North American Medical and Surgical Journal, Vol. 2, No. 3, July, 1826
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Title: North American Medical and Surgical Journal, Vol. 2, No. 3, July, 1826
Author: Various
Editor: Franklin Bache
Benjamin Hornor Coates
Hugh L. Hodge
R. La Roche
Charles D. Meigs
Release date: July 4, 2009 [eBook #29307]
Language: English
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THE
NORTH AMERICAN
MEDICAL AND SURGICAL
JOURNAL.
CONDUCTED BY
HUGH L. HODGE, M.D. | CHAS. D. MEIGS, M.D.
FRANKLIN BACHE, M.D. | B. H. COATES, M.D.
AND
R. LA ROCHE, M.D.
NON DOCTIOR, SED MELIORE IMBUTUS DOCTRINA.
VOL. II.
PHILADELPHIA:
PUBLISHED BY J. DOBSON, AGENT.
JESPER HARDING, PRINTER.
1826.
_Eastern District of Pennsylvania, to wit_
BE IT REMEMBERED, that on the 31st day of March, in the 50th year of the
Independence of the United States of America, A. D. 1826, Hugh L. Hodge,
Franklin Bache, Charles D. Meigs, Benjamin H. Coates, and René La Roche,
of the said District, have deposited in this office the Title of a Book,
the right whereof they claim as Proprietors, in the words following, to
wit:
"_The North American Medical and Surgical Journal. Conducted by Hugh L.
Hodge, M. D., Franklin Bache, M. D., Chas. D. Meigs, M. D., B. H.
Coates, M. D., and R. La Roche, M. D. Non doctior, sed meliore imbutus
doctrina. Vol. II._"
In conformity to the act of Congress of the United States, intituled,
"An act for the encouragement of learning, by securing the copies of
maps, charts, and books, to the authors and proprietors of such copies,
during the times therein mentioned;"--and also to the act, entitled, "An
act supplementary to an act, entitled, "An act for the encouragement of
learning, by securing the copies of maps, charts, and books, to the
authors and proprietors of such copies, during the times therein
mentioned," and extending the benefits thereof to the arts of designing,
engraving, and etching historical and other prints."
D. CALDWELL, Clerk of the Eastern District of Pennsylvania.
CONTENTS
OF VOL. II.
No. III.
ORIGINAL COMMUNICATIONS.
ART. PAGE.
I. Description of the Gangrenous Ulcer of the mouths of children.
By B. H. Coates, M. D., one of the Physicians to the Philadelphia
Children's Asylum, &c. 1
II. Case of Purpura in an Infant, attended with extraordinary
symptoms. By R. M. Huston, M. D. 24
III. History of the Natural and Modified Small Pox, or of the
Variolous and Varioloid Diseases, as they prevailed in
Philadelphia, in the years 1823 and 1824. By John K. Mitchell,
M. D., and John Bell, M. D., attending physicians at the
then Small Pox Hospital. With a plate. 27
IV. Remarks on the Pathology and Treatment of Yellow Fever.
Arranged from the notes of Dr. J. A. Monges, of Philadelphia. 53
V. Remarks on the Prophylactic Treatment of Cholera Infantum.
By Joseph Parrish, M. D., one of the Surgeons to the Pennsylvania
Hospital. 68
VI. Case of Neuralgia cured by Acupuncturation. Communicated
by J. Hunter Ewing, M. D. 77
ANALYTICAL REVIEWS.
VII. Researches into the Nature and Treatment of Dropsy in the
Brain, Chest, Abdomen, Ovarium, and Skin. By Joseph Ayre,
M. D., &c. 79
VIII. An Essay on Venereal Diseases, and the Uses and Abuses of
Mercury in their Treatment. By Richard Carmichael, M. R. I. A.
With Practical Notes, &c. By G. Emerson, M. D. 109
IX. Remarks on some Means employed to destroy Tænia, and expel
them from the Human Body. By Louis Frank, M. D.
Privy Counsellor of her Majesty, Maria Louisa, Duchess of
Parma. 114
X. Researches, Physiological and Pathological, instituted principally
with a View to the Improvement of Medical and Surgical
Practice. By James Blundell, M. D., Lecturer on
Physiology and Midwifery at the United Hospitals of St.
Thomas and Guy. 119
XI. An Inquiry into the Nature and Treatment of Diabetes, Calculus
and other Affections of the Urinary Organs. By William
Prout, M. D., F. R. S. With Notes and Additions, by S.
Colhoun, M. D. 125
MEDICAL LITERATURE.--RETROSPECTIVE REVIEW.
XII. Tractatus de Ventriculo et Intestinis, cui præmittitur alius, de
Partibus continentibus in Genere, et in Specie de iis Abdominis.
Authore Francisco Glissonio. Lond. 1677, 4to. 138
QUARTERLY SUMMARY OF MEDICAL AND SURGICAL INTELLIGENCE.
ANATOMY, 155
1, Papillæ of the Tongue. 2, Villi of the Stomach and Intestines. 3,
Minute distribution of the Vessels of the Liver. 4, Trachea perforating
the Aorta. 5, Monsters. 6, Malformation of the Heart. 7, Acephalous
Mummy. 8, New Anatomical Plates. 9, A Manual of Osteology. 10,
Soemmering's Work on the Anatomy of the Ear. 11, Does the conjunctiva
run over the Cornea?
PHYSIOLOGY, 158
12, Electro-Galvanic phenomena of Acupuncturation. 13, Variations in
Milk. 14, Hyoscyamus dilates the Pupils of the Eyes. 15, Worms in the
Eye. 16, Digestion.
PATHOLOGY, 161
17, Dothinenteria--Pustules of the small Intestines. 18, Dr. Broussais.
19, Whooping Cough. 20, Antiperistaltic Globus--Globus Hystericus.
21, Non-contagion of Yellow Fever.
THERAPEUTICS, MATERIA MEDICA, AND THE PRACTICE OF MEDICINE, 166
22, Iodine. 23, Non-mercurial Treatment of Syphilis. 24, Cancer treated
by Antiphlogistics. 25, Essential Oil of Male Fern as a remedy in Cases
of Tænia. 26, Tincture of Bastard Saffron for the expulsion of Tænia.
27, Oil of Turpentine in Tænia. 28, Action of the Oil of the Euphorbia
Lathyris. 29, Medicinal Properties of the Apocynum Cannabinum or Indian
Hemp. 30, Remarkable Effects from the external application of the
Acetate of Morphia. 31, Cure of Urinary Calculi, by means of the
internal use of the Bicarbonate of Soda. 32, Attempt to cure Abdominal
Dropsy by exciting Peritoneal Inflammation. 33, Artificial Respiration.
34, Secale Cornutum. 35, Animal Magnetism. 36, Sketch of the Medical
Literature of Denmark, Sweden, and Norway. 37, Erysipelatous Mumps or
Angina Parotidiana. 38, Tænia. 39, Scrophula. 40, Digitalis.
SURGERY, 192
41, Dr. Physick's Operation for Artificial Anus denied to have been
performed. 42, Gangrenous Sore Mouth of Children. 43, Operation for
Phymosis. 44, Lunar Caustic on Wounds and Ulcers. 45, Hæmorrhage from
Lithotomy. 46, Extirpation of the Parotid Gland. 47, Aneurism from a
Wound, cured by Valsaiva's method. 48, Protrusion and Wound of the
Stomach. 49, Oesophagotomy. 50, Retention of Urine, caused by a
Stricture of the Urethra, relieved by a forcible but gradual Injection.
51, Tracheotomy. 52, Fistula Lachrymalis. 53, Aneurisma Herniosum. 54,
Extirpation of the Two Dental Arches affected with Osteo-sarcoma. 55,
Traumatic Erysipelas. 56, Obliteration of a portion of the Urethra,
remedied by an Operation. 57, Artificial Joint cured by Caustic. 58,
Epilepsy cured by Trephining.
MIDWIFERY, 205
59, Gastrotomy. 60, Cæsarian Operation, performed with safety to the
Mother and Foetus. 61, Extirpation of the Uterus. 62, Uterine Hæmorrhage.
CHEMISTRY AND PHARMACY, 208
63, State in which Morphia exists in Opium. 64, Peculiar Principles of
Narcotic Plants. 65, Relative quantities of Cinchonia and Quinia with
indention in the most esteemed Varieties of Peruvian Bark. 66, Sulphate
of Quinia, extracted from the Cinchona Bark, exhausted by Decoction.
67, Analysis of Rhubarb. 68, Alkaline Lozenges of Bicarbonate of Soda.
69, Presence of Mercury in Samples of Medicinal Prussic Acid. 70, Proposed
Method of preparing Protoxide of Mercury by precipitation, for
Medical Employment. 71, Goulard's Extract of Lead.
QUARTERLY LIST OF AMERICAN MEDICAL PUBLICATIONS, 214-16
No. IV.
ORIGINAL COMMUNICATIONS.
ART.
I. On the Epidemic of 1825 in Natchez, Miss. By Ayres P.
Merrill, M. D. 217
II. History of the Natural and Modified Small Pox, or of the Variolous
and Varioloid Diseases, as they prevailed in Philadelphia,
in the years 1823 and 1824. By John K. Mitchell,
M. D., and John Bell, M. D., Physicians at the then Small
Pox Hospital. (Concluded from page 53.) 238
III. Cases of Nervous Irritation, exhibiting the Efficacy of Cold as
a Remedy. By S. Jackson, M. D. 250
IV. Remarks on the Pathology of Jaundice. By G. B. Wood, M. D. 260
V. Account of a Case in which a New and Peculiar Operation for
Artificial Anus was performed in 1809. By Philip Syng Physick, M. D.,
Professor of Surgery in the University of Pennsylvania, &c. Drawn up for
publication by B. H. Coates, M. D. 269
VI. Observations on Asphyxia from Drowning, to which is added
a Case of Resuscitation. By Edward Jenner Coxe, M. D. 276
ANALYTICAL REVIEWS.
VII. Traité Zoologique et Physiologique, Sur les Vers Intestinaux de
l'Homme. Par M. Bremser, D. M. Traduit de l'Allemande
par M. Grundler, D. M. P. Revue et Augmentée de Notes.
Par M. de Blainville, D. M., &c. Avec un Atlas. Paris, 1824.
Anatomie des Vers Intestinaux, Ascaride, Lombricoide, et
Echynorhynque Geant. Memoire Couronné par l'Academie
Royale des Sciences, qui en avoit mit le sujet au Concours,
pour l'année 1818. Avec 8 Planches. Par Jules Cloquet,
&c. &c. A Paris, 1824 297
VIII. Precis Theorique et Pratique, sur les Maladies de la Peau.
Par M. S. L. Alibert. 2 Tomes. 8vo. Paris, 1810-1820. 322
IX. Thoughts on Medical Education, and a Plan for its Improvement;
addressed to the Council of the University of London.
Dictu Necessaria. Plin. London, 1826.
Projet de Loi, presenté aux Chambres dans la Séance du 14
Fevrier 1825, par S. E. le Ministre de l'Intérieur, Sur les
Ecoles Secondaries de Medécine, les Chambres de Discipline,
et les Eaux Minerales Artificielles. 344
MEDICAL LITERATURE--RETROSPECTIVE REVIEWS.
X. Recherches sur le Tissu Muqueux, ou l'Organe Cellulaire, et
Sur Quelques Maladies de la Poitrine. Par Théophile Bordeu,
Docteur en Medécine des Facultés de Paris, et de
Montpélier. Paris, 1767, 12mo. 376
QUARTERLY SUMMARY OF IMPROVEMENTS IN MEDICINE AND
SURGERY
ANATOMY, 395
1, Notice of a Double Male Foetus, by W. E. Horner, M. D., &c. 2,
Imperfect Development of the Cerebral Organs in Monsters. 3, Imperforate
Vagina. 4, Fallopian Tubes. 5, Monsters. 6, Foetus grafted into
the Chest of another. 7, Foetus without a Stomach, Head or Anus. 8,
Congenital Hydrocephalus, with Transposition of the Viscera. 9, Unusual
Arrangement of the Aortic Branches.
PHYSIOLOGY, 403
10, Influence of the Great Sympathetic Nerve on the Functions of Sense.
11, Cutaneous Absorption. 12, Abstinence. 13, Hippomane Mancinella.
14, Cutaneous Absorption. 15, Regeneration of Divided Arteries.
16, Mineral Poisons.
PATHOLOGY, 406
17, Are we followers of Dr. Broussais? 18, Influenza. 19, Diarrhoea
Infantum. 20, Tetanus. 21, Small Pox.
THERAPEUTICS, MATERIA MEDICA, AND THE PRACTICE OF MEDICINE. 411
22, Tincture of Iodine in Gonorrhoea, Bubo, Scrofula, &c. 23, Acetate
of Lead and Tincture of Opium in Dysentery. 24, Powers of Digitalis in
Palpitatio Cordis. 25, Tartar-Emetic Ointment in Epilepsy. 26,
Antiphlogistics
in Recent Cases of Epilepsy. 27, On the Efficacy of Nitrate
of Silver in the Treatment of Zona or Shingles. 28, On the Remedial
Effects of Camphor in Acute and Chronic Rheumatism. 29, Examination
of the Question, whether the Medical Use of Phosphorus internally, is
useful, injurious, or equivocal. 30, Nitrous Acid and Opium in Dysentery,
Cholera and Diarrhoea. 31, Tartar Emetic in Pneumonia Biliosa. 32,
Bark of the Ampelopsis in Catarrhal Consumption. 33, Obstinate Vomiting
cured with Extract of Marigold. 34, Vomiting of Fat and Blood. 35,
Rupture of the Spleen. 36, Chilblains cured with Chloride of Lime. 37,
Local Spontaneous Combustion. 38, Dr. Painchaud on Tic Douloureux.
39, Duration of Life among the Romans. 40, Difference of Mortality
from 1775, to 1825. 41, New Method of Percussion of the Thorax. 42,
Acid Nitrate of Mercury. 43, Effects of Ardent Spirits. 44, Colombo
Root. 45, Poison of Mushrooms. 46, Antisyphilitic Decoction of Zittmann.
47, Acetate of Ammonia, a Remedy for Drunkenness. 48, Mortality
of Leeches. 49, Black Drop. 50, Doses of Calomel in days of
yore. 51, Buying a good Practice. 52, Sore Nipples. 53, Anderson's
Quarterly. 54, Antiquity of Cow Pox and Origin of Small Pox from it.
SURGERY, 431
55, Lithotritie, on Breaking the Stone in the Bladder. 56, The High
Operation. 57, Sutures in Wounds of the Bladder. 58, Paracentesis
Thoracis. 59, Stricture of the Oesophagus. 60, Wound of the Brain. 61,
Luxation of the Metatarsus; the history drawn up by M. Dusol, D. M.
MIDWIFERY, 438
62, Uterine Hæmorrhage. 63, Polypi of the Uterus. 64, Cæsarian
Section. 65, Case of Difficult Parturition. 66, Case of the Pelvis becoming
enlarged.
CHEMISTRY AND PHARMACY, 440
67, L'Artigue's Process of preparing the Watery Extract of Opium. 68,
Berzelius' Method of Detecting Arsenic in the bodies of Persons poisoned
by it. 69, Action of Certain Metallic Substances on the Animal Economy.
QUARTERLY LIST OF AMERICAN MEDICAL PUBLICATIONS, 444-48
CONTENTS
ORIGINAL COMMUNICATIONS.
PAGE
ART. I. Description of the Gangrenous Ulcer of the Mouths
of Children. By B. H. Coates, M. D. one of the
Physicians to the Philadelphia Children's Asylum,
&c. 1
II. Case of Purpura in an Infant, attended with extraordinary
Symptoms. By R. M. Huston, M. D. 24
III. History of the Natural and Modified Small-pox, or
of the Variolous and Varioloid Diseases, as they
prevailed in Philadelphia in the years 1823 and
1824. By John K. Mitchell, M. D., and John
Bell, M. D., attending Physicians at the then
Small-pox Hospital.--With a plate. 27
IV. Remarks on the Pathology and Treatment of Yellow
Fever. Arranged from the Notes of Dr. J.
A. Monges, of Philadelphia. 53
V. Remarks on the Prophylactic Treatment of Cholera
Infantum. By Joseph Parrish, M. D., one of the
Surgeons to the Pennsylvania Hospital. 68
VI. Case of Neuralgia, cured by Acupuncturation.
Communicated by J. Hunter Ewing, M. D. 77
ANALYTICAL REVIEWS.
VII. Researches into the Nature and Treatment of
Dropsy in the Brain, Chest, Abdomen, Ovarium,
and Skin. By Joseph Ayre, M. D., &c. 79
VIII. An Essay on Venereal Diseases, and the Uses and
Abuses of Mercury in their Treatment. By
Richard Carmichael, M. R. I. A., with Practical
Notes, &c. by G. Emerson, M. D. 109
IX. Remarks on some means employed to destroy
Tænia, and expel them from the Human Body.
By Louis Frank, M. D., Privy Counsellor of her
Majesty, Maria Louisa, Duchess of Parma. 114
X. Researches Physiological and Pathological, instituted
principally with a View to the Improvement
of Medical and Surgical Practice. By James
Blundell, M. D., Lecturer on Physiology and
Midwifery, at the United Hospitals of St. Thomas
and Guy. 119
XI. An Inquiry into the Nature and Treatment of Diabetes,
Calculus, and other Affections of the Urinary
Organs. By William Prout, M.D. F.R.S.
With Notes and Additions, by S. Colhoun, M. D. 125
MEDICAL LITERATURE.
XII. Retrospective Review.--Tractatus de Ventriculo
et Intestinis, cui præmittitur alius, de Partibus
continentibus in Genere, et in Specie de iis Abdominis.
Authore Francisco Glissonio. Lond.
1677, 4to. 138
QUARTERLY SUMMARY OF MEDICAL AND SURGICAL
INTELLIGENCE.
I. Anatomy. 155
II. Physiology. 158
III. Pathology. 161
IV. Therapeutics, Materia Medica, and the Practice of Medicine. 166
V. Surgery. 192
VI. Midwifery. 205
VII. Chemistry and Pharmacy. 208
QUARTERLY LIST OF AMERICAN MEDICAL PUBLICATIONS. 214
FOOTNOTES:
THE
NORTH AMERICAN
Medical and Surgical Journal.
JULY, 1826.
ORIGINAL COMMUNICATIONS.
FOOTNOTES:
ARTICLE I.--_Description of the Gangrenous Ulcer of the Mouths of
Children._ By B. H. Coates, M. D. one of the Physicians to the
Philadelphia Children's Asylum, &c.
Having had opportunities of witnessing the ravages and unmanageable
character of this destructive disease, I have long and deeply felt the
want of some written account, both of the malady, and of a proper mode
of treatment. Some research and observation, made in consequence of this
feeling, have terminated in the acquisition of more fixed ideas, and of
a practice hitherto successful. This convinced me, that it became my
duty to lay the result of these inquiries before the public, for the
benefit of others. There is, perhaps, no stronger and more peculiar
reason for wishing American physicians to write, than the opportunities
they possess, of describing and recording many important varieties of
morbid affection, which were either unknown to our predecessors, or the
descriptions of which, uncombined and uncompared, are only to be found
by searching among the more neglected tomes of a public library. Of
this, the present case will afford a fair example; as well as an
instance of an American physician, who had described the disease from
nature, having, from want of encouragement, false modesty, or some other
cause, kept it back from publication.
Ever since the establishment of the Children's Asylum, under the care
of a committee of the guardians of the poor, of the city and liberties
of Philadelphia, in the spring of 1819, this useful institution has been
annually visited by the new and distressing scourge of which we are
treating. It has here prevailed in a considerable number of cases,
forming the principal source of anxiety and trouble during the winter
season, and annually sweeping off its little victims, in a manner
rendered peculiarly awful by its insidious approach, its loathsome
effects, and its apparently uncontrollable progress. Various scattered
cases of a similar affection have come within my knowledge, during the
last few years; occurring in the practice of several physicians, as well
as in my own. In no place, however, near Philadelphia, other than the
above, has there existed, so far as I know, a sufficient number of cases
at the same time, to enable a physician to examine it in much detail, or
to make comparative trials of different modes of treatment, so as
clearly to determine the most successful.
_References to Authors._--The notices of this complaint given by
authors, to which I have been enabled to refer, are few, and generally
too scanty to supply much means of forming a satisfactory judgment, or a
practice in which confidence can be reposed. They consist, principally,
of the mere mention of an affection resembling that of which we treat;
and, in some instances, it is even doubtful whether they are describing
the same disease. No notice is taken of this affection in any of our
common books; with the exception of the last edition of COOPER'S
Surgical Dictionary,[1] and of UNDERWOOD'S work on diseases of children.
It is there described under the erroneous title of _cancrum oris_. A
reference is given to PEARSON'S Surgery; and the article in the
Dictionary is taken exclusively from that work. As this is the only
authority with which I am acquainted, that gives a tolerably full
account of a disease somewhat similar to that of which we are treating,
I have concluded to extract the whole passage, in the words of the
author.
"The canker of the mouth is a deep, foul, irregular, foetid ulcer,
with jagged edges, which appears upon the inside of the lips and cheeks;
and is attended with a copious flow of diseased saliva.
"This disease is seldom seen in adults; but it most commonly attacks
children, from the age of 18 months, to that of 6 or 7 years. When the
ulceration begins at the inner part of the lip, it exhibits a deep,
narrow, sulcated appearance, and quickly spreads along the inside of the
cheek; which becomes hard, and tumefied externally. The gums are very
frequently interested in this complaint, and, in such cases, the teeth
are generally found in a loose and diseased state; matter is often found
in their sockets, and abscesses sometimes burst externally through the
cheek, the lip, or a little below the maxilla inferior: and it is not
uncommon to see an exfoliation of the alveolar processes, or even of the
greater part of the lower jaw. Among the children of poor people, where
this disease is neglected or mismanaged at the beginning, a dreadful
gangrene will sometimes supervene.
"The remote causes that give origin to this disease are not very
obvious. I think it occurs most frequently among children that live in a
marshy situation; that are sustained by unwholesome food; and where a
due attention to cleanliness has been wanting. The cancrum oris has been
described by some writers, as a complaint very common in England and
Ireland, where it is sometimes epidemical among infants. It, however, is
commonly seen in other kingdoms, and prevails more especially in those
houses where a great number of children are crowded together. I am not
able to determine whether it is or is not contagious.
"But adults are not wholly exempted from this morbid affection, and it
is not easy in all cases, to distinguish the cancrum oris from a
cancerous or venereal ulcer in the mouth; since the uvula, tonsils or
fauces may be the seat of each disease. I have seen ulcerations on the
uvula and tonsils, with all the marks of a venereal sore, in patients
where the presence of such a virus could not be suspected; and by
treating them as canker of the mouth, they have been speedily cured.
"The canker of the mouth ought to be distinguished from aphthæ, the
epulis and parulis, scurvy, cancerous ulcers, venereal ulcers and
exulceration from the use of mercury.
"_The mode of treatment._--It will be proper,
"1. To remove the diseased teeth, bone, &c. if possible.
"2. To prescribe a milk and vegetable diet, and to allow a prudent use
of fermented liquors.
"3. It will be adviseable to exhibit such remedies as, Peruvian bark;
sarsaparilla; elm bark; mineral acids.
"The external applications that I have generally found successful have
consisted of such as the following:
"_Preparations of copper_; a diluted mineral acid; burnt alum; decoction
of bark with white vitriol; tincture of myrrh, &c."[2]
Of the above articles, those which we have indicated by italics are
omitted in the last edition of COOPER'S Dictionary; and, in a former
one, they are directly prohibited with strong reprobation. Nevertheless,
it is among these that we have found, beyond comparison, the most
successful one.
Mr. PEARSON prefixes to the preceding article a list of synonymes, with
references to authors, in the manner of writers on natural history. They
are as follow: _Aphthæ Serpentes._--SENNERTUS; Medicinâ Practicâ.
_Labrosulcium, seu Cheilocace._--ARNOLDUS BOOTIUS. _Oris
Cancrum._--MUYS. STALPAART VANDER WIEL. _Gangræna Oris._--VAN SWEITEN.
_Gangrene scorbutique des Gencives._--Auctores Gallici.
Of these, SENNERTUS[3] merely mentions, under the article aphthæ, that
the latter sometimes spread around the frænum and tongue, occasionally
corroding the subjacent parts. He is so far from giving a clear
description, under the head of Aphthæ Serpentes, of any affection
analogous to that we are about to record, that he quotes GALEN as
remarking, very properly, that these are not aphthæ at all, but putrid
ulcers.
ARNOLD BOOTIUS, in his little treatise "de morbis omissis," of diseases
omitted in the books, published in London, in 1649,[4] gives, from his
own observation, an account of a disease, to which he applies the names
above attributed to him. It differs from the cases which have attracted
our attention, chiefly in its situation. He describes it as an ulcer,
soon becoming black and foetid, corroding the inside of both lips,
separating them widely from the gums and allowing them to fall outwards
upon the face; thus producing a horrible deformity. Besides this, the
author states, that a deep fissure usually extended down each half of
the inside of each lip; thus adding four deep and ghastly ramifications
to the ulcer. This shocking affection is stated to have prevailed
extensively, both in England and Ireland; in which latter country the
author practised and held several important offices. It occasionally
became epidemic, and then destroyed great numbers of children. It
principally prevailed between 2 and 4 years of age; though it was
occasionally met with both earlier and later in life. It was frequently,
but not always, accompanied with aphthæ.
This disease was, in general, successfully treated by our author, with a
decoction of "Chærephyllum, Quinquefolium, Myrrhis, Rosæ et Salvia;" in
which was dissolved a "sat magna copia" of white vitriol.--A combination
about as precise as some of the prescriptions which have been
recommended to me, for the present disease, in this country. With this
mixture, he touched the ulcers several times a day; and then washed them
with a liniment of acetate of lead, aqua plantaginis, and oleum
rosaceum. He also used _issues_ in both arms; and confined the patient,
in more obstinate cases, for drink, to a decoction of sarsaparilla,
china, and several other articles, which we will spare our readers. To
this disease, BOOTIUS devotes about five small 18mo. pages, forming his
tenth chapter.
VANDER WIEL cites BOOTIUS, and expresses his belief, that the disease
described by the latter was identical with one which he saw himself.
This last, however, though described in a cursory manner, appears to
resemble much more nearly the disease of the Children's Asylum;
beginning in the gums, and extending to the adjacent parts. He treats it
by the following lotion:
R. Mel. Rosar. [Symbol: ounce]i
---- Ægyptiaci, [Symbol: dram]ij
Olei Vitrioli, gtt. _aliquot._
misce.
Under this treatment, and by removing the teeth, when loose, the small
number of cases he saw recovered in a few days.
VANDER WIEL was a practitioner in Holland; and, though he does not
specify the fact, his cases were probably in a marshy country.[5]
MUYS, in a little treatise entitled "Chirurgia Rationalis,"[6] published
in 1684, has an account of a disease, which is evidently supposed by
PEARSON to be that which he describes. This also, however, appears to
have been a "labrosulcium;" an ulcer between the lips and the incisor
teeth. There is but little to be gathered from his paper; as it is
principally occupied with an attempt to prove, that this ulcer is owing
to an accumulation of _acidity_ in the blood, increased, at this point,
by the putrescence of particles of food which collect there. He
illustrates this doctrine by an examination of a _burnt rag_ under a
microscope; and this he considers as in a state analogous to the
gangrene. "Opinionum commenta delet dies," &c. We give his treatment;
which is aimed at acidity.
R. Theriaci, [Symbol: dram]ijss
Ung. Egypt. [Symbol: dram]iss
Gum. Laccæ, et
Spirit. Sal. _Armon._ aa [Symbol: scruple]ij
---- Cochleariæ, [Symbol: dram]ij
_m._ ft. ung.
To be softened with a little alcohol, the part washed with the mixture
six times a day, and a rag moistened with the same compound left in the
ulcer. Here we take leave of the Chirurgia _Rationalis_.
In the 14th volume of the Memoirs of the French Royal Academy of
Surgery, are papers containing accounts of two cases, which have some
points in common with the disease of which we treat; but the identity of
at least one of which it is hard to establish. The first piece is
entitled, "_Sur la gangrene scorbutique des gencives dans les enfans.
Par feu M. Berthe._"[7] The author is described, in a note, as a young
surgeon of great promise, who was carried off by an early death. M.
BERTHE commences by quoting FABRICIUS HILDANUS; who describes a gangrene
of the gums, occuring principally at about 4 years of age, and of which
all the patients died. FABRICIUS takes the occasion to give a caution to
young surgeons, to avoid being too sanguine in predicting recovery from
gangrenes. Next a case is given us, drawn from M. SAVIARD, in which
death was the result. This author seems, subsequently, to have had
somewhat better success, but at the expense of horrible disfigurements;
such as great holes through the cheek, and the loss of a large piece of
the jaw; which, indeed, are described as having been worse than death.
In another case, recorded by M. POUPART, in the "Histoire de l'Academie
des Sciences," this affection terminated in death; preceded, however,
and in the opinion of the author, caused, by the production of two
tumours, one by the side of the tongue, the other inside of the cheek.
This is not at all unlike the progress, which will be hereafter
mentioned to have taken place in many of the Asylum cases.
M. BERTHE then remarks, that the greater number of instances of gangrene
of the gums had terminated unfavourably.
His own patient was ill from April to September, 1753; and exhibited
swelled and bleeding gums, frequently projecting beyond the
teeth,--black and foetid stools, foetid urine, and ecchymoses over
the surface of the body. He treated it with antiscorbutics, internally
and externally, and apparently with success. The patient, however,
relapsed in January, 1754; when M. BERTHE proceeded to a very different,
and far more severe treatment. The gums were pared away, in many
successive operations; and the wounds were washed with aluminous water.
A roll of linen was, during the intervals, kept fastened in the
patient's mouth, for the purpose of allowing the escape of the fluids of
the part; which he apprehended to possess a putrid character, and to
aggravate the original disease, whenever they passed into the stomach.
At length, his patient recovered, and continued well.
It appears to the writer of these notes to be hardly necessary to state,
that M. BERTHE evidently mistook the disease; the latter being in
reality scorbutic, and not a single symptom of gangrene being described
during its whole history.
The same, however, cannot be said of M. CAPDEVILLE; whose "_Observations
sur les effets rapides de la pourriture des gencives_" appear in the
same volume with the foregoing, and immediately subsequent to it.[8]
This writer's case took place after a fever, and no tumefaction of the
gums nor ecchymoses of the skin are mentioned as occurring in it. M.
CAPDEVILLE attended this case in consultation, in 1764; and complains of
too feeble means being employed, as the case was trusted to
antiscorbutics. This treatment ended in death. M. C. refers to VAN
SWEITEN, whose correct account we shall mention; and it is evident that
it was the disease of the Children's Asylum: though he manifests a
strong propensity to connect it with scorbutus, and the "blanchet," or a
species of aphthæ, which destroyed a great number of children in the
Foundling Hospital, in 1746. Reference is also made to cases which
occurred in "La Pitié," under the care of CHOPART. Of these, a very
scanty account is given. They terminated in death; after a treatment by
lotions of honey of roses and spirit of vitriol, with emollient and
resolvent cataplasms.
VAN SWEITEN, in the article devoted to the consideration of gangrene,[9]
has left us a far more exact description of the disease, into which we
are inquiring. Practising in a marshy country, he had frequent
opportunities of meeting with it; and his account of it, and his mode of
treatment, though brief, are every way worthy of the close, practical
inquirer into nature, and the sound medical philosopher. His description
is not unmixed with strong expressions of horror and commiseration at
its ravages. He describes it in a manner so similar to that in which it
now prevails, that no doubt can exist of the identity of the diseases.
He acknowledges, however, "rubedo, calor, dolor," among its symptoms.
Cochlearia, theriaca and similar articles, according to him, are almost
always injurious. If no foetor exist, (and, of coarse, no actual
mortification,) he applies a solution of sal ammoniac or nitre, with
some vinegar or lemon juice; sometimes as a lotion, sometimes by keeping
a rag imbued with it always in the ulcer. Hard rubbing he reprobates. If
the disease have made progress, and foetor exist, muriatic acid is
used: in the less aggravated stages, diluted with honey of roses and
water; in the worst cases, pure. This practice he states never to have
failed him, unless where the bone was affected.
In an early edition of Dr. UNDERWOOD'S Treatise on Diseases of Children,
in the library of the Pennsylvania Hospital, no mention is made of this
disease; although an article is devoted to "_gangrenous erosion of the
cheek_." The account is wholly borrowed from a work by Mr. DEASE, of
Dublin, "on the diseases of lying-in women," &c. also in the library.
Mr. DEASE describes this affection as occurring from 2 to 6 or 8 years
of age; especially in unhealthy children, including such as have been
subject to worms. The whole body often appeared cold upon the approach
of the disease. A black spot then occurred, but _without marks of
inflammation_, on one of the cheeks or lips. The whole cheek was
sometimes destroyed, and the lower jaw fell down upon the breast.
Muriatic acid, infusion of roses, the effervescing draught, and, in the
decline of the disease, bark, broths, jellies, and wine, besides
magnesia or rhubarb, to remove the putrid matters swallowed, were the
internal remedies employed. The parts were washed and injected with
muriatic acid, diluted with chamomile or sage tea; and afterwards
dressed with the acid, mixed with honey of roses, and, over this, a
carrot poultice. By this practice, Mr. DEASE lays claim to almost total
success.
In the Philadelphia republication of Dr. UNDERWOOD'S book, taken from
the sixth London edition, there is an article entitled Cancrum Oris. The
author appears to have read PEARSON'S account; but as his description
does not at all agree with the disease of which we are treating, nor
with that of Mr. PEARSON, we shall not stop longer to analyse it.
I have no doubt, from views that will be hereafter developed, that many
of the above writers have had cases similar to those which we are about
to describe; but have mistaken them, from the want of a sufficiently
early and close inspection of the ulcers. In the second stage, this
disease much resembles an inflamed sore between the lips and gums,
extending to the latter; although I hope to prove that this state of
things is secondary.
_Locality of the Disease._--The Philadelphia Children's Asylum is
situated in South Fifth street, between Prime and Federal streets, in
the district of Southwark. The soil is what is called alluvial, or
rather diluvial; as is well known to be the case with all that district,
lying south of Philadelphia, as well as the southern part of the city
itself. The house was built, and for many years occupied, as a mansion,
by the head of a most respectable and wealthy family. Its situation
possesses some of the qualities usually selected in choosing the site of
a country seat. The buildings stand on a swell of ground, leaving an
open lawn, now interrupted by several unoccupied streets, and extending,
on the right hand, to the banks of the Delaware, and, on the left, to
the Navy Yard and part of the suburb of Southwark. Towards the north,
it is not far from the edge of a thickly built appendage of the city.
The district immediately south of the Asylum is marshy, and has long
been noted for the prevalence of intermittent fevers; but the slightly
elevated site of the building had been generally healthy, and continued
so, till the universal and distressing epidemic, which infested all the
outskirts of Philadelphia, in 1822 and 1823. Even at this period, the
persons resident at the Asylum, were far from suffering so severely as
the adjacent neighbourhood; and, since those years, it has again become,
in general, tolerably healthy. In 1819, 1820, 1821, and 1822, a lot,
situated at a short distance, on which were deposited the contents of a
number of privies, proved a source of great inconvenience, and some
disease, at the Asylum. This focus of effluvia, together with the
general and copious use of similar materials in manuring the adjacent
fields, occasioned an intolerable stench, and generated diarrhoeas, in
the early part of the spring. When the grass and weeds, however, were
grown sufficiently to protect the surface of the soil from the sun and
wind, this effect entirely ceased; and I know not that any other
inconvenience was experienced from the same source, unless we attribute
to this, as may fairly be done, the destruction of the purity of the
well. This formerly afforded very good water; and, since that period, it
has much improved. When the corporations of Southwark and Moyamensing
shall introduce, as it is to be hoped they will, the Fairmount water
into their streets, one remaining cause of inconvenience and ill health,
will be removed from the Children's Asylum.
_Prevalent Diseases._--Ophthalmias and furuncular eruptions, the latter
principally on the face, are epidemic every year; generally in the
spring and early summer months. When prevalent in the city, the measles,
small pox, and varioloid disease have reached the Asylum; the scarlatina
has, at no period, I believe, been peculiarly troublesome there.
Intermittents, which were anticipated by many, from the nature of the
situation, have seldom, if ever, prevailed in the house, to any very
considerable extent. One of the worst visitations which it has
experienced, in this respect, was in the autumn of 1823. In many cases,
it was in patients who had been labouring under disease of this
description, that the ulcer we are about to describe exhibited itself;
but it was by no means confined to those who were known to have so
suffered. Many, perhaps, most of the children affected, were free from
any apparent ailment; although it is by no means impossible that the
little, uncomplaining subjects were, at the time, labouring under what
has been called "febricula" or "inward fever."
_Regimen._--To the impurity of the water we have already adverted. The
diet of the children furnishes them with meat every day, with the
exception, during a part of the existence of the institution, of two
days in every week. Molasses was freely used; indian mush was greatly in
demand; and the breakfast and supper were of bread and milk. During the
summer months, this diet was abundantly nourishing; but in winter, it
was thought that an additional quantity of animal food was desirable;
and, accordingly, it was, during the two last winters, given every day.
_Description of the Disease._--The ulcer of which we speak, may begin in
many parts of the mouth. In by far the greater number of cases, however,
it commences immediately at the edges of the gums, in contact with the
necks of the teeth, and, most generally, of the two lower incisors. A
separation is found here; which exhibits a slight loss of substance at
the extreme edge of the gums, and, as far as I have observed, a
whitishness of the diseased surface. In some instances, though not very
frequently, this is preceded by a slight swelling and redness. In this
state, the disease may continue for a long time; and I have reason to
believe, that patients have remained thus affected, during the whole
period of three months, for which I attended the Asylum. At one time,
when the disease was at its height, threatening several patients with
destruction, I found upwards of 70 children, out of a population
amounting to about 240, more or less affected with these ulcerations. No
remarkable change is at this stage observable in the functions of the
little sufferer; except a general air of languor and weakness. The
appetite and the muscular activity continue, but are somewhat reduced;
not sufficiently, however, to disable the child from attending school,
taking the air, or continuing his ordinary practices. In this state, no
symptoms of irritation have been at all discovered. The skin is cool
during the day, no pain is complained of; and no account has ever been
given me of any nocturnal paroxysm of fever. It would appear to be
purely a state of asthenia. We are, however, by no means certain, that
there was no concealed irritation in the system. We were, of necessity,
obliged to depend, in a great measure, upon the reports of nurses, and
other females; and these were liable to overlook, or mistake for mere
weakness, the signs of an obscure disease. In this manner, commencing
cases were frequently not discovered, and nothing was done, till the
affection had made further progress; and this continued until the
ascertained existence of the epidemic in the house, combined with the
recollection of its former ravages, had excited an alarm, which led to
the inspection of the mouths of all the children in the institution.
The disease, in this form, must be within the curative powers of nature;
as, if this were not the case, we should hear of more numerous
unfavourable terminations. It has seldom, however, if at all, been
within my power to witness this tendency; and, when not controlled by a
particular treatment, the cases have almost always either remained
stationary, or increased in severity. Its first progress is, most
generally, by extending to the edges of the gums round other teeth;
frequently affecting a large portion of the dental arches. A very early
progress is, however, mostly effected, down the length of the tooth, in
the direction of the socket; and, in this way, the disease commits great
and unsuspected ravages. When it reaches the edges of the bony socket,
the tooth begins to be loose, and when drawn, exhibits portions of the
fang, including parts which had been contained within the alveolus,
entirely denuded of their periosteum. Indeed, from observation, I should
say, that the latter membrane was the part, which was the most
peculiarly liable to injury and death from this disease; and it is by no
means clear, to my apprehension, that this is not frequently the
commencement of the complaint. The injury generally proceeds with
augmenting rapidity; especially when it has affected the deeper parts:
and it is while in the act of rapidly spreading, that it occasions
gangrene.
In the production of gangrenous sloughs, it much resembles the
descriptions usually given of sloughing ulcers. A portion of the parts
immediately subjacent to the ulcer loses its life; this rapidly
separates; and, before or after a complete removal, a fresh slough is
formed in the same manner. The sloughs are generally black, with
ash-coloured edges. I have not been able to discern a change of colour,
the production of vesicles, or any material tumefaction, as antecedent
to the gangrene. There is generally, by this time, an increased heat in
the parts; with the sensation termed "calor mordens." The discharge now,
for the first time, becomes acrimonious; giving pain when it comes in
contact with cuts in the finger; and excoriations are produced on all
parts in contact with the sloughing ulcerations; as the lips, the
cheeks, the tongue, and the adjoining surface of the part where the
ulcer is situated.
As soon as the external gangrene has reached the level of the edge of
the bony socket, and frequently much sooner, the adjacent portion of the
latter is found deprived of its life; forming a necrosis. The death of
the periosteum in the socket, at least that of the fang of the tooth,
precedes, by some interval of time, that of any portion of the bone
itself.
When gangrene is formed, a fever of irritation is generally developed.
In regard to the time at which this takes place, there is a great
diversity in different constitutions. It has appeared to me to depend,
principally, upon the inflammation of the mouth, which is secondary to
the original disease, and, in most cases, to arise from the acrimony of
the discharge. It is aggravated by loss of rest, want of nourishment,
and, probably, by putrid matter finding its way into the stomach. To the
latter cause I also refer a diarrhoea, which almost uniformly comes
on, towards the close.
There are accounts of a similar disease having begun on the inside of
the cheeks. I have, however, never seen a well-marked instance of this;
the cases which were supposed to be such having, in every instance, been
also found to exhibit ulcerations at the edges of the gums. That the
disease spreads from the gums to the cheek, is a fact which have often
seen exemplified. It is, indeed, the most usual termination of bad
cases. After producing gangrene and necrosis in the gums and alveoli,
and after the discharge becomes, as above stated, acrimonious, a
gangrenous spot is not unfrequently found about the opening of the
Stenonian duct, on the inside of the upper or lower lip, opposite the
incisors, in some other part of the inside of the lip or cheek, or in
more than one of these situations at the same time. Whether this be
owing to excoriation from the discharge, or to some other cause, I
cannot say; it has, however, in every instance which I have seen
sufficiently early to witness its rise, been subsequent to the symptoms
previously described.
When the gangrene reaches the cheek or lip, however, very active
inflammatory symptoms are uniformly developed. In the cellular substance
of these parts, they assume the well known characters which have been
attributed to the _phlegmonous_ species. We have a great thickening,
forming, in the cheek, a large, rounded, prominent tumour, with great
heat and pain. Sometimes redness is perceived externally; but, more
frequently, the great distension of the skin of the cheek seems to empty
the cutaneous vessels; giving to the part, a smooth, polished, dense,
white appearance, very much resembling the effect of a violent
salivation. I have no doubt that this is the tumour described by
POUPART, and alluded to in an earlier part of this paper. Great
thickness and hardness have always occurred, in the other situations
where this gangrene has approached the external cellular masses of the
face; in the lip, however, they are less remarkable, perhaps from the
smaller amount of cellular matter. After reaching this stage, a black
spot is frequently seen on the outer surface of the swelling. This
spreads rapidly; and has always been, in my own experience, the
immediate harbinger of death. It is proper to state, however, that I
have heard it said, that cases had recovered in this city, in which the
gangrene had produced a hole through the cheek. Under what physician's
care this occurred, I have never learned.
In two cases it commenced in the fauces; and was marked by the same
unsuspected progress. In one of these, the little patient was remarked
to be languid, but had no positive external marks of disease. The mouth
was examined, and found healthy; but no suspicion of the real situation
of the disease was entertained, till after 3 or 4 days more, when he
complained of a slight sore throat. A large gangrene of the tonsils,
half-arches and pharynx, was now found; and the event need hardly be
told.
The closing stage of this affection is marked by large gangrenous
patches in the gums; deep fissures between these and the teeth; the
latter loose, or falling out; large pieces of the alveolar processes,
often containing the roots of several teeth, in a state of entire
necrosis; the whole lining membrane of the mouth suffering a violent
excoriation; the whole adjacent external cellular substance, hard and
swelled; large gangrenous spots in the inside of the cheek or lips,
occasionally extending quite through to the outer surface; a total
incapability to sleep, or to take the least food; fever; a swelled
abdomen, and diarrhoea.
_Dissection._--The inspection of the body after death had never thrown
much light upon this obscure affection. Since I began to prepare
materials for this paper, I have been able to dissect but one subject.
The appearances were as follow:
_Exterior_, emaciated.
_Alimentary canal_, externally and internally, altogether in a natural
state, except what appeared to me to be owing to the subsidence of blood
to depending portions of the intestines. The mucous membrane was
carefully examined throughout its whole length; but not being at that
time aware of the importance, attached, by some pathologists, to small
rednesses in this organ, it is highly probable that some such may have
been overlooked.
_Liver and Spleen_, enlarged, but of a natural appearance.
_Heart, thoracic oesophagus, and one kidney_, (the other not
examined,) natural.
_Lungs_, containing much mucus in the bronchial cavities. The fore part
of their substance contained much hepatization.
_Pathology._--The nature and production of this disease are certainly
very obscure. We may, however, as in other branches of knowledge,
attempt to develop and record what knowledge we possess respecting it;
carefully separating truth and reason from conjecture. We have already
said, that its access was very frequently preceded by no marks of
visible disease, or at least none that attracted attention. The little
subjects were, apparently, in merely a drooping or enfeebled state. In
other instances, the ulceration followed a common remittent or
intermittent fever; insomuch that, at one time, whenever a child was
brought to the nursery for fever, it was expected, as a matter of
course, that his mouth would become sore. In the other cases, as we have
already had occasion to say, it is quite possible that a concealed
"inward fever" may have existed; and this is rendered the more probable,
by the circumstance of their losing their appetites. In the instance
where the body was opened, we have seen that the original disease was
hepatization of the lungs; and yet it is quite probable, that this
affection had caused, as it often does, that species of disease, which
a rapidly spreading pathology refers to a slow inflammation of the
stomach and intestines. With regard to marks of this last not having
been detected by me, it is evident that I am in the same situation with
a very numerous body of other observers.
The local appearances, at the commencement, did not appear to be of an
_inflammatory_ nature, at least generally. If the gums were really the
first part affected, it was not so; as these parts when inflamed, as
they frequently are in affections of the teeth, exhibit decided
soreness, pain, swelling, and an increase of redness. The ulcerated part
was, in about nine cases out of ten, paler than natural; and then
neither soreness nor increased heat was perceptible, except in a few
cases, in which the mouth was generally hotter than natural, though it
was not, in a striking manner, referrible to the gums. In a few cases,
distinct redness, and a slight swelling, were perceptible round the
ulcer. These patients generally did better than the others.
If, on the other hand, we suppose the original derangement to have taken
place in the periosteum, we shall be enabled, more easily, to explain
some of the phenomena. We then reason thus: The whole of the body had
shrunk considerably, from disease, and, the circulation being deprived
of a part of its usual vigour, the periosteum, a part possessed of
little vitality, was unable to bear the additional extension, which it
underwent, across the unyielding bone of the tooth. The blood ceased to
circulate in it, and it died. Ulceration of the adjacent parts followed,
as a matter of course; and these parts, especially the periosteum, being
possessed of but little sensibility, the sympathies of the other parts
of the system were but little interested, until an extensive portion of
the mucous membrane of the mouth, or a mass of cellular substance,
became affected. We certainly see that, in every case but two, the
disease commenced in contact with the teeth. This doctrine will also
explain the rapid and deep penetration of the ulcer along the roots of
the teeth; and the destruction of the bone. We may recur to the
statement, that a portion of the fang of every loose tooth was always
found deprived of its periosteum.
In the two cases excepted, we have seen it apparently begin in the
mucous membrane of the fauces; and indeed the manner in which it
generally spreads from the gums to the cheek and lips, seems to me,
unquestionably, to indicate a greater liability than common to gangrene
in more than one part of the mouth.
The soreness and pain of the socket, which forms a part of most
tooth-achs, might have been reasonably expected here; but neither was
ever complained of, even when the teeth were loosening: and, as no fever
existed at this time, the original irritation can hardly be considered
as inflammatory; excepting perhaps the cases which exhibited redness,
and slight swelling of the gums.
_Is this disease scorbutic?_--I never observed ecchymoses, nor in more
than a single instance any the minutest red specks upon the cutis, which
might be thought to resemble petechiæ. The patients never fainted; the
gums were never spongy, nor did they bleed more than those of any other
child would have bled, under an equal degree of violence. I however
requested my friend, Dr. HARRIS, who has had ample opportunities of
making himself acquainted with scorbutus, to see some patients with me.
He complied, with his usual kindness, and pronounced their disease not
at all to resemble the scurvy.
_The teeth._--But few cases occurred during the second dentition; and it
is doubtful whether any one took place during the first. It should be
remarked, however, that children under 2 years, were not admitted to the
institution, unless by deception on the part of the parents. No child
ever lost a tooth of the second set; and, indeed, the second dentition
seemed often to cure the complaint. The greater number of cases occurred
between 2 and 5 years of age, but some as late as 8 or 10. In several
instances, the ulcer destroyed a portion of the enamel capsule; and the
teeth were then cut, with _very perfect enamel_ upon the lower part,
while the bone was entirely bare at the ulcerated portion of the
capsule. This singular fact proves that no inflammation of the capsule,
sufficient to interrupt the function of its remaining portion, took
place in consequence of the opening of its cavity.
_Prevalence of this disease in our own country._--Many elderly persons
remember during different periods of their lives, a tradition and
particular instances of a formidable disease of the mouth, by the name
of "Black Canker."[10] Round Philadelphia, it appears to have been
rare. Having been informed by a friend, that the disease had prevailed
extensively at Salem, New Jersey, under the notice of my friend, Dr.
THEOPHILUS R. BEESLEY, I addressed a letter to that gentleman, to which
he furnished me with an obliging and instructive reply, which I have
unfortunately mislaid. Numerous cases have occurred, in that vicinity,
within the last 30 years; and were, in general, successfully treated by
the women. Cases seldom came under the view of physicians, until
gangrene had commenced; and of these, many died: so that the old women
were generally more in vogue for its cure, than the regular
practitioners. Dr. BEESLEY, Dr. VANMETER, and my friend Dr. E. Q.
KEASBEY, had met with much of this complaint; and the result of many of
their observations had been combined in a thesis, written, but,
according to our unfortunate custom, not published, by the younger Dr.
VANMETER. It was there considered as a sequela of intermittent and slow
remittent fevers, and seldom occurred but in marshy districts, and among
the poor. It generally prevailed between the ages of 2 and 10 years. Of
the remedies employed we shall again speak. Dr. SAMUEL TUCKER has also
seen it in marshy situations near Burlington. I have heard of its
existence on the Schuylkill. Dr. PARRISH has for several years noticed a
stage of this complaint, under the name of "a disease resembling the
effects of mercury," in his private lectures. Drs. PHYSICK, HARTSHORNE,
HEWSON, MEIGS, WOOD, RHEA BARTON, and REMINGTON, and several others who
will pardon me for omitting their names, have also met with cases.
_Prevention._--Our precautionary measures should be directed to the
predisposed or commencing state already described; to the prevention and
cure of fevers, to the removal of "febricula," and other internal
disorders, and to the general restoration of strength. Finally, its
commencing stage should be watched, and promptly met; and success, I
believe, will always attend our endeavours.
At the Children's Asylum, all the weakly children were made to take
bitters, of different descriptions; and Dr. SYLVESTER'S antiscorbutic
drink, composed of cream of tartar and juniper berries, infused in
water. As the disease declined in the house, under this administration
of bitters, it is highly probable that they had a preventive agency. I
much question, however, whether Dr. SYLVESTER'S drink was productive of
any advantage.
One question of some importance yet remains. _Has mercury any agency in
producing this affection?_ The salivary glands have never been observed
to be affected in it. Dr. PARRISH informs me, that, after a strict
examination, he has come to the conclusion that the previous use of
mercury does not bring on, or aggravate this complaint, as he has
noticed it. I have made the same observation; and, not being peculiarly
sparing of the use of calomel in fevers, have had opportunities to
verify it. I think I can add, that, in some cases, by shortening and
moderating an attack of fever, calomel has been useful in preventing the
ulceration. Given during the progress of one, and that a fatal case, it
did not appear to aggravate it.
There is no evidence whatever tending to excite the suspicion of
_contagion_.
_Treatment._--A variety of remedies had been tried within my knowledge;
most of them with but little success, and one or two with somewhat
better. Feeling much disappointed with the results of my practice, in
the small number of cases which fell under my care in the spring months
at the Asylum, as well as elsewhere, I wished to exchange with another
physician for a period when the disease was more prevalent; for the
purpose of studying it, and making comparative trials of different
remedies. Dr. JOS. G. NANCREDE was so polite as to indulge me. Having
then a large number of patients under my care, I was enabled to make
more extensive observations, and with more precision; the results of
which course gave me the first satisfaction I had ever felt relative to
this disease. Trials were made of every thing that was suggested by
friends, and generally upon 4 or 5 selected patients at a time. Thus,
choosing them in the ulcerative stage, and having several at a time
before our eyes, the result was seen in a very few days, much sooner
than if patients had been successively subjected to the remedies; and no
material time was lost in appealing to the article which appeared to
answer best.
The remedy which beyond all comparison succeeded best, was sulphate of
copper. The usefulness of this substance, though known at Salem, New
Jersey, was discovered, at the Asylum, by the mistake of a nurse. It had
been previously used, in lotions of the strength of gr. ij or iij to the
ounce of water; and with little advantage. Observing that the empirical
remedies said to have succeeded, were, as I considered them,
immoderately strong, I furnished the nurse with a common solution of
sulphate of copper, and with a vial containing 72 grains of the sulphate
in an ounce of water, for the purpose of being progressively added to
the other at different periods. This stronger solution was applied, by
mistake, instead of the diluted one; and it was the first remedy which
had produced a rapid tendency to a cure. I finally settled down, after
various trials, in the employment of the following:
R. Sulph. Cupri, [Symbol: dram]ij
Pulv. Cinchonæ, [Symbol: ounce]ss
Aquæ, [Symbol: ounce]iv _m._
S. To be applied twice a day, very carefully, to the full extent of the
ulcerations and excoriations.
The cinchona here is not absolutely necessary; but operates by retaining
the sulphate longer in contact with the edges of the gums.
Simple ulcerations and small gangrenes, as well as the troublesome
excoriation, when not in the last stage, yielded promptly to this
remedy; the good effect being generally visible from the first
application.
Dr. FOX, my friend and fellow-labourer in the Asylum, had already taught
me that it was important early to extract the teeth. I was not, however,
sensible of the full extent of this rule, till after examining the fangs
of some of them which were drawn. The separation of a portion of the
periosteum from the fang, within the socket, which was universally found
whenever the tooth was loose, among two or three hundred specimens,
proved the existence of the disease in a deep, narrow crevice, into
which it was impossible, by any contrivance, to insinuate the lotion.
This cavity was laid open by extracting the tooth; and when the remedy
was applied, the sanatory effect was surprisingly prompt. From this
period, forwards, the universal rule was to extract all teeth, the
moment they were discovered to be in the slightest degree loose; and
"the blue wash" above described, became the standing remedy.
It is at all times a dangerous boast for a physician to make, to say
that, in the treatment of any complaint, he has always succeeded. He is
frequently not credited; and he can never know at what moment disbelief
may be borne out by his subsequent failures. A faithful adherence to
fact, and justice to the medical art, oblige me to say that it was owing
to the observation of these means, that I never had an opportunity of
making a dissection, after the one mentioned in a preceding page.
Upwards of 120 ulcerated gums came under my notice in the course of
three months; of which 70 were affected at one time. Of these, by far
the greater number would, unquestionably, have escaped gangrene. The
experience of past winters, however, and that of the preceding autumn,
justifies the belief that there would have been several gangrenous
cases, and some deaths; unless interrupted by remedial means. Some 3 or
4 suffered small spots of mortification, and one, by the delay arising
from the tardy report of a nurse, suffered necrosis in a portion of an
alveolus; but they were speedily arrested, and the production of more
such cases, I believe, prevented, by the employment of the above means.
I have been once, since then, called in consultation to a case in which
this remedy failed; but this was only two days previous to death, and
during the existence of swelled cheek, and of a thick gangrenous eschar,
and it was in fact only once imperfectly applied.
The farthest advanced of all the cases which I have seen, since that
time, relieved by this remedy, was in the practice of my friend, Dr. R.
M. HUSTON. He aided it by the application of a poultice with lead-water
to the external surface of the cheek. This was thought to be productive
of much relief.
Great attention and care are requisite on the part of the physician, to
see that every part of the ulceration and excoriation is made visible,
and brought under the influence of the applications employed. Without
this entire knowledge of the extent of the evil, the result will be
failure. The disgusting sloughs and discharge, and the fear of an
imaginary _contagion_, make the nurses very unwilling to introduce their
fingers into the reluctant little patient's mouth, and without this
scrutiny all is in vain. The physician is compelled to set the example,
to try the looseness of the teeth with his own fingers, and to ensure
the nurse's entire knowledge of the extent of the disease.
Dr. BEESLEY writes that the women in his neighbourhood, frequently used
considerable _roughness_ in applying the lotions. _Certainty_ is
absolutely necessary.
After the remedy had been thus accidentally discovered in the Asylum,
and used for a few days, I received Dr. BEESLEY'S letter mentioned
above; and I then learned that the sulphate of copper was the principal
dependence of the physicians at Salem. As, however, I had never seen Dr.
VANMETER'S thesis, the use of it at the Asylum was new to me.
An excellent remedy, and one on which the sole dependence should be
placed, were we not in possession of one which possesses a decided
superiority, is one which was communicated to me by Dr. PARRISH. It is
as follows, including a slight correction made by the apothecary:
R. Sulph. Zinci, [Symbol: dram]i
Aquæ, [Symbol: dram]ij Solve.
Dein adde, Mellis Despum. et
Tinct. Myrrhæ, aa [Symbol: ounce]ij
To be used in the manner described above. Some bad cases yielded to the
following:
R. Sulph. Zinci, [Symbol: dram]ij
Aquæ, [Symbol: ounce]i _m._
It is useful to record failures and unsuccessful trials; as they serve
to deter others from unnecessary risk. We therefore record the following
as not having succeeded in our hands:
R. Mellis et
Tinct. Myrrhæ, aa [Symbol: ounce]i _m._
The same, with the addition of powdered bark.
R. Aluminis, [Symbol: scruple]ij
Tinct. Myrrhæ, et
Mellis, aa [Symbol: ounce]ij _m._
R. Pulv. Cinchonæ, [Symbol: ounce]i
Myrrhæ et
Pulv. Carbonis. a [Symbol: ounce]ss _m._ et adde
Succ. Limonum, q. s. ad massam
faciendam, quâ illineantur gingivæ.
Caustic potassa; and nitrate of silver.
Pyroligneous acid, both pure and variously diluted with water. This had
but a very limited effect, even in destroying the foetor; and I am by
no means sure that it was of any use in arresting the disease.
Muriatic acid, though praised by such high authorities, did not seem
productive of any distinct useful effects. Nitric acid, variously
diluted, and sulphuric acid, which was tried in one case, diluted with
an equal quantity of water, were entirely useless.
Of _constitutional_ treatment, the disease seemed to admit very little.
In the early stage, the means employed, were the same mentioned above as
means of prevention. It was by no means evident that any of these were
useful in retarding the progress of the complaint. Towards the decline
of the worst cases, aromatic sirup of rhubarb, with magnesia, were
employed, to remove the putrid matters swallowed; and to relieve the
diarrhoea which generally took place, by the astringent operation of
the first mentioned medicine. It is extremely doubtful whether these
means were productive of any benefit.
* * * * *
While the above was in press, I have met with the article, "_Gangrene de
la bouche des enfans_," in the Dictionnaire de Medicine; written by M.
MARJOLIN. The author in the Dictionnaire des Sciences Medicales, has
given nothing material but references to some of the writers mentioned
above; with one or two which were not within my reach. M. MARJOLIN has
evidently identified the disease. He cites FABRICIUS HILDANUS, though we
have not found a distinct account of it in that writer's works. He
remarks that it is identical with the _necrosis infantilis_ of SAUVAGES.
He also refers to SAVIARD, VAN SWEITEN, whom he justly mentions with the
highest praise, UNDERWOOD, BERTHE, CAPDEVILLE, M. BARON, and the
inaugural thesis of M. ISNARD. As we have no means of referring to the
two last, we must judge of them by M. MARJOLIN'S statements. He observes
the dissimilarity of BERTHE'S case. From the thesis of M. ISNARD, he
gives us an account of the disease which corresponds very nearly,
indeed, with that of VAN SWEITEN, and with the appearances observed at
the Children's Asylum.
"Almost all the infants affected with this disease in the hospitals of
Paris," says M. MARJOLIN, "sink under it." He recommends, after VAN
SWEITEN, the use of muriatic acid, which he mixes with honey in equal
proportions. Thick sloughs he cuts away with a bistouri or with
scissors. MM. JADELOT, GUERSENT, and BARON, have employed the actual
cautery with success in several instances. M. MARJOLIN has cured three
cases; one by the actual cautery, one by caustic potassa, and a third by
_muriate of soda!_ which, he believes, will always destroy the foetor.
It would be interesting, undoubtedly, to make repeated trials of this
simple remedy; and we shall endeavour to do so in cases which admit of
delay.
FOOTNOTES:
[1] Vol. I. p. 319, Anderson's edition.
[2] Principles of Surgery; by JOHN PEARSON. Lond. 1788. p. 262, et seq.
[3] Opera omnia. Vol. II. p. 271. In the Loganian Library.
[4] Ibidem.
[5] See CORNELII STALPAART VANDER WIEL Observationes Medico-Anatomicæ.
p. 167. Note by the editor, P. STALPAART VANDER WIEL. Amsterdam, 1687.
In the Loganian Library.
[6] In the Loganian Library.
[7] Page 193.
[8] Page 217.
[9] Commentaria.--Edit. Lugd. Bat. 1742. Vol. I. pp. 766, 767.
[10] This name may be either from the ancient English or the low Dutch;
if the one, by tradition, if the other, from the use of it by medical
men. _Cancrum_ is an odd grammatical blunder; being, in reality, nothing
but the accusative of Cancer, put instead of the nominative. The latter
name was, as is well known, frequently applied by the older surgeons, in
a vague manner, to any terrific and unmanageable ulcer; and, in
particular, it was often applied to gangrene. The error appears to have
been first made by Pearson, and copied by Mr. Cooper. Compare Muys and
Vander Wiel, with Pearson, at the above references.
ARTICLE II.--_Case of Purpura in an Infant, attended with Extraordinary
Symptoms._ By R. M. HUSTON, M. D., &c.
On the 28th of August last, A---- V----, after a moderate labour of four
hours' continuance, was delivered of a female child. About a month
previously, she had laboured under an attack of intermittent fever,
which yielded, in a few days, to the ordinary treatment. She was 23
years of age, an English-woman by birth, had generally enjoyed good
health, and was as well as usual at the time of her confinement. Her
labour was strictly natural, and her delivery accomplished without any
extraordinary assistance.
At birth there was nothing remarkable about the child. Its breathing was
natural, its skin of the usual colour and appearance; in short, all the
common indications of a continuance of life and health were present. A
few hours, however, after birth, it became uneasy, cried much, and
showed signs of colic. The nurse, supposing these symptoms to arise from
flatulence, administered some warm tea; but without any apparent
advantage. On the following day, I saw it again, and learned, that it
had evacuated a considerable quantity of urine, and some intestinal
matter, of the ordinary appearance after birth. The spasms continuing at
intervals, a teaspoonful of castor oil was ordered, to evacuate any
remaining meconium, that might lie in the bowels, producing irritation;
upon the presence of which, it was presumed the spasms depended. It
operated well, but without producing the desired relief. On the next
day, viz. forty-eight hours after birth, a number of bluish or purple
spots were observed on different parts of the child's body, but most
numerous on the extremities. They were of various sizes, from that of a
mustard seed, up to that of a grain of Indian corn. Some were slightly
elevated, but most of them were not in the least so. In the majority,
there was a minute central spot, or little point, more red or pink
coloured than the blue areola, by which it was surrounded. In many
instances, these little points projected, so as to become manifest to
the touch. In the course of twenty-four hours, the spots, which had
first appeared, began to decline, leaving a greenish mark, very like the
remains of a bruise; but much more rapidly than these declined, others
of larger size appeared on different parts of the child's body.
On the third day after birth, large blotches appeared, one behind each
ear. These rapidly increased, until they covered the whole extent of the
parietal bones, and considerably elevated the skin, giving it a puffy or
tumid appearance, like that caused by a blow from a large or blunt
instrument. The parts soon became hot and tender to the touch; and this
tenderness extended over the greater part of the scalp. A blotch,
similar to those upon the exterior surface, was likewise observed within
the mouth, covering the whole extent of the palate bones. The child
experienced great difficulty in swallowing after the third day; and the
_nurse_ thought the spasms were often excited by attempts of this kind.
But the most singular feature of the case was the appearance, on the
night of the second day, of a discharge from the vagina, _resembling_
the menstrual flux. It resembled that flux in _colour_, _consistence_,
_want of coagulability_, and in being, withal, accompanied by a
considerable quantity of _slimy or mucous matter_. Every diaper which
was used during that night, and the greater part of the next day, was
stained more or less with this discharge. It was also observed, that,
during the flow of this fluid, the spasms ceased; and that, whenever the
discharge was suppressed, even for a very short time, they uniformly
returned. In this manner they alternated at intervals of a few hours,
until the occurrence of the death of the child, which happened on the
eighth day after birth.
As this case is related more for its singularity than from an
expectation that any practical suggestions will be furnished by its
perusal, but few remarks will be necessary, either upon its pathology or
treatment. Although it will be perceived by the scientific reader, that
the disease observed, differed materially from any of the forms of
_purpura_, described by systematic writers on diseases of the skin;
still I apprehend it may be justly considered as more nearly allied to
that genus, than to any other.
The spots were evidently caused by an effusion of blood beneath the
cutis, and the presumption is strong, that it issued from the little
point discoverable in the centre of each spot. Those points were, in all
probability, _arterial_. That they were arterial terminations, I think
is evident, from the great extent to which the cellular membrane was
injected, especially over the parietal bones. The force exerted must
have been very considerable to elevate so large a portion of scalp, and
yet no pulsation could be discovered in any one of the points.
But whence came the vaginal discharge? That it issued from the _vagina_
was most certain; but whether it was furnished by that canal, or by _the
uterus_, was not ascertained. To assert that it was menstrual, would be
hazarding more than a prudent regard for truth would justify. But, if
not, why the pain and spasms which preceded it, and the alternation of
these symptoms with each other? and, especially, why the slimy
appearance, mixed with red matter, without a trace of any thing like
coagula? Certainly we do not find these appearances in ordinary cases of
hæmorrhage. So that there is no other way of accounting for the
discharge in this case, except by considering it as having been secreted
by the vessels of the parts from which it came.
From the difficulty which the child experienced in swallowing, but
little food could be taken; and the same difficulty precluded the
administration of medicines. What caused this impediment could not be
ascertained, but it was supposed to result from a spasmodic action of
the muscles of the part.
The only medicine attempted to be given was a weak infusion of bark, and
this was soon abandoned.
The spots, particularly the large ecchymosed surface on the head,
exhibited no change in appearance, when _viewed superficially_, a few
hours after death. No other examination was permitted.
FOOTNOTES:
ARTICLE III.--_History of the Natural and Modified Small-Pox, or of the
Variolous and Varioloid Diseases, as they prevailed in Philadelphia in
the years 1823 and 1824._ By JOHN K. MITCHELL, M. D., and JOHN BELL, M.
D. attending physicians at the then Small-Pox Hospital. With a Plate.
In a question of less moment, some apology might seem due for once more
directing public attention to that which has been so oft discussed and
described by many eminent physicians and experienced observers. But, if
descriptions of any disease be valuable; if to record faithfully an evil
be among the first steps for its removal and prevention; and, still
more, if additional confidence, derived from enlarged experience, can be
imparted to the means hitherto adopted to guaranty the human frame
against a mortal and loathsome malady, our efforts at this time may
claim the favourable notice of our professional brethren, and of the
community at large.
Sedulously abstaining from the parade of erudite research or indulgence
in speculations, however ingenious, it is our intention to describe with
accuracy all that we saw; and if, in so doing, we shall be found
repeating what others have said before us, and proposing inferences
previously drawn, the observations and deductions are to be considered
as not the less our own, since we only speak from conviction, founded on
the evidence presented to our senses. Our opportunities for accurate
judgment were most ample, being derived as well from an attendance of
nine months on the hospital for the reception of the poor, labouring
under the disease, as from one of us prescribing, during a part of the
time, for the Philadelphia Dispensary, added to the cases furnished us
by private practice, and very many others, the records of which have
been kindly placed at our disposal by professional friends.
The ravages committed by the small-pox in Baltimore, and the fact of
many who had been previously vaccinated having been attacked by the
disease during the years 1821 and 1822 were notorious to us all, but
were productive of little alarm in Philadelphia. The non-appearance of
the scourge in the greater part of the period, when the former city was
suffering under it, justified, to a certain extent, this feeling of
security, and seemed to call more on our sympathies for our neighbours
than on our fears for ourselves.
In the month of September, 1823, some cases of fever, with pustular
eruption, first arrested the attention of the medical faculty, some of
whom were, of course, called on to render professional assistance. The
residence of some of the persons, thus attacked, in Water street, and
their emigration from Europe, naturally induced a suspicion of this
disease being no other than the small-pox, imported by, or brought in
with them. Very nearly about the same time, however, some scattered
cases of a similar eruptive disease, were noticed in the upper or
western portion of the city, without our being able to trace any
intercourse or connexion between these and the others in the lower or
eastern part, viz. Water street.
The first return of death from small-pox, furnished by the Board of
Health, was in the week between the 13th and 20th of September. The next
was between the 4th and 11th of October. From this time to the end of
the year there was a progressive increase of mortality, and the annual
return for 1823, presented no fewer than one hundred and sixty deaths by
small-pox. The greatest mortality in any one week was thirty-three, from
December 20 to 27. During the months of January, February and March,
1824, the disease prevailed extensively, and was fatal to many. In the
following months its violence subsided, and in the month of June our
attendance on the temporary hospital[11] was discontinued, in
consequence of a resolution of the Managers of the Alms House to close
it. Though a few patients were afterwards received into it, yet the
malady soon disappearing, justified its final closure. The annual return
for 1824 exhibited three hundred and twenty-four deaths by small-pox.
The entire mortality from this cause was four hundred and seventy-three,
in a period of twelve months, from November 1, 1823, to November 1,
1824. The deaths before the first, and after the second date, were but
eleven.[12] Contagious as this disease unquestionably was, we cannot, at
the same time, withhold our belief of its having been in a measure
subjected to epidemical influences, viz. in a particular character of
the seasons and atmospherical changes. It is then within our province,
as historians of events, rather than as expounders of causes, to present
our readers with a summary account of the weather during the years 1823
and 1824. We do this both from a sense of duty, considering it as
pertinent to our present labour, and from a wish to encourage others by
our example to preserve and transmit the meteorological registers, in
their respective districts, of those years, marked by new or aggravated
diseases.
METEOROLOGICAL REGISTER.[13]
------------------------------------------------------------------------
| | | | | |Winds--Days.| |
| | | | |Snow & |------|-----| |
| | | | |Rain |N. W. |N. E.| |
| |Mean |Variat.|Variat.|Water. | to | to | |
| 1823. |Temp. |Therm. |Barom. |Inches.|S. W. |S. E.| |
|-------------|------|-------|-------|-------|------|-----| The |
|January, | 31 | 44 | 0.94 | 3.38 | 22 | 8 | |
|February, | 25 | 42 | 1.17 | 1.93 | 22 | 6 |temperature |
|March, | 37 | 52 | 1.65 | 6.87 | 21 | 9 | |
|April, | 55 | 47 | 1.08 | 1.77 | 16 | 14 | of |
|May, | 61 | 52 | 0.88 | 1.60 | 19 | 8 | |
|June, | 68 | 46 | 0.65 | 0.87 | 20 | 10 | the |
|July, | 72 | 30 | 0.58 | 6.12 | 23 | 6 | |
|August, | 72 | 35 | 0.60 | 4.68 | 21 | 8 | wells |
|September, | 63 | 51 | 0.61 | 3.46 | 15 | 12 | |
|October, | 53 | 42 | 0.60 | 2.02 | 21 | 9 | and |
|November, | 38 | 38 | 0.81 | 2.47 | 21 | 9 | |
|December, | 34 | 31 | 1.07 | 7.37 | 21 | 10 | springs, |
| | | | |-------|------|-----| |
|For the year,|50-3/4| 88 | 1.70 |42.54 | 242 | 109 | in |
|-------------|------|-------|-------|-------|------|-----| |
| 1824. | | | | | | | and |
|January, | 36 | 48 | 1.25 | 3.67 | 24 | 7 | |
|February, | 31 | 59 | 1.55 | 3.94 | 21 | 7 | near |
|March, | 40 | 39 | 0.71 | 2.63 | 16 | 15 | |
|April, | 50 | 45 | 1.08 | 4.54 | 22 | 8 |Philadelphia,|
|May, | 60 | 44 | 0.88 | 1.59 | 24 | 7 | |
|June, | 73 | 46 | 0.69 | 6.09 | 25 | 5 | |
|July, | 74 | 30 | 0.38 | 8.80 | 19 | 8 | is |
|August, | 70 | 36 | 0.45 | 6.39 | 20 | 11 | |
|September, | 64 | 41 | 0.65 | 6.60 | 17 | 7 | 52° |
|October, | 54 | 43 | 0.65 | 1.53 | 23 | 5 | |
|November, | 42 | 38 | 0.89 | 2.49 | 24 | 6 |Fahrenheit. |
|December, | 37 | 43 | 0.95 | 2.11 | 24 | 7 | |
| | | | |-------|------|-----| |
|For the year,|52-1/2| 85 | 1.55 |50.38 | 259 | 93 | |
------------------------------------------------------------------------
1823.
Maximum of Therm. 91, June 19. Maximum of Barom. 30.45, Nov. 29.
Minimum " 3, Feb. 7. Minimum " 28.75, March 30.
-- -----
Variation, 88 1.70
1824.
Maximum of Therm. 90, June 8. Maximum of Barom. 30.45, Feb. 6.
Minimum " 5, Feb. 2. Minimum " 28.90, Feb. 26.
-- -----
Variation, 85 1.55
The amount of water which fell in rain and snow during the four years,
from 1822 to 1825, inclusive, was,
1822. 1823. 1824. 1825.
Inches, 35.20 | 42.54 | 50.38 | 33.26 |
We next subjoin a summary of deaths by fever, erysipelas and measles, in
the above period; being more desirous of narrating all the circumstances
associated with the appearance and continuance of the small-pox, than of
insisting on them as supporting causes or necessary connexions. It will
appear from the accompanying statement, that the diseases febrile and
eruptive were in number, violence and mortality unusually great, in the
above mentioned years, as we discover by comparison with the returns for
1822 and 1825.
Deaths by
Fevers. Erysipelas. Measles. Small-pox.
1822 510 4 0 0
1823 758 24 156 160
1824 654 28 102 324
1825 375 12 38 6
In New York and Baltimore, the coincidence between increase of fevers,
measles and erysipelas, and the mortality from small-pox, is not so well
marked.
In New York--Deaths by
Fevers. Erysipelas. Measles. Small-pox.
1822 393[14] 6 1 0
1823 192[15] 13 117 18
1824 191[16] 14 100 394
1825 445 20 53 40
In Baltimore--Deaths by
Fevers. Erysipelas. Measles. Small-pox.
1821 400 0 2 21
1822 430 1 4 122
1823 304 2 175 2
1824 183 3 14 2
1825 138 0 9 3
We now proceed to give a brief sketch of the disease called the natural
small-pox, (occurring in persons unprotected by previous vaccination or
inoculation,) and the deaths from which are given in the above
statements. We must, in advance, insist on the great diversity in the
appearance of the eruption in different individuals; so great, that an
attempt to make an accurate picture of one case pass for a faithful
representation of the many, must be deceptive and injurious.
In the premonitory symptoms, constituting the characters of the fever
precursory to the eruption, there was considerable uniformity: the
complaint of nearly all those attacked being at first chills and rigors;
pains in the loins, head and limbs, with thirst and want of appetite;
with which were soon associated gastric uneasiness, and in many,
soreness of throat, rendering deglutition painful, hoarseness and
weeping eyes. The duration of these symptoms, aggravated by febrile
exacerbations, varied from one to three days, more usually the latter,
after which the eruption begins to appear. It is first seen round the
forehead and temples, near the hairy scalp; then on the cheeks and
breast and back; on the arms near the shoulders; the abdomen and thighs;
and subsequently on the fore-arms and hands, and finally on the legs and
feet. The appearance of the eruption is that of red or scarlet papulæ,
presenting to the touch a sensible resistance, but not much raised, and
without roughness or hardness. These papulæ, becoming more and more
defined and elevated, are after a day or two converted into vesicles,
with small elevated centres or bodies of a yellowish-white, and more
diffused red and somewhat hard bases or margins. The redness extending
as the eruption becomes copious, converts the skin, especially of the
face, neck, and hands, into a red ground, from which project, in relief,
the whitish vesicles. Similar appearances, but of a less marked nature,
owing to the eruption being more scattered, are found on the trunk. The
vesicles, containing at first a thin, semi-transparent fluid, become
gradually larger, fuller and yellower, and filled with a thick,
tenacious matter. This change is completed, and the pustules are
entirely formed, after a lapse of time from the first eruptive effort,
which varies from the fifth to the ninth day, and is occasionally
longer. The mean for the beginning of maturation, or the finishing of
the secretion of matter in the pustule, may be received as five days for
the face, and eight or nine days for the body generally. The stages of
the eruption, as regards its appearance, may be very properly called
papular, vesicular, and pustular. This last having attained its height,
completes what is termed the period of maturation, during which the
pustules retain their fulness and spheroid figure; and exhibit the
greatest proportion of whitish-yellow shining surface of their body, and
diminished extent of redness at their base. A yellow dry point on the
summit of the pustule, which loses thereby somewhat of its former
spheroidal shape, by becoming flatter, or slightly indented, indicates
beginning desiccation, at which time the body exhales that peculiar
odour, so unpleasant, and so readily recognizable, after it has once
been perceived. There is no uniformity in the size of the pustules on
the body generally, nor any equality among them on a particular part:
more usually one larger and fuller is surrounded by others less so. Nor
is it to be supposed that the changes above mentioned are gone through
in regular succession on all parts of the surface, uniformly. It was no
uncommon thing to see the eruption papular on the legs, vesicular on the
trunk and arms, and pustular on the face, at the same epoch. One part
even, as the arm for instance, has exhibited to us the three forms at
the same time.
Maturation complete and desiccation going on, the pustules break, and
have their thin coverings converted into a yellow hard coat or crust, to
which adheres the pus that was not removed by absorption, and the
residue, by evaporation of its watery part, is now converted into a scab
of varying thickness, firm and prominent in its centre, and made up
outwardly of concentric circles. The margins of the pustules, before of
a distinct red, now assume a bluish-red or purplish colour, and the skin
begins to desquamate.
The constitutional sympathies, or the symptoms in the milder and regular
variety of the disease, are not of any great violence or intensity. The
premonitory pains, diminishing or disappearing, after the coming out of
the eruption, leave in their place a regular fever. The action of the
heart and capillaries is hurried during the papular and vesicular
stages; but becomes more equable while maturation is going on. During
the former period, the loaded and not unfrequently furred tongue
evidences disordered stomach, the cravings of which are for cold drinks.
The somewhat laborious respiration may, in some cases, depend on the
swelling and soreness of the fauces and pharynx; in others, on the
eruption extending along the lining membrane of the larynx; whilst in
others, it may be caused by bronchial engorgement.
The febrile symptoms, which abate during the process of maturation, are
apt to return during desiccation; and when the skin begins to
desquamate, they then constitute what is called secondary fever. The
skin which had suffered so much, occasionally exhibits at this time an
erysipelatous blush, accompanied by an inflammation of the subjacent
cellular tissue, and the formation of troublesome boils, or infiltration
of serum, especially where there is much laxity of structure, as in the
eyelids, cheeks, lips, &c. The cutaneous system, during and immediately
after the removal of its cuticle, and much of its rete mucosum, is of
course very sensible, as well to the impression of clothes as to
atmospherical extremes, and particularly cold. This is with many a
critical time. It not unfrequently happened that persons, who had passed
through the different stages of the disease, and were advancing rapidly
to convalescence, were suddenly seized with an affection of the chest,
pleurisy, bronchitis or pneumonia, and speedily carried off by the
violence of the inflammation. The skin, exquisitely sensible in its
denuded state to atmospherical vicissitudes, transmits with great
promptness the morbid impression to the lungs, already prone to take on
disease, in consequence of the active part they are compelled to play
during the eruptive fever.
The anomalous varieties, if we can admit any standard form of the
disease, were numerous. Those which most fixed our attention were the
_confluent_, the _roseate_, the _tuberculous_, and the _erysipelatous_.
The _confluent_ was ushered in by symptoms of greater febrile disorder
than the regular distinct variety: the throat was sorer; eyes more
suffused and watery, and more intolerant of light; gastric and pulmonic
uneasiness, and oppression more aggravated. In place of the papulæ being
separate, or merely in clusters, they are so crowded, that on the
progress of the eruption the vesicles first and then the pustules are
contiguous at their bases, and often run into each other, forming at
times, a large irregular bag filled with pus, and technically called
blebs, or else exhibiting over a considerable space of skin the
appearance of imperfect vesication. The vesicles and pustules are, in
such cases, flattened, and with indented centres, which latter display
at times a dark point or spot, while the edges are of a livid red. This
is the appearance of the limbs and trunk. The cheeks and forehead during
the process of maturation present a continuous puffy elevation of a
pearly white colour. The eyes are nearly closed by the swelling of the
lids, and the thick copious secretion from the borders and the
conjunctiva; the lips are tumid and the angles of the mouth ulcerated.
In fact the human face divine, deprived of all lineaments and
expression, is now a foul, misshapen mass. Associated with this state
are swelled throat, rendering deglutition very painful--salivation,
cough--occasional vomiting, delirium, sometimes phrenitical, sometimes
evidencing itself in low mutterings and jactation.
The _roseate_ variety of small-pox might, without creating much
confusion, be ranked with the confluent, which it closely resembles in
its second stage. The first is characterized by the rose or pink colour
of the face, which is covered with a copious eruption of papulæ, some
with dry points, while from others, the bases of which are small and
hard, arise minute vesicles of a pearly colour, which soon dry away. The
inflammation, however, still continues, but spreads under the cuticle,
which is raised in large patches of a white colour, but not vesicular,
or distinctly pustular, or containing fluid: they approximate and
produce the continuous puffy elevation already described. On the trunk
and extremities, the eruption is either of confluent patches or of
pustules dry and flat, with indented centres, the intermediate skin
being of a deep red or crimson colour.
The constitutional disorder runs high in these cases,--delirium and
great gastric distress being very common symptoms. The tongue,
especially at its border, is frequently the seat of eruption, which may
be compared to the vesicular stage on the skin, with the summits cut
off. The lining membrane of the mouth and fauces and pharynx, are, we
presume, similarly affected, judging from the soreness of these parts,
and the thick muco-purulent matter sometimes mixed with blood, which is
spit out or brought up by screatus. The subjects most liable to the
roseate eruption, were the intemperate and debauched of the sanguine
temperament.
The _tuberculous_ variety of small-pox was most frequent among the
negroes. The eruption at first consisted of broad papulæ, which were
converted into hard, rough, and knotted prominences, tuberculous at base
and flattened in the centre. This was not unaptly called by some the
seal skin eruption. Sore throat, causing the greatest difficulty in
deglutition, and delirium were the almost invariable concomitants of
this variety. Occasionally the patient was in a state of stupor and
disinclination to motion--at other times wakeful and restless, and
requiring coercive means to confine him to his bed. In many instances,
the muscular strength was retained to within a few hours of death. The
fatal termination in these three varieties, confluent, roseate, and
tuberculous, was in the second period of the disease, that is, in the
one corresponding with the completion of maturation, and the absorption
and drying away of the pus in the simple distinct form of small pox.
After some experience, we were enabled, from the appearance of the
eruption at the outset, to presage the event, which in the above
described kinds, was almost universally fatal.
The _erysipelatous_ variety was more an adventitious conversion of the
primary form of the disease, by hospital air and delicacy of the
cutaneous tissue induced by prior irregularities of life, than a
distinct kind to be met with in general practice. It was most commonly
presented to us in persons who had a very copious eruption, interesting
to a great degree the whole cutaneous surface, and in whom the process
of maturation was complete, and the cuticle began to lose its adhesion
to the subjacent tissue. In some cases, even after desquamation was
almost completed, and the skin nearly dry and smooth, erysipelatous
inflammation would supervene, and seem to be repeated on the pulmonary
and gastric surfaces, producing great trouble in respiration and
derangement in the digestive functions, accelerated pulse, and other
symptoms of fever.
We could readily pourtray other nicer shades of the natural small-pox,
but the originals might not perhaps be so readily recognized by
succeeding observers, or their nature well understood by our
readers.[17] Our object being to convey practical knowledge, we pass on
to a notice of the subjects, most liable to suffer from exposure to the
variolous poison.
The African race would seem to be peculiarly obnoxious to the small-pox:
the actual number of people of colour brought to the hospital being
greater than the whites, and the proportionate mortality much more
considerable; being as four deaths to six cases of disease in the
former, and two deaths to four cases of disease in the latter. As
regards sex, the proportion of deaths among the males was three-fifths,
among the females two-fifths, of the entire number under treatment in
the hospital. In both, the violence of the disease, and the number of
anomalous symptoms and complications, depended greatly on their prior
dissolute life. Drunkards among the men, and prostitutes among the
women, rarely escaped death. The former had the roseate eruption, and
the latter the confluent, on which dark spots as if gangrenous were a
frequent appearance. Menorrhagia, at any time in the course of the
disease, was a bad augury.
The better to elucidate the nature of this dire malady, we shall now
give from our records some cases of fatal termination, and add an
account of the appearances on _post mortem_ examination of these same
subjects.
CASES.--I. Wilhelmina Smith, white, aged nineteen years, of irregular
habits, has a well defined circular scar, with smaller pits in it, on
the left arm; but has no recollection of having been vaccinated, nor
does she remember ever having heard her parents, who are now dead, speak
of it.
She was taken sick on Thursday night, the 11th of March, 1824, and in
the morning had vomiting and pains in the back. On the 13th in the
afternoon, the eruption first appeared.
15th. Admitted and visited. Eruption on face slightly prominent, is red,
tuberculous and rough--small and scattered on the arms, like flea bites.
Legs nearly clear: they have many cicatrices, especially on the shin and
outer part. There is at present an ulcer above the inner ancle. Tongue
yellow, and furred in centre, white at borders. Pulse small and
threaded.
16th. Eruption rising vesicular from face and limbs; no fever; tongue
greenish and loaded; coughs much.
17th. Eruption fine, dry, flat, and partly indented in centre on the
face, which burns much; skin red and inflamed; on limbs same appearance,
but eruption less copious; pulse small, threaded, and frequent; tongue
furred and yellow in centre; complains of pain in deglutition; cough.
18th. Eruption on face dry, flat, white and small in size, and copious;
rather more elevated on limbs and neck; tongue dry and furred; pulse
frequent and threaded; throat sore.
19th. Eruption same as yesterday; pulse scarcely to be felt; skin cool;
coughs with an appearance of choking.
Dead at midnight. She retained her muscular strength and ability to sit
up to the last.
_Examination_ in the afternoon of March 21.--On removing the sternum and
anterior portion of the ribs, the anterior mediastinum was found filled
with a frothy adipo-mucous collection of a yellowish colour. The lungs
on both sides adherent to the thorax, and the left lobes to each other.
A sanguineo-serous effusion on both sides, probably a quart on the
right, the lungs of which were changed in texture, and shrunk. The
pericardium contained a large quantity of the same kind of fluid, which
was found in the cavity of the thorax. The heart was highly injected. On
removing the lungs and the trachea, and larynx, the lining membrane of
the two last showed a brownish-red, coated with mucus, and deeply
injected. Same appearances in a more marked degree in the bifurcations
of the trachea.
The oesophagus next examined, was found of a natural appearance,
except near the stomach, where it was injected and assumed a red hue,
contrasting with the whiteness of its upper part. The mucous membrane
of the stomach near the cardiac orifice was in some parts of a roseate
hue, in others a brownish-red; while in others it was ash-coloured, and
dotted with red and yellow points. Towards the pyloric orifice, less
disease. The stomach contained nothing but dark green bile and mucus.
The duodenum was also highly injected. Lower down, the small intestines
were in places lined with a dark red and brown, and the mesentery highly
injected in the portions corresponding to these spots. Intestines much
inflated, and omentum dark and injected. The uterus was not examined.
The ovaria were large, white and soft; in the left was a small sac of
dark blood, which readily burst on pressure.
The liver was very large, of a soft texture and white colour;
gall-bladder full of dark green bile, which had in part transuded
through its coats.
On looking at the trachea after it was washed, it exhibited in places
whitish elevated spots, having all the appearance of an eruption.
II. Ann Collins, white, aged 18 years, unprotected, became sick on
Tuesday evening, March 23, 1824, and was taken to the Alms House, as one
having the measles, on Wednesday. On Thursday evening, some eruption was
visible; on Saturday evening, March 27, admitted.
28th. Visited. Face covered with a red, flat, dry eruption, particularly
on the cheeks; small and vesicular on the chin and around the mouth. On
the arms, it has the appearance of measles; on the hands, it is of a
deep scarlet, with central vesicular elevations; on the legs is slight;
tongue loaded and yellow, except at the borders, which are clean; pulse
natural; complains much of pain in the back and sickness of stomach.
30th. Eruption covering the face, vesicular on a deep red ground with
some tumefaction; rising vesicular on the limbs with scarlet bases.
Tongue smooth and shining anteriorly, and with vesicles on it. Throat
sore. Salivation. Pulse small and feeble. Has had menorrhagia since her
admission into the hospital.
31st. The menorrhagia continues. Had last night epistaxis. Pulse small
and slow. Tongue furred and red. Eruption confluent with indented and
dark centres. Surface white and dry. Skin between, red and inflamed.
Very slight eruption on legs, and none on feet.
April 1. Menorrhagia continues. Pulse small and labouring. Respiration
laborious and hurried. Face swelled. Surface smooth, with white spots to
represent the pustules. On breast and arms the eruption is in confluent
patches which are nearly continuous--some pustules flat and indented,
others smooth, with appearance of radii, and some more elevated forming
blebs. Skin of the feet cold, and blue in spots; no elevated eruption on
lower extremities. Tongue furred and yellowish. Throat sore. Eruption
very copious on body, generally with blebs.
_Vespere_; pulse hardly perceptible. Anxiety and distress great. Dead at
10, P. M.
_Examination_ April 2nd, in the afternoon.--On opening the thorax, the
lungs and heart were found of the natural appearance and size. The
larynx and trachea being divided, exhibited all the way down to the
lungs an injected surface with whitish irregular spots, having nearly
the same appearance as the flat smooth eruption on the face: in parts it
was more evidently pointed, and showed, by the aid of the microscope, a
pustular appearance. In the lungs, the inner surface was still darker.
The root of the tongue was covered with large and rather hard papillæ,
with open summits. The oesophagus was smooth and white. The stomach
near the cardia injected, and of a brownish-red in spots: the remaining
portion white, presenting no diseased appearance. The spleen was very
large and covered with copious miliary points. The omentum, to
appearance gangrened, was dark, and altered in texture. The peritoneum,
especially in the pelvis, was injected and inflamed, being of a
semi-opaque dark colour. The uterus, small and firm, contained some
bloody mucus in its cavity.
III. Joseph Foster, white, aged 22 years, unprotected, became sick on
Monday evening 8th of March. The eruption began to show itself on
Wednesday morning, 10th.
12th. Admitted and visited. Face covered with a red, dry, tubercular
eruption, with some few yellow pustules. Same on arms, but no pustular
appearance; partly tuberculous, partly vesicular. More sparse and
scattered on breast and legs: none on feet. Slight cough. Tongue white,
clammy, and loaded in middle--red at borders. Pulse rather frequent.
14th. Face covered with a pustulo-vesicular eruption, with whitish
summits, red and inflamed bases. Skin between, of same colour. Eruption
dry and hard; very red, copious on limbs; less so on trunk. Tongue moist
and less loaded. Pulse regular.
15th. No fever. Face of a deep red colour; eruption rising from it
rather flat, irregular in figure and white at summits. Eyes inflamed. On
limbs the eruption is red at base, vesicular in body and summit: on
trunk in clusters. Tongue yellowish and rather furred. No complaint
made; rests easy; sleeps well.
16th. No fever: tongue moist and a little loaded. Pustules nearly white.
Some yellow, and beginning to dry on summits. Skin between still of a
deep red. Eruption filling on limbs and trunk.
17th. Pulse strong and frequent; skin hot; tongue moist and loaded.
Pustules scabbing on face. Not yet entirely filled on limbs, where they
are in clusters with inflamed bases.
18th. Pustules full and matured on limbs. Running into each other in
places. Tongue dry, brown, and furred in centre, yellow and loaded at
sides. Pulse quick and frequent. Lies easy.
19th. Blebs formed on arms; pustules running into each other, beginning
to shrink; matter oozing out. Tongue covered with a dark crust. Pulse
quick and frequent. Erysipelas of eyelids and ophthalmia. Throat sore.
20th. Blebs larger and more numerous on hands and arms; purulent matter
oozing out from some of the pustules. Face nearly scabbed over. Some
small white pustules formed on the eyelids. Pulse frequent and
vibrating. Tongue as yesterday. Gums tender.
21st. Pulse weaker. Desquamation going on; pustules shrunk and drying on
limbs. Tongue as yesterday.
22nd. Matter much absorbed on limbs, leaving a shrunk cuticle. Face
covered with a brown and yellow scab and scurf. Tongue black and furred;
clear at apex.
23d. Some erysipelatous inflammation of the skin; pustules all nearly
disappeared from arms, trunk and thighs; some few, white and soft remain
scattered over breast. Pulse frequent. Tongue black and incrusted.
24th. Was brought into town from Bush Hill.
30th. Desquamation nearly complete. Low frequent pulse. Respiration slow
and laboured. Tongue incrusted.
April 2nd. Dead at 10, A. M.
Calomel had been freely given to this man in the earlier stage of his
disease: and during the last week, spts. terebinth. and nutritive
farinaceous food.
_Examination._--The pericardium, of a greenish colour and its
capillaries finely injected, was full of yellow serum. The lining
membrane of the larynx and trachea was of a greenish-yellow colour
throughout, and in the spaces between the cartilages ulcerated and
disorganized in several spots. Beneath the membrane was a venous
injection. About the bifurcation it was injected; and in the
ramifications of the trachea were seen several inflamed, and in places
abraded and disorganized spots. A chocolate coloured liquor with a
sediment filled the bronchiæ and the larger tracheal subdivisions.
The oesophagus was sound. The stomach showed clusters of bright red
and brownish-red spots, in stellated and other regular figures extending
along the smaller curvature. The duodenum, at its commencement and in
its course, presented similar clusters. The rest of the intestine was
healthy. The brain was to appearance in a natural state.
IV. Peter Johnson, black man, aged 38 years, unprotected, was taken sick
on Monday, 29th March, in Sandy Hook. Eruption of small-pox appeared
April 3d, Saturday morning. Admitted same day.
4th. Eruption copious on face; papular and of irregular figure. Eyes
suffused and red. On arms, same appearance as on face, but less
tuberculous. On breast and body, eruption small and pointed; beginning
to show on legs. Throat sore. Tongue yellow and loaded at sides; red in
centre. Pulse full, equal, and rather frequent. Cough.
5th. Much anxiety and moaning. Eruption rough and tuberculous on face.
On arms, it is in parts papillary and pointed, and in parts flat with
indented centres. Pulse slow and equal.
6th. Eruption hard and tuberculous on face and arms; small and pointed
on breast. Pulse slow; throat less sore; mind wandering. Is sitting up
in bed, dressed. Tongue moist and yellow.
7th. Delirious through the preceding night; is now dozing. Eruption same
as yesterday. Not so thick on legs, but hard and tuberculous.
8th. Tongue black and incrusted. Throat very sore. Eruption hard and
flat. Pulse active.
9th. In a comatose state. Pulse slow. Skin cool.
10th. In the same condition. Drawn down in the bed, the thighs flexed on
the abdomen, and lies on his side.
11th. Dead at six A. M.
_Examination._--The upper surface of the tongue of a brownish yellow,
full of holes and rough. At the posterior part, in place of the larger
papillæ, were ulcers and cavities. The posterior nares and pharynx were
covered with holes, formed by ulceration, and of a brownish hue,
adjoining injected and apparent pustular parts. Tonsils ulcerated, and
their investing membrane mostly destroyed. The oesophagus immediately
below the glottis, smooth and sound. Yellowish matter flowing from the
glottis. On opening the larynx, it was found half filled with a viscid
light olive-coloured fluid; on removing which, the whole lining
membrane, down to the bifurcation of the trachea, was found covered with
clusters of ulcerated pustules of a yellow colour, with the intervening
spaces of a brownish-red, highly injected, and destitute of its natural
smooth, shining appearance. The internal surface of the glottis and
epiglottis was in a similar but less marked state as the larynx and
trachea. The pustular surface extends to the minute ramifications of the
bronchiæ, and their cells beyond were highly injected.
On opening the abdomen, the omentum was found dark and shrunk. Stomach
contracted. Intestines distended, shining, and very vascular, with
capillary injection when viewed externally. The peritoneal covering of
the stomach showed a similarly injected appearance.
The stomach being opened, displayed at its upper curvature, spaces
studded with spots of a deep red or purple; apparently effusions
surrounded by a vascular net-work. Same appearance towards the pyloric
orifice, and in places on the duodenum, which, together with the
jejunum, particularly the latter, is of a dark leaden colour, and
injected.
The diaphragm on its upper surface, highly injected, as was also the
pleura lining the thorax. The pericardium healthy.
The brain was not, unfortunately, examined.
V. Jacob Fry, black man, aged 30 years, unprotected, was taken sick on
Sunday, 11th April, 1824. Eruption appeared on Thursday, April 15th.
16th. Admitted and visited. Eruption copious and papular on face; smooth
and flat, with dark centres, on trunk and arms. Tongue loaded. Cough.
Tenderness of epigastrium on pressure. Throat sore. Pulse small and
threaded. Eyes muddy.
18th. Eruption flat and rough; diffused over face. On breast red and
flat; on limbs in clusters, shrunk, and hollow in centre. Pulse small.
19th. Tongue moist. Pulse small and frequent. Throat much swelled.
Restless, and somewhat delirious.
20th. In a comatose state; but is roused to attention by calling him.
21st. Dead at five P. M.
_Examination._ April 22nd.--On opening the thorax, the lungs were seen
to appearance healthy. Both adhered to the pleura costalis. The pleura
lining the diaphragm, and also the pericardium, were finely injected.
Fauces inflamed, injected, and ulcerated. From the tonsils oozed out
pus.
The larynx contains a light olive coloured fluid, muco-serous, which
likewise covered the trachea and bronchiæ. The lining membrane
throughout was rough, and exhibited a net-work of a brownish-red colour,
finely injected.
The oesophagus about half way down, has its lining membrane removed
for one-third its length, showing miliary points on its muscular coat.
The stomach on its outer surface, and near its upper end, showed a black
spot, like effusion of black blood, under the peritoneal coat. On
examining the oesophagus near the cardia, it was found of a dark
colour in lines. From the cardia, half over the inner surface of the
stomach, radiates inflamed membrane of a deep red colour, and corroded
at the place corresponding to the dark spot above mentioned. Red spots
near the pyloric orifice. Intestines not diseased. Liver adherent by its
right lobe to the ribs; this lobe was of a greenish leaden colour. No
alteration of its structure. Brain injected in its arachnoid coat.
Ventricles contained some serum. Tela choroides dark and gorged.
VI. William Lawrence, aged 18 years, unprotected, became sick on
Saturday, April 17th. On Sunday taken to the Alms House, and on
Wednesday, 21st was transferred to the Hospital.
21st. Eruption fine and papillary on face; red and scarcely raised on
arms. None on legs. Has cough since yesterday. Pulse slow and regular.
Tongue brown, and incrusted in centre. Moist on sides.
22nd. Eruption confluent and red. Papulo-vesicular on face and arms.
Flat, dry, and copious all over the trunk. Scattered and small on legs
and feet. Pulse small and regular. Tongue loaded and brown in middle.
Eyes sparkling. Is delirious and very restless.
23rd. Eruption very copious all over the body, rising vesicular from red
margin. Pulse small and slow. Tongue loaded, furred, and yellow. Head
and back easier. Has slept well. Face deeply suffused with red.
24th. Cough. Eruption flat, indented centres, dark in places. It is now
coming out on legs. Pulse small and firm. Skin cool. Much uneasiness and
hurried breathing.
25th. Dead at seven A. M.
This man had been bled twice before his admission, and once again on the
22nd. Cold affusions had been freely used.
_Examination_, on the 26th April.--Pericardium sound, but contained much
sanguinolent serum. Pleura sound. Lining membrane of pharynx partly
destroyed. No ulceration. Tonsils give out pus on pressure.
Oesophagus of a dark red, and partly lost its inner membrane. Larynx
and trachea injected; but the membrane lining them is entire, without
pustules or ulceration. Some frothy effusion in bronchiæ.
Liver healthy. Spleen large. Omentum sound, and of a natural white
colour, traversed by some large veins. Stomach externally of a brown-red
colour; and when opened, presents, spread out from the cardiac orifice,
dark brown-red streaks; and towards the pyloric orifice and upper side,
an extensive surface shaded over with vermillion and darker spots. Near
the duodenum, the surface is white. Intestines slightly injected.
Bladder dotted all over with bright red spots on its inner surface,
which is covered with a fine capillary reticulated structure.
VII. An infant, white, unprotected, aged three weeks, child of Clarissa
Clarke, who had been inoculated twenty-one years ago. Taken sick on
Sunday, 2nd May. Eruption appeared Thursday, 6th. Admitted 9th.
10th. Eruption copious, and in confluent patches, with red bases, and
flat vesicular summits. Has also aphthæ.
13th. Eruption confluent, in large white patches on face. Throat very
sore.
15th. Dead at eight A. M.
_Examination._--The stomach of a light colour, perfectly healthy. Folds
and plaits of mucous membrane strongly marked. Mucous surface of trachea
nearly healthy.
VIII. Infant, female, of a woman who died in the Alms House of varioloid
disease, shortly after giving birth to this child. It is three weeks
old; was admitted Sunday, 25th April, second day of the eruption. Dead
on Thursday, 29th. The skin became livid after death..
_Examination._--Pharynx inflamed, and the eruption on it extending all
the way down the oesophagus, to near the cardiac orifice; the lining
membrane being also in part destroyed. Stomach of a fine clear red, and
beautifully injected to the minutest capillaries all over the mucous
surface. Intestines, both large and small, red and injected.
The larynx has some eruption on its lining membrane. The trachea and
bronchiæ nearly healthy; there being no eruption or secretion on their
surface.
Doctor DARRACH was present at the majority of the above detailed
examinations, and kindly officiated at some of them. This gentleman,
well known for his zeal in the study of comparative and morbid anatomy,
made many interesting microscopical examinations of the various kinds of
variolous pustules, and the corresponding changes in the cutaneous
tissue, the results of which, we hope, he will make public.
Having thus freely described what we saw, we wish it were in our power
to lay down next, for the benefit of those who come after us, a
satisfactory method of treating small-pox. The hospital returns are not
of such an encouraging nature as to make our self-love predominate over
observation and experience, and lead us to inferences which might seem
to sanction the utility of this or that medicine, or curative plan. We
had to deal, it is true, with the worst portion of the community;
persons of constitutions exhausted or perverted by excess of sensual
indulgences, or by poverty, or both conjoined. In private and even
dispensary practice, where the subjects were of a better physical and
moral nature, we often saw the disease subside, and health return, after
less attention to administer medical aid, or to supply other wants, than
was exhibited at the hospital. We are, notwithstanding, sanguine enough
to anticipate useful results from our attentive study of the symptoms of
the disease, in connexion with that of the post mortem examinations, and
to consider ourselves as in possession of lights to guide us with more
certainty than before. Let us see how far a cautious analysis will tend
to dispel old errors, and establish useful truths.
The gastric distress, and the associated uneasiness and pain in the
head, back, and limbs, with evening exacerbations of fever, for the
three days preceding the eruption, evince conclusively a disease to
which the skin is a stranger, except by its usual sympathies of heat and
coldness, moisture and dryness. The appearance of the tongue, the loss
of appetite, thirst, nausea, and occasionally vomiting, are testimonies
to the impeded function of the stomach in this first period, or that of
precursory fever: and if to this we add the soreness of the fauces and
pharynx, producing impeded deglutition, we cannot refuse our assent to
the belief that the mucous surface, on which the _preparatory process_
of digestion takes place, is mainly affected. The next leading symptom
is the appearance of the eruption on the skin. The character of the
disease is now fixed, and the physician feels himself compelled to
respect the cutaneous inflammation, throughout its entire course,
naturally enough regarding it as the disease itself, rather than the
last link in the chain of morbid actions. To support the circulatory
system at such a degree as shall enable the skin to secrete this new
matter of small-pox, is nearly as much as he proposes to himself. But
here arises a question of great practical moment. To what extent, if
any, is the eruption a natural or necessary sequence of the previous
symptoms or condition of the system. Perhaps in the existing state of
medical science, we hardly dare reply positively to this question. This
much we know, that there is no correspondence in general between the
intensity of the precursory fever, and the copiousness of the after
eruption. We are, moreover, well apprized of the fact of very many, who
had been protected in earlier life by inoculation or vaccination, being
seized with all the symptoms of the precursory fever of the small-pox,
and remaining seriously indisposed for a few days, yet with very little
eruption in some cases, and without any in others.
Next we may inquire, what control, salutary or otherwise, we can
exercise over the skin in reference to its eruption, by adopting certain
methods in medicine and hygeine, during the period of invasion or of
precursory fever. To foster the germ of the poison, as yet only
affecting the inner surfaces, into efflorescence on the outer or
cutaneous one, by hot air, warm and heavy clothes, and cordial drinks,
is a practice, which, though at one time advocated on what was thought
very sufficient theory, is now abandoned as at war with experience. Of
these means, clothing acts primarily on the skin, and we will suppose
heat to do the same: the cordial drinks must however affect this organ
by stimulating and irritating the gastric and intestinal surface.
Against all stimulation of this surface we are then bound, from
knowledge and theory, to object.
The cooling regimen as it is called, was substituted for the
alexipharmic, in so far as regards light clothing and cool air. Can
emetics and purgatives be viewed as a part of this regimen, and exert as
such a salutary influence over the second period of the disease, or that
when the eruptive effort takes place? Admitting they are but local
stimulants, can they as such be with advantage applied to a surface, as
that of the stomach and intestines, already highly irritable, and which,
as the disease advances, becomes inflamed? If our object be in this
first period to diminish the violence of the second or eruptive one, we
doubt whether our expectations will be at all met by any kind of
stimulant to parts, which so promptly transfer their irritation to the
cetaceous surface. Whatever may be thought of these suggestions; whether
they are to be regarded as well-founded, or merely speculative, must be
a subject of future investigation; since we are as yet compelled to deny
that experience can be adduced in favour of the practice of vomiting and
purging to the first period of variolous disease.
On the same line with the remedies just mentioned, have been placed
bleeding, general and local, though as we apprehend, very erroneously.
There is not in bleeding as in purging, conflicting and alternating
effects of debility from evacuation, and irritation, primary and
sympathetic, from local stimulation; but a direct diminution of morbid
action, more tranquil movements of the heart and capillary system, that
is of the circulatory apparatus, and of the membranes, mucous, serous
and cutaneous, &c. Bleeding, unlike most other remedial agents, produces
a direct calmness and ease in the animal economy: it does not like them
substitute one disturbance for another, or make the great appear the
lesser evil. The experienced physician well knows the value of this
remedy, in the first period or invasion of the phlegmasiæ, and of some
fevers called general. He is fully aware, that if he cannot produce by
it a decided impression on the malady in the commencement, he is but too
often afterwards a prey to doubts and anxieties, wishing to relieve, but
unknowing what to attempt. Conceding, however, the power of venesection,
in the forming stage of the disease, now under review, so that we by
this remedy may control the series of morbid actions in the second
period, and diminish the extent of the eruption; it may yet be seriously
asked, whether we can with safety and propriety prevent or destroy the
succession of changes to which the skin is subjected, from the first
papulæ on to desiccation. On this point, we believe, has turned the
practice of the profession at all times, whether in the ages of
humoralism, or in the reign of solidism. In addition to the reasons
already assigned, which would lead us to doubt the necessity of the
eruption being left uncontrolled, or even suffered to run its course, we
may appeal to the practice of inoculation, which as effectually
saturated the system, and indisposed to subsequent attacks, as if the
skin had formed a continuous pustular surface; and yet this benefit was
often gained by the trifling tax of a few days' fever, and half a dozen
of pustules. Where the fever runs high and the respiration is much
affected, in the first period of measles, and before there is the
slightest appearance of eruption, we conceive it often so be our duty to
bleed freely, without reference to the subsequent disease of the skin,
or any nicety of calculation about this latter going through its regular
stages. Indeed, we have usually reason to congratulate ourselves for
having, by this means, rendered the subsequent disease milder and more
tractable. That affection of the urethra termed gonorrhoea, the
product of contagion, will, if left to itself, go through its several
stages; and, if rest and regimen be enjoined, will often leave the
subject healthy as before. But we can, notwithstanding, cut it short
with perfect impunity, by suitable remedies, and thereby prevent
numerous unpleasant symptoms and effects, which are often present when
the disease is left to nature. Syphilis has its several stages, each
marked by characteristic symptoms; but the skilful treatment of the
first stage prevents, how beneficially we all know, the appearance of
the others. We must then in small-pox, as well as in other diseases,
beware how we confound a common and even natural, with a necessary and
unavoidable succession of symptoms and periods.
The precursory fever in small-pox is seldom marked by the same common
inflammatory symptoms as that in measles; and does not seem, by its
actual violence, to urge the physician to deplete with freedom, if he
only have regard to the existing condition, rather than to the impending
danger and complication. The diversity in the two diseases consists not
so much in the greater intensity of the latter, as in the more decided
gastro-enteritic derangement in the former. Experience has not yet
sanctioned the benefit of copious bleeding from the arm, in incipient
disease, or irritation verging to inflammation of the intestinal
surface, as in small-pox; while its efficacy is admitted in measles. But
conceding its doubtful character, local bleeding, as by cupping, and
leeching on the abdomen, might be serviceably employed in the form of
disease now under consideration; as we know it to have been in other
febrile affections, where the same parts were diseased. Topical
depletion does unquestionably exercise the best effect on membranous
inflammation. In addition to cool air, we may with some confidence have
applied at this time to the skin, cool, if not cold, affusions; while
cold or cool drinks, and these of mucilaginous kind, would constitute
the principal ingestæ and medicines. Our own experience was little
favourable to the efficacy of cold water, applied to the surface during
the eruptive stage; and we apprehend, that, if decided benefit can grow
out of its use, it must be during the first or precursory fever, before
the formation of vesicles has commenced, when every thing is to be
attempted to sooth irritation, and prevent febrile reaction.
The first period over, the eruption on the skin now appears, and
constitutes a leading and exceedingly important symptom of the disease.
This eruption, like many others the product of gastric derangement,
acts for a time as a counter-irritant, and as such affords temporary
relief to the internal organs; but when continued, as in the farther
progress of the disease, it, in common with all irritants on the skin,
returns with interest to the digestive tube, the irritation which it
first received from this latter.
We must not lose sight of the state of the lining membrane of the lungs
during this time. It cannot be said so much to sympathize with the skin,
as to be affected by continuous disease; since the eruption on the
mucous membrane of the larynx, trachea, and its ramifications, undergoes
nearly the same changes, in the same time with that on the cutaneous
surface. The danger and violence of a disease in which the three
surfaces, cutaneous, pulmonary, and gastric, are all organically
affected at the same time, must be very apparent. Even though there be
no eruption on the internal coat of the stomach, its appearance after
death, of high vascularity and sanguineous injection, corresponding
precisely in appearance with the circles found in the lungs, of which
the pustules were the centres, justifies this belief of its being
organically affected. Each of the three above mentioned surfaces is in
degree ancillary to the others, and each may, on occasions, partially
supply their functions; but in this period of variolous disease, our
hopes of such vicarious action must be very faint indeed, and hence the
hazard attending any application to any one of them.
Are we from these appearances to pronounce the eruption a phlegmasia of
the skin and lungs, associated with a previous one of the stomach, and
recommend the free use of venesection? Life may occasionally be
prolonged, or at times saved by this means; but the disease will not be
thereby materially arrested in its course, or modified in its
appearance. We shall find that the inflammation of the membranes,
consisting as most of them do of cellular tissue and minute capillary
vessels, is often not susceptible of being checked by general depletion,
carried even so far as to almost empty the larger arteries, and arrest
the heart's motion.
Still more will this inflammation persist, if it have gone to the extent
of forming new parts, whether phlegmons or pustules. The intensity of
the inflammation may be somewhat moderated, but it cannot be conquered
now as at the commencement, or during the first period, or that of
invasion. We cannot, from our own experience, speak favourably of the
remedy in the second, or eruptive stage. It did not answer our
expectations, though employed in subjects apparently the best
constituted to derive the good effects proposed from it. We must at the
same time grant, that it was complicated with other remedies. Of topical
bleeding, we are unable to speak, not having seen it tried. In this
period of the disease, it must be of very difficult execution. Still
less reason have we to boast of the good effects of purging. Though the
skin may for a while be relieved by the watery secretions from the
intestinal canal; yet the irritation of the latter, consequent on
purging, is soon communicated to the cutaneous surface with the effect
of aggravating the eruption. To the class of stimuli or stimulating
diaphoretics, the same objections apply with increased force. As on the
one hand, in cases of high fever, seeming to call for great depletion,
the surfaces are often not relieved by general bleeding, but retain
their own vitality; so on the other, in cases of apparent prostration,
and feebleness of circulation, they often retain all their morbid
activity, and will of course be materially injured by stimulation,
either of hot air to the skin, or heating drinks to the gastric and
intestinal surface. Of the various diaphoretics employed, we had reason
to be least dissatisfied with the combination of opium and ipecacuanha
in small doses. In some few cases, tartrate of antimony and cream of
tartar, dissolved in rice or barley water, and the solution used as a
drink, seemed to be beneficial. Several grains of the former were thus
taken in the 24 hours, without its producing vomiting or purging. But in
very many other instances of the disease, this medicine had no
ameliorating effects. Calomel alone, or in combination with opium, was
given, and in a few cases caused _ptyalism_. We did not lose persons
thus affected, but we cannot speak with any confidence of the propriety
of the treatment.
The application of cold water to the skin, was tried by us on the
strength of its alleged good effects in this disease, but in no case had
we reason to be satisfied with it. The state of the cutaneous surface,
during the vesicular and pustular stages, is such as to prevent its
transmitting the usual impressions to the interior. Cold may deaden it,
and hasten the disorganization of its tissue, but cannot arrest and
suspend morbid capillary action here, as in ordinary fevers, or diseases
with great local determination, as to the head, &c. If useful at all,
it will, we apprehend, be in the forming stage of the disease, before
the skin is altered by the eruptive effort. The same objections do not
hold against the internal use of cool or cold liquids. We have in this
instance to be regulated by the usual precautions, as in all febrile
disease where the gastric system is the greatest sufferer. More benefit
will follow the sustained use of cool, than the occasional
administration of very cold draughts; since in the former case the
morbid action of the mucous surface may be restrained in due bounds,
without the risk and danger of reaction, and increase of heat and
thirst, which are apt to ensue from the latter. The same principle will
guide us in the temperature of the air to be inhaled by the lungs.
The secondary diseases, erysipelas, catarrh, and pneumonia, occurring on
the decline or subsidence of the variolous disease, would, we may now
presume from the phenomena in life, and the autopsic examinations, bear
and require a treatment, nearly similar to that used in these diseases
arising under other circumstances. Perhaps leeching and cupping ought to
be substituted, in such emergencies, for bleeding from the arm.
The extension unavoidably given to this first branch of our subject,
requires that we should defer the history of the modified small-pox, or
varioloid disease, to the next quarter, when it shall appear in the
corresponding number of this Journal.
EXPLANATION OF THE PLATE.
Figures 1, 2, 3, represent various appearances of the lining membrane of
the stomach.
Fig. 4, is a portion of the oesophagus; but the red bands ought to run
vertically, and not horizontally, as in the plate.
Fig. 13, is another appearance of the stomach.
Fig. 12, indicates the eruption having gone on to ulceration in the
pharynx.
Fig. 6, displays the appearance of the lining membrane of the trachea,
on the 6th day of the eruption, as in the case of Ann Collins.
Fig. 5, is intended to represent the same part in an advanced stage of
the disease, as in the case of Joseph Foster.
Resembling this is the case of Peter Johnson, as far as regards the
ulceration and dark colour of the intermediate surface; but differing in
the disorganization of the membrane being less.
Figs. 7, 8, 9, 10, and 11, represent the progress of the eruption, in a
female, from its incipient to its maturated state. The same section of
skin is represented from the 1st to the 5th day of the eruptive stage,
on which day the patient died. On the 2nd day, (fig. 8,) the vesicles
began to exhibit a central lividness, which was augmented on the
subsequent days. The patient had been some years before successfully
vaccinated. She was delivered of a child on the 1st day of the eruptive
stage. The minutes of this case have been mislaid; but the post mortem
appearances were indicative of high action, if not inflammation, of the
uterus and its appendages. The infant of this woman, forming Case VIII.
died of small-pox three weeks afterwards, on the sixth day of the
eruption.
This plate, together with some others yet unpublished, are from the
accurate pencil of Mr. now Dr. HARRINGTON, of this city.
(TO BE CONTINUED.)
FOOTNOTES:
[11] This was first at Bush Hill, and subsequently at the Sugar House,
near the Alms House.
[12] The largest proportion of these deaths was in the six months from
the 1st of November, 1823, to 1st of May, 1824, being in that period
about four hundred.
[13] Kept by Reuben Haines, at Germantown, seven miles from the city.
The thermometrical mean is that from daily observations made by this
gentleman at sunrise and at 2 P. M.
[14] Of these 165 were by yellow fever.
[15] The deaths from inflammation of the different viscera, were as
reported in this year, 290, and from infantile flux and cholera morbus,
177.
[16] Same proportion of inflammations as last year, viz. 339.
[17] Should it be hereafter necessary, we can illustrate other varieties
of the disease by drawings which were taken at the same time with those,
of which coloured engravings are now furnished.
ARTICLE IV.--_Remarks on the Pathology and Treatment of Yellow Fever._
Arranged from the Notes of Dr. J. A. MONGES, of Philadelphia.
I arrived at St. Domingo in the year 1785, and from that period to the
time of my departure from thence, I had very ample opportunities of
observing and treating the diseases of that island, both in the country
and at the Cape. During the whole time of my residence there, the
ordinary febrile diseases of hot climates were of very frequent
occurrence, especially among the new comers, and those not acclimated;
but the real yellow fever, or vomito negro, never prevailed. So that
when I reached this city in 1793, I never had had an opportunity of
observing this disease.
As introductory to the subject more particularly before us, I shall
offer a few remarks on the nature and treatment of the fever, which
prevailed in that island. It was usually of the remittent type, of a
bilious nature, and rather violent in its character; presenting very
often symptoms of a typhoid, or malignant condition of the system. In
almost every case, it was attended with great gastric irritability and
pain; and, in very many instances, accompanied with vomiting of dark
green, and even of black bilious matter,--determination to the brain
producing delirium, coma, &c. &c. In general, this fever differed but
little from the bilious fevers of this country; except, perhaps, in its
greater severity, and in a larger quantity of bile commonly evacuated.
The treatment of this disease, at the time of my arrival, was generally
attended with some difficulty, owing to the great prejudice prevailing
against the use of the lancet; not only among the mass of the
population, but even among the old physicians of the island. Experience,
however, having taught me, that venesection was essentially necessary in
fevers of the same sort, which I had noticed in other places, I resorted
to it, notwithstanding the existing opinion; and am now convinced, that
by its means I saved many patients. Nor was I the only one to adopt this
mode of practice; as it was commonly resorted to by all _new_
physicians, who were soon found to be more successful than the older
practitioners. To arrest the violent vomiting, already alluded to, it
was of the highest utility, and, in many instances, the only remedy that
could be depended upon. Emetics were very commonly used, and sometimes
with great benefit; but, in many instances, they were contraindicated by
the pain and irritation of the stomach.
Cooling and saline purgatives were advantageously employed, as well as
the saline mixture, and nitre and camphor in small and repeated doses, a
very favourite practice in the place. In a more advanced period, and
when the fever assumed a typhoid type, blisters, bark, and serpentaria
were resorted to.
I arrived in Philadelphia on the 20th of August, 1793, and on the 22nd
of the same month, began to see patients. The epidemic was then at its
height, and such was the demand for physicians, and the prevalence of
the idea, that, as I came from the West Indies, I must be familiar with
the yellow fever, that I soon became very extensively employed. Such,
indeed, was soon the extent of my engagements, that I was compelled for
a time to refuse my attendance on many patients, and to limit my visits
from Race to Dock streets, and from the water to Third street.
From the first time I had an opportunity of seeing the yellow fever, I
perceived that there existed but a very distant, if any, analogy between
it and the fevers I had been in the habit of treating in the West
Indies. And this opinion I have ever since entertained, in opposition to
the statement of many respectable authorities; but in conjunction with
some highly respectable physicians and friends, who, like myself, had
had an opportunity of treating both diseases. The points of difference
between these fevers will be noticed in a subsequent part of these
observations. But although entertaining this sentiment, I very early
came to the conclusion, that the yellow fever was the effect of a
gastro-duodenic inflammation, somewhat modified by some unknown
cause,--requiring the usual remedies for such a complaint, proportioned
only to the strength of the patient, and the force of reaction in the
system; and all my subsequent experience has only served to confirm me
in this belief. Differing from many physicians respecting its bilious
character, I have been led to believe, that the liver is very seldom
implicated in the disease;--the secretion of bile, in the majority of
cases, being very little, if at all altered. This may very readily be
discovered by an attentive examination of the symptoms of the disease,
as well as by the appearances noticed on dissection; the lining membrane
of the stomach and duodenum presenting in almost every case, marks of
inflammation, and giving passage to a large quantity of black matter,
which I have always been led to regard as altered blood, mixed with
mucus. The liver, on the contrary, so rarely showed marks of disease,
that when it did, it was natural to regard its alteration as secondary.
Such being my opinion respecting the pathology of yellow fever, I cannot
view otherwise than as secondary to the gastric affection, all the
morbid conditions of other organs, indicated during life by their
peculiar symptoms, and revealed on dissection by the ordinary marks of
inflammation; such as affections of the lungs, kidneys, &c. This view of
the subject will cease to be regarded as merely hypothetical, when it is
recollected, that these symptoms and morbid appearances are occasionally
not found; whilst the symptoms referrible to the gastric and duodenic
irritation, being the true characteristics of the disease, are always
present. Indeed, what would authorize us to regard any subject as
affected with yellow fever, who would not present the pain in the
stomach, the redness of the tip of the tongue, the thirst, irritability
of the stomach, and vomiting either of simple mucus, or black matter?
And, on the other hand, how many have died with these symptoms, who were
not affected with all the others we have noticed, and, on dissection,
have shown no mark of disease, except in the digestive apparatus?
Finally, can pain in the head, affections of the kidneys, vomiting of
bile, &c. constitute yellow fever, without the concurrence of some of
the gastric symptoms we have enumerated?
With respect to the characteristic features of yellow fever, and the
different signs, by which it may be distinguished from bilious fever, I
must be very brief; as a great deal having been written on the subject,
any long details in this place would occasion undue repetition of what
is already known to the profession. A few words, however, may not be
improper. Every one who has had frequent opportunities of seeing the
yellow fever, must have noticed, among its most habitual signs, a
peculiar inflamed glassy appearance of the eye, easily recognised, but
difficult to describe. It is one, however, on which I should be willing
to place considerable reliance, in establishing my diagnosis of this
disease; as I do not recollect to have noticed it in any other form of
febrile affection. Together with this, there is, in the majority of
cases, an intense supra-orbitar pain, apparently unconnected with great
disordered action of the brain, as the intellectual functions are
generally unimpaired. These two signs, together with pain in the loins,
and, in more advanced periods, the peculiar appearance of the skin, the
vomiting of the coffee grounds matter, the intermission on the 4th day,
the retention of muscular strength, and suppression of urine, are the
only signs by which the yellow fever, so far as I am prepared to say,
may be recognised. In regard to the supposed identity of this fever with
the bilious, a great deal has been written; but I must confess, that I
feel inclined to doubt the correctness of this opinion, for the
following reasons:
1st. Bilious fever is almost always a remittent fever, presenting
regular exacerbations, and, unless arrested by medical aid or some
effort of nature, running its course, in a progressive manner, either to
a happy or fatal termination; whereas the yellow fever is almost
invariably a continued fever, presenting obscure and irregular, or even
_no_ remissions. On the fourth day, it generally presents so perfect a
remission, as to cause the patient, in many cases, to imagine himself
perfectly free from disease, and induce him to get up, and even
sometimes to walk out. This remission, which sometimes amounts to an
intermission, so far as an experience of upwards of forty years can
authorize me to decide, is never found to attend in bilious fever, in
which, if there be any remission, and recurrence of the unpleasant
symptoms, the former is always a real convalescence, and the latter an
accidental relapse.
2nd. The red colour of the eye, to which I have alluded above as
occurring in the early stage of the yellow fever, and its peculiar
yellow tinge in the after part of the disease, are different from the
redness and yellowness of the same organ in bilious fever; in the first
stage of which the eye presents a more fiery redness, and in the
subsequent period, a more saffron yellowness.
3d. The colour of the skin in the two diseases presents also some
difference, being more constantly noticed in yellow fever, and
disappearing much more rapidly than in bilious fever. In yellow fever,
moreover, it assumes, most commonly, a yellowish-brown or even mahogany
tinge; whereas in bilious fever, when it occurs, it does not differ from
the ordinary jaundice colour, of a lighter or deeper shade.
4th. These fevers may likewise be distinguished by an attention to the
state of the intellectual faculties, and of the muscular strength; these
remaining often unimpaired to the last in yellow fever, whereas, in a
very large majority of cases of bilious fever, the mind becomes soon
involved in the disorder of the system, and the greatest muscular
debility prevails, even from the very onset of the attack.
5th. The matter vomited might of itself serve to distinguish the two
diseases. Independently of the difference we shall notice when speaking
of the black vomit, we may mention that patients complain, even
sometimes from the commencement of the attack, of the acidity of the
vomited matter; whereas in bilious fever, the mouth is bitter, and the
matter ejected of the same taste.
6th. As a further mark of difference, we may state, that, in yellow
fever, the tongue, except at the tip, the skin, and the pulse are
sometimes little altered; whereas in bilious fever they are usually
pretty much so.
7th. In respect to the duration of the two diseases, we may state as a
general rule, that yellow fever runs its course to death or
convalescence, in a much shorter time than bilious fever. Nor is the
promptness of recovery from yellow fever less different from the
slowness of convalescence, noticed in most cases of bilious fever.
8th. The suppression of urine is a frequent attendant on the last stage
of yellow fever, and is seldom noticed in bilious fever.
9th. I have never witnessed a second attack of yellow fever in the same
individual; whilst on the contrary, so far as I have seen, there is no
limitation to the number of times a person may be affected with the
other form of fever.
_Prognosis._--As regards the prognosis in yellow fever, I shall merely
state, that I generally found, an early evacuation from the alimentary
canal, and a disposition to diaphoresis during the first twenty-four or
thirty-six hours, and its continuance during the course of the disease,
to be favourable omens. When the disease continued beyond the 7th, 9th,
or 11th day, greater hopes might be entertained. It was likewise found,
that the mortality was much smaller among patients, who remained free
from apprehensions as to the nature and termination of the disease. To
this cause, more than any other, do I refer my greater success among
Quakers; who, being generally surrounded and comforted by their friends,
retained more than any other class of people, the necessary tranquillity
of mind.
Among the unfavourable signs may be mentioned, a discoloration of the
skin before the fourth day. This symptom was, indeed, almost always a
fatal one. Obstinate vomiting and costiveness, hæmorrhages from
different parts of the body, unattended with an abatement of the
symptoms, and vomiting of black matter, were very unfavourable; whilst a
suppression of urine, agreeably to my experience, was always a fatal
sign.
_Black Vomit._--In a preceding part of these observations, in alluding
to the black vomit, I took occasion to express my views respecting its
nature,--stating that I regard it as consisting of mucous flakes, mixed
with a large proportion of altered blood. That such is the true nature
of this substance, on which so much has been said and written, I have
had sufficient reason to be convinced. The opinion that it consists of
altered bile, I deem totally untenable, for the following reasons: The
matter is occasionally voided in large quantities, in cases in which the
liver is not at all affected, and in which, after death, the gall
bladder is discovered to be more or less filled with _natural_ bile.
Independently, of this, it may be stated, that the appearance of the two
substances is very dissimilar;--the black bile vomited in bilious fever
being of a homogeneous nature, and of a black or deep green colour;
whilst the matter of the black vomit is, in a large majority of cases, a
compound of a mucous, flaky substance, and a sanguineous matter, bearing
some resemblance to the grounds of coffee, and, for the most part, of a
brown tinge. When mixed with water, the two substances produce very
different effects,--the bile mixing with and imparting a greenish tinge
to it without difficulty, whilst the grounds of the other, float on the
surface of the water, without mixing with and colouring it, in the same
manner as bran, deprived of all its mucilage, or rather like mahogany
saw-dust. This I consider as one of the best modes of distinguishing
these two substances,--serving at the same time to establish a
difference between the fevers, I was in the habit of observing in the
West Indies, and the yellow fever of this country. Nor are these the
only reasons for rejecting the supposition of the black vomit of yellow
fever being of a bilious nature; for I have known this substance (and I
suppose other practitioners have observed the same fact) occasionally to
exude from surfaces, from which, in all probability, bile is excluded. I
allude particularly to the skin and verous membranes. Thus it has often
happened, that the application of a blister, especially in the advanced
stage of the disease, has been followed by a copious exudation of a
fluid, resembling, in all respects, the matter ejected from the stomach;
an occurrence which was strikingly exemplified in a case, which fell
under my immediate observation during the last visitation of the disease
in this city, in 1820. During the same epidemic, I had occasion to
attend a Mrs. H. about 70 years of age, who presented a curious example
of the exudation of a similar substance from the peritoneum. She had not
been exposed to the causes of the yellow fever, and indeed presented
none of its ordinary pathognomonic signs. She was attacked very early in
the morning with violent colic, attended with fever, great tenderness of
the abdomen, and high colour of the face. She was bled at 10 o'clock; at
11 vomited a large quantity of coffee ground matter, and died in about
12 or 15 hours from the commencement of the attack. The next morning her
body was examined in the presence of several highly respectable and
experienced physicians, who all coincided in the opinion, that the
matter vomited and which continued to be discharged from the nose, was
identical with that discharged in yellow fever. The stomach as well as
the intestines were found to contain a large quantity of a similar
substance. The cavity of the peritoneum being likewise found filled with
a large portion of it, we at first suspected the existence of an opening
in the intestines, by which an effusion had taken place. After a careful
and minute examination, however, no such opening was discovered. Our
attention was now directed to the condition of the peritoneum itself,
which was highly inflamed. It was, moreover, found, that the substance
in question exuded from its surface,--the membrane, in many places,
especially the portion of it which covers the liver, being coated so
thickly with the grounds, that they could readily be scraped off with
the back of a scalpel.
These cases show conclusively, that the matter of the black vomit,
occurring in yellow fever, should not be regarded as altered bile; and
that the supposition of its consisting of a secretion of the mucous
membrane of the stomach, does not rest on a much more solid foundation.
For bile can hardly be admitted to exude from the skin and serous
membranes, and we cannot suppose, that fluids, similar in every respect,
can be secreted from two surfaces, so very distinct in their
organization, and in the nature of their ordinary products, as those of
the mucous and serous membranes.
From these facts I am led to regard the black vomit as a true
hæmorrhage, resulting from a state of previous irritation of the surface
which furnishes it. That inflammation may be cause of it, we have a
sufficient proof in the fact, that a similar fluid is occasionally
vomited in cases of puerperal fever, when the irritation progresses from
the serous to the mucous membrane of the intestines; as well as in cases
of inflammation from blows on the stomach, and the action of poisons. A
case of this kind, arising from a kick of a horse, was attended by
myself and two respectable physicians in consultation, a few years ago;
and another case arising from a large dose of carbonate of potassa,
swallowed by mistake, occurred in my practice not long since. But as it
would occupy too much time to give them here in detail, I pass them by
without further notice.
That the matter of the black vomit is the product of a hæmorrhage, I
have thought may also be inferred from the fact, often noticed by myself
and others, of large portions of coagulated blood being found in the
intestines; the surface having the appearance of the common black
matter, whilst on cutting into them, the centre is found to consist of a
red solid coagulum. I have also sometimes noticed, that the duodenum
contained the coffee ground matter, and the intestines, coagulated
blood. In such cases, in order to adopt the opinion of secretion, we
must believe, that the same vessels, occupied in the secretory process,
afforded, at the same time, passage to a portion of common blood; for we
can hardly admit, that the mucous follicles are the organs secreting the
black matter. Besides, is this not a mere dispute about words; and is it
proved that what are called sanguineous secretions are not the result of
the same action, which gives rise to hæmorrhagic exudations? and is
there any other difference between the hæmorrhage of yellow fever, and
of ordinary cases of hematemesis, than that arising from a difference in
the _quality_ of the blood?
Nor do I find much difficulty in believing, that the colour of the skin,
which is more frequently brown than yellow, as well as the petechiæ, &c.
are the effects of the stagnation of blood, altered by the capillaries
of the surface, in the same manner as that exuding from the mucous
surfaces. I believe that this opinion, suggested by some European
writers, is supported by the fact, that this fluid exudes from the
orifices made by the bites of leeches and the incisions of scarified
cups; as well as from the raw surface occasioned by blisters; and that
the vibices contain a serous fluid mixed with blood.
_Analogy to Plague._--On comparing the symptoms of the yellow fever of
this country with those of plague, as detailed so minutely and, I
believe, accurately by authors, and especially by the physicians who
accompanied Bonaparte to Egypt, I have been led to regard these diseases
as bearing a closer analogy to each other than has hitherto been
admitted. I do not pretend to assert that they are the same disease, but
only that they are so nearly allied, as on some occasion, to lead even
an experienced observer into an error of diagnosis. The great difference
between them consists in the frequency of the affection of the lymphatic
glands in the plague, and its comparative rareness in yellow fever; and
in the greater predominance of gastric symptoms in the latter.
Nevertheless, I have had, on many occasions, during our different
epidemics, opportunities of noticing buboes, situated in the same parts
as those mentioned by writers on the plague, running the same course,
and curable by the same means. Carbuncles are frequently seen in both
diseases, though not so frequently in yellow fever as in the plague.
Both diseases present what are called the walking cases. Patients in
both, though more frequently in yellow fever, retain their muscular
strength as well as their intellectual faculties. So far as we are
informed, the mortality in both is pretty nearly the same, and the
treatment similar.
_Contagion of Yellow Fever._--The question of the contagion or
non-contagion of yellow fever has so long occupied the attention of the
profession and been discussed so extensively, that I deem it unnecessary
to devote much space to it here. Nevertheless, as I have had frequent
opportunities of noticing the disease under all circumstances; in all
parts of the city, and in the country; among the wealthy and the poor, I
may without much impropriety offer, in a few words, the result of my
observations and reflections on this head. I must unhesitatingly
declare, that, establishing my opinion on what I have seen, I am led to
the conviction, that the yellow fever is not a contagious disease; that
it never has been carried hither in the way mentioned by contagionists;
and that it has invariably proved an infectious disease, using this word
to express a malady arising from a local source of contamination, other
than a living body. It is plain, that this view of the subject does not
exclude the possibility of a vessel carrying the disease to this or any
other port; but, in that case, the vessel itself or its cargo, must be
the source of infection, and not the individuals on board. And this may
take place, when the port from whence the vessel sailed is free from the
disease. That such has been the case, there cannot be any doubt; and
that the idea, predicated on it, of the contagiousness of the fever is
erroneous, I have not the least hesitation in believing.
How else than on the principle of infection, and not of contagion, can
we explain the attack of individuals frequenting those parts of the
city, where the disease had originated, and which (all the inhabitants
having been removed to some distant situation) had been barricaded? How
could we, in any other way, account for the exemption from the fever of
individuals, who, out of the infected district, nursed, touched, and
even slept with their diseased relatives and friends; and not always in
clean and well ventilated apartments and parts of the city; but, in very
many instances, in the filthiest hovels, and alleys, and among the
lowest classes of society. Striking and unanswerable facts of the sort
have frequently presented themselves to my observation, during our
various epidemics. Children have sucked their parents, affected with the
fever, and, in one case which fell under my notice, the child continued
attached to the breast after its mother's death; and in all such
instances with impunity. I have constantly reprobated the practice of
burning the clothes and bedding of the dead, and have never found any
bad results to occur to those who followed my advice. From a
consideration of all these facts, I must once more express it as my
decided opinion, that the yellow fever, so far as I have had an
opportunity of observing it, is not a contagious disease.
_Treatment._--Whatever opinion we may entertain respecting the specific
nature of yellow fever, I was early convinced that this disease was not
to be treated by specific remedies, and that our curative indications
should be formed on an attentive consideration of the condition of the
system in general, and of particular organs, as pointed out by the
symptoms during life and the morbid lesions after death.
In a former part of these remarks, I suggested the opinion, that the
yellow fever is a gastro-duodenic inflammation, (perhaps of a specific
kind,) and that it required a mode of treatment appropriate to this
morbid state; but proportioned to the strength of the patient, to the
violence of the attack, and to the power of re-action. In general,
however, I have not found active depletion by the lancet, as easily
borne in this, as in bilious and other fevers;--the disease assuming
more rapidly, under this plan, a state of prostration or adynamia. Nor
can this appear surprising, since the same circumstance of a disease
being of an inflammatory nature, but, under a peculiar condition of the
system, contraindicating ample depletion, is a subject of frequent
notice during certain epidemics; for example, of scarlatina, pneumonia,
&c. With the exception of those cases, therefore, occurring in very
robust and plethoric constitutions, and accompanied with much pain in
the head, high febrile excitement, and hard pulse, either large or
small, I have seldom resorted freely to the lancet. When, however, these
symptoms presented themselves, especially the hardness of the pulse, I
have not been sparing of blood-letting, and have sometimes repeated it
several times with the most decided success. But even under these
circumstances, I have seldom found that _large_ bleedings were as
beneficial as small and repeated ones;--the system not reacting always
as energetically as could have been desired, and symptoms of prostration
occurring with much more rapidity. I do not recollect to have bled with
advantage, patients presenting a large, full, but _compressible_ pulse,
owing to the want of reaction; although the other symptoms might seem to
indicate the propriety of the practice. The effect of bleeding on the
vomiting was very different in this, from what I mentioned it to have
been in the bilious fevers of the West Indies; owing probably to the
circumstance, that, when, in yellow fever, the irritation of the stomach
became sufficiently violent to give rise to this symptom, the state of
the system was very often such as to contraindicate the use of the
lancet.
The application of scarified and dry cups to the epigastrium and head,
when there existed pain in these regions, was often resorted to, and
afforded much relief. And I very much regret, that, during our
epidemics, it was out of my power to make use of leeches to the former
part, as so warmly recommended, at the present day, by the French and
Spanish physicians; as I am inclined to the opinion, from the view I
have adopted respecting the pathology of the disease, that, used early
and in large numbers, they would prove very serviceable.
In conjunction with general and local bleeding, fomentations were had
recourse to in almost every case, and applied to the epigastrium in the
form of poultices, or flannels wrung out of warm emollient decoctions.
In order to excite perspiration and to determine action to the surface,
a tepid bath was occasionally prescribed, and in some cases afforded
considerable relief; but as it was an inconvenient remedy, pediluvia,
and hot bricks on which water, or water mixed with vinegar was poured,
were substituted. In cases, however, in which much arterial action
existed, these last means were not prescribed, until the pulse had been
brought down by the lancet, and other remedies presently to be
mentioned.
On the subject of emetics, I shall not enlarge; as I can safely assert,
that I very seldom saw a patient recover from yellow fever, to whom
tartarized antimony, or any other active remedy of the same class, had
been administered. Of the impropriety and danger of this practice in the
present disease, I was early convinced from a careful analysis of the
symptoms, indicating an acute irritation of the stomach and upper
portion of the small intestines, and from the circumstance, that, of the
first family in which I was called to prescribe, five members, to whom
emetics had been administered, had already fallen victims to the fever,
under the care of a very respectable physician, and that three
succeeding ones, who were treated agreeably to my view of the pathology
of the disease, recovered. From these facts and reflections, I was
induced to watch the effects of these remedies in subsequent cases, in
my own practice, and in the practice of other physicians, and was soon
led, from this extended experience, to abandon totally the use of tartar
emetic in the treatment of this malady. Ipecacuanha in emetic doses was
also tried by me; but although, thus administered, it did not occasion
the bad effects resulting from the exhibition of the preceding article,
yet it was often productive of harm, and never of benefit. These
remarks, however, apply more particularly to the use of tartar emetic
during the state of excitement of the fever, and not to that of collapse
which sometimes precede it, and in which it is recommended by some
physicians of the southern states. In this condition of the system, I
have never resorted to it, and, I must confess, could not easily be
persuaded to do so; suspecting that even in such cases, the digestive
organs are already too far implicated, to justify the use of so powerful
and acrid a remedy.
It would seem that the bad effects of emetics, and more particularly of
tartarized antimony, resulted, not only from their irritating qualities,
but also from the efforts of vomiting, during which the stomach is
compressed by the abdominal muscles, and made to contract very forcibly.
To this opinion I am naturally led from the circumstance, that
purgatives, whose action is certainly primarily irritating, are very
advantageously employed in yellow fever. It is not my intention to
attempt here an explanation of this seeming contradiction. Leaving to
others the accomplishment of this difficult task, I shall content myself
with stating, that during the whole course of my long practice, I have
seldom seen a patient die of this disease, whose bowels had been well
evacuated, and in whom perspiration had been excited within the first
twenty-four hours after the attack. I exhibited purgatives in almost
every instance _every day_, until copious evacuations had been procured,
and I generally found, that the mild purges were of greater service than
those of a severe and irritating nature. Senna, acidulated with lemon
juice or tamarinds, answered sometimes remarkably well, when the stomach
could retain it. Castor oil, manna, salts, magnesia, were frequently
employed by me with advantage; and although I did not make an extensive
use of calomel in this disease, yet I prescribed it to children, and to
adults, who, owing to great irritability of the stomach, could not
retain other purgative medicines. When I resorted to it, I generally did
so in doses sufficient to ensure a purgative effect, and never with a
view of exciting ptyalism. In doing this, I was not guided, however, by
any fear of the effects of a salivation, since I was well aware that a
ptyalism occurring in malignant diseases is often a favourable crisis;
but by a knowledge of the great difficulty experienced in producing it,
and from the observation, that in cases in which it was obtained, much
valuable time had been lost, and the patient might have recovered
without.
To promote the operation of the above remedies, purgative enemata were
resorted to, in the early stage of the fever; and were followed by the
frequent use of injections, composed of emollient decoctions, from which
the patient derived considerable relief and comfort.
As counter-irritants, blisters and sinapisms were used, and often with
great advantage. They were found of much value when applied to the
epigastric region, for the purpose of arresting the vomiting. Sinapisms
were in general preferred to blisters, as being more prompt in their
effects and more easily renewed. Blisters were sometimes applied to the
extremities in the different stages of the disease; but so far as I can
judge, from my experience, not with much real benefit.
I seldom derived much advantage from the use of tonics and stimuli in
yellow fever; except when the powers of life seemed to fail, and
petechiæ, vibices, hæmorrhages, and other signs of malignancy had
occurred. In general, under such circumstances, the Peruvian bark,
either alone or combined with serpentaria, was administered in
preference to any other remedy of the same class. In cases, however,
unattended with reaction, tonics and diffusible stimuli internally, and
revulsives of all sorts externally, were had recourse to from the
commencement of the attack, and sometimes with the desired effect of
arousing the powers of the system. _Opium_ was never found beneficial,
on account of its tendency to aggravate or produce coma, as well as from
its effect in suppressing intestinal evacuations.
Whilst making use of the above remedies, the plentiful exhibition of
diluent drinks was not neglected,--care being taken, however, not to
load unduly the stomach, and to select such drinks as would suit the
taste of the patient. In almost every case, acids did not answer so well
as the bland mucilaginous infusions. The drinks were almost universally
allowed cold, except when there existed a tendency to perspiration;
under which circumstances they were administered slightly warm and a
little aromatic.
During the course of the yellow fever, some of the symptoms demanded
particular attention. Influenced by the idea of prostration and
dissolution, many practitioners, and myself for some time among the
rest, resorted to the bark and other tonics for the purpose of arresting
the black vomit, and of correcting that condition of the organs, which
gave rise to this effusion; but after many unsuccessful trials, I was
led to abandon this practice and to resort to other means. Of all the
remedies employed to attain this effect, calcined magnesia mixed in a
thick solution of gum arabic seemed to me to answer best; for whilst it
succeeded, in many cases, in arresting the vomiting, it tended to keep
the bowels open. Together with this, revulsive remedies were applied to
the skin, and sometimes succeeded very well,--a sufficient proof, I
think, that this hæmorrhage is the effect of an increased action of the
mucous membrane of the digestive tube, and not of a passive condition of
the capillaries of the parts. For the purpose of controlling the great
irritability of the stomach, and arresting the vomiting occurring in the
early stage of the disease, besides the usual remedies used in such
cases, I found advantage in the use of small and frequently repeated
injections with a solution of salts, an infusion of senna, or the like
substances. Such a practice, however, did not seem to succeed so well in
the latter stage of the disease.
With the intention of promoting the secretion of urine, in cases in
which it was suppressed, all the diuretics, as well as every external
stimuli, were in vain employed;--this symptom, as I have already
mentioned, being, in all instances which fell under my immediate
observation, the forerunner of death.
ARTICLE V.--_Remarks on the Prophylactic Treatment of Cholera Infantum._
By JOSEPH PARRISH, M. D., one of the Surgeons to the Pennsylvania
Hospital.
The great mortality of cholera infantum renders it one of the most
interesting diseases, which come under the notice of the physician. Its
ravages among the infant population of our large cities, are too well
known, and too strongly felt, to require any comment. No disease
contributes so largely to swell our bills of mortality during its
prevalence; and were it not restricted to the summer season, it would
prove a greater scourge to the community than consumption itself.
This mortality is owing less to our ignorance of the nature of the
complaint, and the proper mode of treatment, than to the continued
operation of the causes by which it is produced. I have often compared
our endeavours to cure cholera infantum, while these causes remain, to
an attempt to relieve inflammation in a part, while a thorn is sticking
in the flesh. We may resort to bleeding and leeching; we may restrict
our patient to the lowest diet, and the most perfect rest; we may employ
all those remedies, which are ordinarily best calculated to reduce
inflammation: but so long as the thorn continues in the wound, our
efforts will be fruitless. Thus it is with cholera. We may obviate the
more violent symptoms; we may procure temporary relief; we may even
flatter ourselves that a cure has been effected: but the original causes
have not lost their power; an increased susceptibility to their
operation remains; relapse upon relapse is experienced; and at last the
little sufferer, worn out by the successive attacks, sinks beyond the
reach of medicine, and expires. Unhappily, the nature of the causes is
such, that, in very many instances, their removal is exceedingly
difficult, if not altogether impossible; and, under such circumstances,
the patient who has once been severely affected, seldom recovers in the
end. Hence it becomes of the greatest importance to prevent the
occurrence of the disease; and attention to the prophylactic treatment
is no less essential than the adoption of curative measures. It is with
the view of calling the attention of the profession to this subject,
that I have been induced to offer the following observations.
It is obvious, that, in the preventive treatment, two objects demand
attention; first, to remove, as far as possible, the causes of the
disease; and secondly, where their entire removal is not attainable, to
fortify the system against their influence. On each of these, I shall
offer a few observations.
I. Excessive and continued heat is, perhaps, the most fruitful source of
cholera. Thus we find, that the disease makes its first appearance in
the commencement of the hot weather, increases and becomes more fatal
with the rise of the thermometer, and declines with the return of cool
weather in autumn. During its continuance, it may be observed to vary
with every permanent change of temperature. A few very hot days in
succession, in the 6th month, are sufficient to call it into action; and
during the height of its prevalence, a spell of cold weather will
diminish, if not suppress it. In the summer of 1806, which was
remarkably cool and pleasant, there was very little of the disease; and
generally in moderate summers, it is much less prevalent than in those
of a contrary character.
I believe that it is by a direct operation on the system, and not by the
generation of miasmata, that heat proves so deleterious to the infant.
In the country, where miasmata are most abundant, there is comparatively
little cholera; for the heat of the sun is there moderated by the free
circulation of the air; and the debilitating operation of the high
temperature of the day is counteracted by the refreshing coolness of the
morning and evening. It is in the close air of cities, that the
complaint flourishes with greatest vigour; and the most confined
situations are the most favourable to its production. Let any one take
a walk, in a summer's morning, through the thickly built lanes and
alleys of Philadelphia. He will be struck with the appearance of the
children, reclining their heads, as if exhausted, upon the breast of
their mothers, with a pale and languid countenance, a cool and clammy
skin, a shrunk neck, and other signs of debility, arising from their
confinement, during the night, to close and hot apartments. It will
readily be believed, that such places are the very hot beds of cholera.
Heat, therefore, connected with confined air, being among the most
frequent causes of the complaint, it is necessary, as far as possible,
to counteract them. Should a strong predisposition to cholera be
suspected, the best plan will be to send the child into the country
during the summer. Both as a preventive and a remedy, country air is
decidedly the most effectual, to which we can resort. But in most
instances, it would be exceedingly inconvenient, sometimes impossible
for mothers to leave their homes and occupations in the city; and, under
such circumstances, it becomes necessary to substitute measures, which
may produce, as nearly as possible, the same effects. To keep the child
cool, and expose him to the fresh air, are the ends to be obtained. For
this purpose, he should be carried frequently into the open squares, or
beyond the suburbs of the city. I am in the habit of recommending to
parents, whose circumstances will not allow of a removal from the city
during the summer season, to make frequent excursions across the
Delaware, and into the neighbouring woods of New Jersey. The refreshing
effects of the air on the river are truly surprising. The brightened eye
and animated countenance of the infant, give speedy proof of their
favourable influence; and when labouring under the disease, even in its
lowest stage, the little patient will often exhibit immediate signs of
amendment.
In the prevention of cholera, much may also be expected from a proper
attention to the lodging of children. Many parents have a great dread of
the night air; and exclude it from their chambers, as sedulously as if
it were infected with poison. But, in guarding their children from
taking cold, they expose them to a much greater danger. Observe their
mode of treatment. The doors and windows are carefully closed; the child
is placed in a feather bed, with his parents on each side, and almost
smothered with the bed-clothes. Perhaps other children are lodged in the
same apartment; and thus the delicate system of the infant is exposed to
the debilitating influence of great heat and stagnant air, combined with
the effluvia, which, in such a situation, must be abundantly generated.
Simply to enter such a room in the morning, is almost sufficient to
sicken a healthy individual; how much more injurious must be its effects
upon the lodgers themselves. Examine in the morning a child, who has
passed the night thus confined. You will find him limber as a rag,
exhausted by perspiration, wholly destitute of animation, without
appetite, and on the very verge of cholera. I should recommend an
entirely different plan of management. Instead of a feather bed, the
child should be placed on a hard mattress, or on blankets folded and
laid upon the floor. The covering should be light, but comfortable. The
doors and windows should be open; so that fresh air, that _pabulum
vitæ_, without which health cannot be sustained, may be freely admitted.
Thus treated, instead of the feeble and sickly appearance before
mentioned, he will present a lively countenance, with all that activity
of motion, and enjoyment of existence, which are natural to his age, and
afford the surest criterion of vigorous health. Experience has fully
convinced me of the great importance of attention to the lodging of
children, as a prophylactic measure; and this renders me desirous of
impressing upon the profession generally, the truth of my own
convictions on the subject.
With the same design of obviating the injurious effects of a high
temperature upon the infantile system, I advise frequent ablutions with
cool water, and its free employment as a beverage. Infants, unable to
make their wants known, often suffer exceedingly from the inability of
their attendants to understand them. During the heat of summer, the
increased evaporation from their surface is necessarily productive of
increased thirst, which, if unsatisfied, renders them uneasy and
restless. To quiet them, the breast or bottle is offered. Aliment is
thus given, where drink only was required; and the stomach, overloaded
and oppressed, is apt to become irritable, and is thus brought into a
condition most favourable to the occurrence of cholera. By attention to
the peculiar language of infants, expressed not by words, but by signs,
I have often been able to detect their wants; and, in many instances,
have afforded the most decided relief, by simply giving them a little
cool water for drink. From the dread which some individuals have for
cool air and cold water, it would seem that they were considered rather
as destructive poisons than as absolute necessaries. I have no fear of
either, when judiciously employed; and as prophylactics in cholera, I do
not think their place can be supplied.
But heat is not the only cause of this complaint. Dentition is well
known both to predispose the system to its attack, and, after it has
occurred, to increase its violence, and diminish the chances of
recovery. In the employment, therefore, of preventive measures, it is
highly necessary to attend to the state of the gums, and to remove or
counteract this source of irritation. If at all swelled or painful, they
should be lanced freely, and the operation should be repeated as often
as their inflammatory condition may demand. In severe cases, much good
may be expected from the application of blisters behind the ears. The
irritation thus receives an external direction, and the stomach and
bowels are in less danger of an attack. I was led to this practice, by
observing that the eruption, which, during dentition, is apt to make its
appearance behind the ears, often proves a most salutary effort of
nature; and that, while it continues, the infant generally enjoys an
exemption from those dangerous disorders, incident to this critical
period of life. To imitate nature as closely as possible, the discharge
from the blistered surface should be maintained for some time by
stimulating dressings. I have witnessed the most beneficial effects from
the practice, and can strongly recommend it to the attention of the
profession.
II. At the same time that we endeavour to remove or diminish the causes
of cholera, we should not neglect to put the system of the child in such
a condition, as may enable it most effectually to resist their
operation. As cholera is a disease of irritation, originating generally
in a debilitated state of the alimentary canal, I believe this end may
be most easily attained, by preserving the natural tone of the digestive
organs. For this purpose, all flatulent and indigestible food should be
carefully avoided. During the first year, the mother's milk is, in
general, the most appropriate nutriment. When the stomach of the infant
is very delicate, the diet of the mother should be strictly regulated;
and, in all cases, it would be adviseable for her to avoid articles of a
flatulent nature. While the child is still at the breast, if a
predisposition to cholera be suspected, I would recommend the occasional
use of nutritious animal juices. The sucking of small pieces of salt
meat, as ham or dried beef for example, will sometimes be found
productive of advantage. After weaning, animal food should always enter
into the diet of the child. Many parents, fearing to render their
children gross and unhealthy, restrict them altogether to vegetable
aliments; and thus, by weakening the powers of digestion, prepare the
way for that very result which they are most anxious to avoid.
With the same view of giving tone to the stomach, aromatics should be
used habitually during the summer, in those cases, in which there is
strong reason to apprehend the occurrence of cholera. While they produce
a cordial impression on the stomach, and invigorate generally the
digestive powers, they are liable to none of those objections which may
be urged against the employment of the narcotic stimulants. Indeed,
nature herself seems to have pointed them out as prophylactics against
the diseases of hot weather. Our most powerful and valuable spices are
the products of warm countries. Cinnamon, ginger, pepper, the clove, the
nutmeg, are to be found only in tropical climates. In this arrangement,
we see the hand of a beneficent Creator, who has provided, that, by the
same high temperature, which renders the equatorial regions so fruitful
of cholera, and other disorders of the bowels, the growth of those
plants should be promoted, which are best calculated to invigorate the
alimentary canal, and to fortify it against the inroads of disease.
Facts are not wanting to prove the efficacy of spices in preventing
intestinal complaints. We are informed by DEWAR, in his treatise on the
Diarrhoea and Dysentery, by which the British army in Egypt was
attacked, that among the Mamalukes of that country, it was a universal
practice, when they apprehended the approach of these disorders, to make
use of cinnamon or ginger, with the almost uniform effect of averting
them; and where the same practice was followed by the British soldiers,
equal advantages were experienced. In the French army, so highly was the
prophylactic power of the aromatics estimated, that every soldier was
provided with a box of spices, which he was directed to use freely with
his diet of fruit and melons.
When attending surgeon of the Alms-house hospital in this city, I had
occasion frequently to prescribe in a syphilitic ward, which being
situated directly under the roof, in a large garret, was liable, in the
summer season, to become very much heated. As the patients were
numerous, and the windows insufficient to admit of proper ventilation,
the air became much contaminated; and the consequence was, that bowel
complaints were very frequent and troublesome. I have often entered the
ward on a summer's morning, and found almost every patient affected more
or less with diarrhoea or cholera. It occurred to me, that the free
use of some of the aromatics might be found serviceable in preventing
the occurrence of these complaints. I accordingly directed, that every
individual in the ward should drink a portion of strong ginger tea
daily. I also ordered, that salt meat should be used twice in the week.
By the steady pursuit of this plan, a very considerable change for the
better was effected.
The employment of aromatics as prophylactics is not less beneficial in
children than in adults. I would not, however, advise, that they should
be given indiscriminately to all children, during the summer. It is only
to those cases, in which a predisposition to cholera infantum exists,
that I consider them peculiarly applicable; and here I believe they are
capable of producing much good.
Before dismissing the subject of the paper, I will simply remark, in
addition to what has been already said, that the occasional use of the
cold bath, by the vigour it imparts to the system generally, and through
it to the digestive organs, will often be found an excellent
preservative against the summer complaint of children.
In this short account of the preventive treatment of cholera infantum, I
have been less anxious to give a dissertation, embracing all that might
be said on the subject, than to communicate those particular measures,
which, according to my own experience, I have found most effectual. I
will conclude the paper by the relation of a case, in which a strong
predisposition to the disease was successfully counteracted. It will be
proper, however, to premise, that the treatment of this case is by no
means held out as an example to be generally followed with every
infant, which may possibly become the subject of cholera. It is
applicable in all its details only to those, in which, as in the present
instance, there is every reason to apprehend, that the only alternative
is between almost certain death, and the most careful prophylactic
treatment.
CASE.--A gentleman of this city, whose wife had arrived at a period of
life, when she could not expect to be the mother of many more children,
consulted me respecting an infant daughter, their only surviving child.
I was informed, that they had already lost eight children, all of whom,
with one exception, had died of cholera. It may readily be imagined,
that every feeling of parental anxiety was awakened for their babe; and
that no degree of attention on their part was considered too great,
which might contribute to its preservation. It was placed under my care,
not to be cured, but that I might, if possible, devise some plan of
management which would avert the disease they had so much reason to
apprehend. I felt the responsibility of the trust, and endeavoured to
find it to the best of my ability. Every opportunity which I could
desire was afforded me; for the infant, from its birth was submitted to
my direction; and both the disposition and ability existed, on the part
of the parents, to carry implicitly into effect every measure which I
might recommend.
As the mother was unable to furnish sufficient nourishment, the first
step was to provide a healthy wet-nurse, who might be willing to submit
to the necessary regulations in respect to diet.
I believed the children of these parents to possess a constitutional
weakness in the alimentary canal; and, on inquiry, I was told, that they
had been kept upon a vapid diet, under the impression that it would
contribute to their health. In the present case, therefore, the
principal object was to communicate strength to the stomach and bowels.
With this view, the child was accustomed, from an early period of
infancy, to a generous diet. When very young, portions of ginger tea
were given to it daily; and as soon as it was old enough to suck the
juice of meat, it was encouraged to do so. The nurse, during the warm
season, was kept upon a nutritious diet, consisting principally of
animal food, with the occasional use of ginger tea; and every
description of recent fruit and fresh vegetable food was forbidden.
Under this management, the first summer was passed without any symptom
of the disease; but I looked forward to the second with no little
anxiety, when the child would have to struggle with the irritation
arising from dentition.
The same plan was continued during the second summer, and still more
rigidly enforced. The child was now old enough to take animal food
freely in addition to the breast. It was allowed as much salt fish, ham,
beef-steak, essence of beef, &c. as it desired; ginger tea was given
daily; a little sound old port wine was occasionally directed; and both
the child and the nurse were restricted from every species of flatulent
and indigestible aliment. So anxious, indeed, were the parents, and so
careful to carry my directions into full effect, that they allowed no
forbidden article of food to enter the house, and denied themselves
their wonted comforts, lest possibly their child might be injured.
The gums were carefully attended to, and lanced whenever the operation
appeared to be requisite. All those measures, which I have before
mentioned as serviceable in obviating the effects of great heat, so far
as they were applicable to the case, were adopted. The second summer was
spent wholly in the country.
Very little medicine was required, and none was administered, except of
the mildest description. Frequently, when summoned to visit the babe, I
have found the mother trembling with fear, and anxious that something
might be done; and often, under such circumstances, have I begged it off
from a dose of physic, having determined to avoid a resort to every
thing of the kind, unless real necessity should demand it.
By a strict adherence to the plan above detailed, the period of
dentition was passed in safety; and it is with heartfelt pleasure I can
say, that no symptom of cholera afterwards made its appearance.
ARTICLE VI.--_Case of Neuralgia cured by Acupuncturation._ Communicated
by J. HUNTER EWING, M. D.
The attention of the medical public having been of late much excited on
the subject of acupuncturation, I am induced to communicate the
following case.
For eighteen months, Miss ---- had been afflicted, at intervals, with a
severely painful affection of the nerves of the right cheek, immediately
below the orbit of the eye, and extending to the angle of the lower jaw.
On the 14th of January 1826, she was attacked more violently than usual,
and the remedies, which had previously afforded some relief, now failed.
Stimulating cataplasms, warm embrocations, laudanum, internally and
externally, heat applied externally to the cheek by means of very hot
flannels, produced not the slightest mitigation of the pain; and she
continued to suffer excessively until the afternoon of the 15th; when
acupuncturation being proposed, she consented to the operation with this
remark,--"any thing to relieve me from this agony."
The needles were immediately procured, and three inserted about an inch
from each other. Two in a line parallel with the inferior edge of the
orbit of the eye, and half an inch below it; and a third below, and
equidistant from the others. The first two were introduced to the depth
of three-fourths of an inch; the last, a full inch. They were inserted
very gradually and with a rotary motion.
The second needle was scarcely introduced, before the patient exclaimed,
"the pain has entirely left me." When the third was introduced, she
experienced a stiffness in the muscles of the cheek, and a creeping
sensation, as if a spider's web had been drawn across the face; but no
painful sensation whatever.
Such was the exhausted state of her system from the excessive pain she
had suffered, that when thus relieved, she requested a pillow to rest
her head on, and fell into a gentle slumber.
About two hours after the insertion of the needles, I again visited my
patient, and
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