about six weeks. It spread from New-York and Philadelphia in all directions, and in the course of a few months pervaded every state in the union. It was carried from the United States to several of the West-India islands. It prevailed in the island of Grenada in the month of November, 1789, and it was heard of in the course of the ensuing winter in the Spanish settlements in South-America.
The following winter was unusually mild, insomuch that the navigation of the Delaware was not interrupted during the whole season, only from the 7th to the 24th of February. The weather on the 3d and 4th days of March was very cold, and on the 8th and 9th days of the same month, the mercury in Fahrenheit's thermometer stood at 4° at 7 o'clock in the morning. On the 10th and 11th, there fell a deep snow. The weather during the remaining part of the month was cold, rainy, and variable. It continued to be variable during the month of April. About the middle of the month there fell an unusual quantity of rain. The showers which fell on the night of the 17th will long be connected in the memories of the citizens of Philadelphia with the time of the death of the celebrated Dr. Franklin. Several pleurisies appeared during this month; also a few cases of measles. In the last week of the month the influenza made its appearance. It was brought to the city from New-England, and affected, in its course, all the intermediate states. Its symptoms were nearly the same as they were in the preceding autumn, but in many people it put on some new appearances. Several persons who were affected by it had symptoms of madness, one of whom destroyed himself by jumping out of a window. Some had no cough, but very acute pains in the back and head. It was remarked that those who had the disease chiefly in the breast the last year, complained now chiefly of their heads, while those whose heads were affected formerly, now complained chiefly of their breasts. In many it put on the type of an intermitting fever. Several complained of constant chills, or constant sweats; and some were much alarmed by an uncommon blue and dark colour in their hands. I saw one case of ischuria, another of an acute pain in the rectum, a third of anasarca, and a fourth of a palsy in the tongue and arms; all of which appeared to be anomalous symptoms of the influenza. Sneezing, and pains in the ears and frontal sinus, were less common now than they were in the fall; but a pain in the eye-balls was a universal symptom. Some had a pain in the one eye only, and a few had sore eyes, and swellings in the face. Many women who had it, were affected by an irregular appearance of the catamenia. In two persons whom I saw, the cough was incessant for three days, nor could it be composed by any other remedy than plentiful bleeding. A patient of Dr. Samuel Duffield informed me, after his recovery, that he had had no other symptom of the disease than an efflorescence on his skin, and a large swelling in his groin, which terminated in a tedious abscess.
The prisoners in the jail who had it in the autumn, escaped it this spring.
During the prevalence of this disease, I saw no sign of any other epidemic.
It declined sensibly about the first week in June, and after the 12th day of this month I was not called to a single patient in it.
The remedies for it were the same as were used in the fall.
I used bleeding in several cases on the second, third, and fourth days of the disease, where it had appeared to be improper in its first stage. The cases which required bleeding were far from being general. I saw two instances of syncope of an alarming nature, after the loss of ten ounces of blood; and I heard of one instance of a boy who died in half an hour after this evacuation.
I remarked that purges of all kinds worked more violently than usual in this disease.
The convalescence from it was very slow, and a general languor appeared to pervade the citizens for several weeks after it left the city.
The month of December, 1790, was extremely and uniformly cold. In the beginning of the month of January, 1791, the weather moderated, and continued to be pleasant till the 17th, on which day the navigation of the Delaware, which had been completely obstructed by the ice, was opened so as to admit of the arrival of several vessels. During the month of December many people complained of colds; but they were ascribed wholly to the weather. In January four or five persons in a family were affected by colds at the same time; which created a suspicion of a return of the influenza. This suspicion was soon confirmed by accounts of its prevailing in the neighbouring counties of Chester and Montgomery, in Pennsylvania, and in the distant states of Virginia and Rhode-Island. It did not affect near so generally as in the two former times of appearance. There was no difference in the method of treating it. While the common inflammatory diseases of the winter bore the lancet as usual, it was remarked that patients who were attacked by the influenza, did not bear bleeding in a greater proportion, or in a larger quantity, than in the two former times of its appearance in the city.
I shall conclude this account of the influenza by the following observations:
1. It exists independently of the sensible qualities of the air, and in all kinds of weather. Dr. Patrick Russel has proved the plague to be equally independent of the influence of the sensible qualities of the atmosphere, to a certain degree.
2. The influenza passes with the utmost rapidity through a country, and affects the greatest number of people, in a given time, of any disease in the world.
3. It appears from the histories of it which are upon record, that neither climate, nor the different states of society, have produced any material change in the disease. This will appear from comparing the account I have given, with the histories of it which have lately been given by Dr. Grey, Dr. Hamilton, Dr. A. Fothergill, Mr. Chisholm, and other modern physicians. It appears further, that even time itself has not been able materially to change the type of this disease. This is evident, from comparing modern accounts of it with those which have been handed down to us by ancient physicians.
I have hinted in a former essay at the diminutives of certain diseases. There is a state of influenza, which is less violent and more local, than that which has been described. It generally prevails in the winter season. It seems to originate from a morbid matter, generated in crowded and heated churches, and other assemblies of the people. I have seen a cold, or influenza, frequently universal in Philadelphia, which I have distinctly traced to this source. It would seem as if the same species of diseases resembled pictures, and that while some of them partook of the deep and vivid nature of mosaic work, others appeared like the feeble and transient impressions of water colours.
Footnote:
[88] Mr. Howard informs us that the use of tobacco is not a preservative against the plague, as has formerly been supposed; of course that apology for the use of an offensive weed should not be admitted.