disease, to be universal. In eighteen or twenty dissections, he tells
us, he found the pia mater always distended with blood[55]. Where signs
of inflammation have not occurred, the blood-vessels had probably
relieved themselves by the effusion of serum, or the morbid action of
the blood-vessels had exceeded that grade of excitement, in which only
inflammation can take place. I have seen one case of death from this
disease, in which there was not more than a tea-spoonful of water in the
ventricles of the brain. Dr. Quin mentions a similar case. Here death
was induced by simple excess of excitement. The water which is found in
the ventricles of the brain refuses to coagulate by heat, and is always
pale in those diseases, in which the serum of the blood, in every other
part of the body, is of a yellow colour.
[55] Medical Journal, vol. VIII.
In addition to these facts, in support of the internal dropsy of the
brain being the effect of inflammation, I shall mention one more,
communicated to me in a letter, dated July 17th, 1795, by my former
pupil, Dr. Coxe, while he was prosecuting his studies in London. "It
so happened (says my ingenious correspondent), that at the time of my
receiving your letter, Dr. Clark was at the hospital. I read to him that
part which relates to your success in the treatment of hydrocephalus
internus. He was much pleased with it, and mentioned to me a fact which
strongly corroborates your idea of its being a primary inflammation of
the brain. This fact was, that upon opening, not long since, the head of
a child that had died of this disease, he found between three and four
ounces of water in the ventricles of the brain; also an inflammatory
crust on the optic nerves, as thick as he had ever observed it on the
intestines in a state of inflammation. The child lost its sight before
it died. The crust accounted in a satisfactory manner for its blindness.
Perhaps something similar may always be noticed in the dissections of
such as die of this disease, in whom the eyes are much affected."
Having adopted the theory of this disease, which I have delivered, I
resolved upon such a change in my practice as should accord with it. The
first remedy indicated by it was
I. _Blood-letting._ I shall briefly mention the effects of this remedy
in a few of the first cases in which I prescribed it.
CASE I.
On the 15th of November, 1790, I was called to visit the daughter
of William Webb, aged four years, who was indisposed with a cough, a
pain in her bowels, a coma, great sensibility of her eyes to light,
costiveness, and a suppression of urine, a slow and irregular, but
tense pulse, dilated pupils, but no head-ach. I found, upon inquiry,
that she had received a hurt on her head by a fall, about seven weeks
before I saw her. From this information, as well as from her symptoms,
I had no doubt of the disease being the internal dropsy of the brain. I
advised the loss of five ounces of blood, which gave her some relief.
The blood was sizy. The next day she took a dose of jalap and calomel,
which operated twelve times. On the 18th she lost four ounces more of
blood, which was more sizy than that drawn on the 15th. From this time
she mended rapidly. Her coma left her on the 20th, and her appetite
returned; on the 21st she made a large quantity of turbid dark coloured
urine. On the 22d her pulse became again a little tense, for which she
took a gentle puke. On the 23d she had a natural stool. On the 24th her
pupils appeared to be contracted to their natural size, and on the 30th
I had the pleasure of seeing her seated at a tea-table in good health.
Her pulse notwithstanding, was a little more active and tense than
natural.
CASE II.
On the 24th of the same month, I was called to visit the son of John
Cypher, in South-street, aged four years, who had been hurt about a
month before, by a wound on his forehead with a brick-bat, the mark of
which still appeared. He had been ill for near two weeks with coma,
head-ach, colic, vomiting, and frequent startings in his sleep. His
evacuations by stool and urine were suppressed; he had discharged three
worms, and had had two convulsion fits just before I saw him. The pupil
of the right eye was larger than that of the left. His pulse was full,
tense, and slow, and intermitted every _fourth_ stroke. The symptoms
plainly indicated an internal dropsy of the brain. I ordered him to lose
four or five ounces of blood. But three ounces of blood were drawn,
which produced a small change in his pulse. It rendered the intermission
of a pulsation perceptible only after every tenth stroke. On the 25th
he lost five ounces of blood, and took a purge of calomel and jalap. On
the 26th he was better. On the 27th the vomiting was troublesome, and
his pulse was still full and tense, but regular. I ordered him to lose
four ounces of blood. On the 28th his puking and head-ach continued;
his pulse was a little tense, but regular; and his right pupil less
dilated. On the 29th his head-ach and puking ceased, and he played
about the room. On the 4th of December he grew worse; his head-ach and
puking returned, with a hard pulse, for which I ordered him to lose five
ounces of blood. On the 5th he was better, but on the 6th his head-ach
and puking returned. On the 7th I ordered his forehead to be bathed
frequently with vinegar, in which ice had been dissolved. On the 8th he
was much better. On the 9th his pulse became soft, and he complained but
little of head-ach. After appearing to be well for near three weeks,
except that he complained of a little head-ach, on the 29th his pulse
became again full and tense, for which I ordered him to lose six ounces
of blood, which for the first time discovered a buffy coat. After this
last bleeding, he discharged a large quantity of water. From this time
he recovered slowly, but his pulse was a little fuller than natural on
the 19th of January following. He afterwards enjoyed good health.
CASES III. AND IV.
In the month of March, 1792, I attended two children of three years of
age, the one the daughter of William King, the other the daughter of
William Blake: each of whom had most of the symptoms of the inflammatory
stage of the internal dropsy of the brain. I prescribed the loss of four
ounces of blood, and a smart purge in both cases, and in the course of a
few days had the pleasure of observing all the symptoms of the disease
perfectly subdued in each of them.
CASE V.
In the months of July and August, 1792, I attended a female slave of
Mrs. Oneal, of St. Croix, who had an obstinate head-ach, coma, vomiting,
and a tense, full, and _slow_ pulse. I believed it to be the phrenicula,
or internal dropsy of the brain, in its inflammatory stage. I bled her
five times in the course of two months, and each time with obvious
relief of all the symptoms of the disease. Finding that her head-ach,
and a disposition to vomit, continued after the tension of her pulse
was nearly reduced, I gave her as much calomel as excited a gentle
salivation, which in a few weeks completed her cure.
CASE VI.
The daughter of Robert Moffat, aged eight years, in consequence of the
suppression of a habitual discharge from sores on her head, in the
month of April, 1793, was affected by violent head-ach, puking, great
pains and weakness in her limbs, and a full, tense, and _slow_ pulse.
I believed these symptoms to be produced by an inflammation of the
brain. I ordered her to lose six or seven ounces of blood, and gave her
two purges of jalap and calomel, which operated very plentifully. I
afterwards applied a blister to her neck. In one week from the time of
my first visit to her she appeared to be in perfect health.
CASE VII.
A young woman of eighteen years of age, a hired servant in the family
of Mrs. Elizabeth Smith, had been subject to a head-ach every spring for
several years. The unusually warm days which occurred in the beginning
of April, 1793, produced a return of this periodical pain. On the eighth
of the month, it was so severe as to confine her to her bed. I was
called to visit her on the ninth. I found her comatose, and, when awake,
delirious. Her pupils were unusually dilated, and insensible to the
light. She was constantly sick at her stomach, and vomited frequently.
Her bowels were obstinately costive, and her pulse was full, tense, and
so slow as seldom to exceed, for several days, from 56 to 60 strokes in
a minute. I ordered her to lose ten ounces of blood every day, for three
days successively, and gave her, on each of those days, strong doses of
jalap and aloes. The last blood which was drawn from her was sizy. The
purges procured from three to ten discharges every day from her bowels.
On the 12th, she appeared to be much better. Her pulse was less tense,
and beat 80 strokes in a minute. On the 14th, she had a fainting fit. On
the 15th, she sat up, and called for food. The pupils of her eyes now
recovered their sensibility to light, as well as their natural size. Her
head-ach left her, and, on the 17th, she appeared to be in good health.
Her pulse, however, continued to beat between 50 and 60 strokes in a
minute, and retained a small portion of irregular action for several
days after she recovered.
I am the more disposed to pronounce the cases which have been described
to have been internal dropsy of the brain, from my having never been
deceived in a single case in which I have examined the brains of
patients whom I have suspected to have died of it.
I could add many other cases to those which have been related, but
enough, I hope, have been mentioned to establish the safety and efficacy
of the remedies that have been recommended.
I believe, with Dr. Quin, that this disease is much more frequent
than is commonly supposed. I can recollect many cases of anomalous
fever and head-ach in children, which have excited the most distressing
apprehensions of an approaching internal dropsy of the brain, but which
have yielded in a few days to bleeding, or to purges and blisters. I
think it probable, that some, or perhaps most of these cases, might have
terminated in an effusion of water in the brain, had they been left
to themselves, or not been treated with the above remedies. I believe
further, that it is often prevented by all those physicians who treat
the first stage of febrile diseases in children with evacuations, just
as the pulmonary consumption is prevented by bleeding, and low diet, in
an inflammatory catarrh.
Where blood-letting has failed of curing this disease, I am disposed
to ascribe it to its being used less copiously than the disease
required. If its relation to pneumonicula be the same in its cure,
that I have supposed it to be in its cause, then I am persuaded, that
the same excess in blood-letting is indicated in it, above what is
necessary in phrenitis, that has been practised in pneumonicula, above
what is necessary in the cure of an acute inflammation of the lungs.
The continuance, and, in some instances, the increase of the appetite
in the internal dropsy of the brain, would seem to favour this opinion
no less in this disease, than in the inflammatory state of pulmonary
consumption. The extreme danger from the effusion of water into the
ventricles of the brain, and the certainty of death from its confinement
there, is a reason likewise why more blood should be drawn in this
disease, than in diseases of the same force in other parts of the body,
where the products of inflammation have a prompt, or certain outlet from
the body. Where the internal dropsy is obviously the effect of a fall,
or of any other cause which acts _directly_ on the brain, there can be
no doubt of the safety of very plentiful bleeding; all practical writers
upon surgery concur in advising it. The late Dr. Pennington favoured
me with an extract from Mr. Cline's manuscript lectures upon anatomy,
delivered in London in the winter of 1792, which places the advantage
of blood-letting, in that species of inflammation which follows a local
injury of the brain, in a very strong point of light. "I know (says he)
that several practitioners object to the use of evacuations as remedies
for concussions of the brain, because of the weakness of the pulse; but
in these cases the pulse is _depressed_. Besides, experience shows,
that evacuations are frequently attended with very great advantages. I
remember a remarkable case of a man in this [St. Thomas's] hospital, who
was under the care of Mr. Baker. He lay in a comatose state for three
weeks after an injury of the head. During that time he was bled _twenty_
times, that is to say, he was bled once every day upon an average. He
was bled twice a day _plentifully_, but towards the conclusion he was
bled more sparingly, and only every other day; but at each bleeding,
there were taken, upon an average, about sixteen ounces of blood. In
consequence of this treatment, the man perfectly recovered his health
and reason."
Local bleeding by cups, leaches, scarifications, or arteriotomy, should
be combined with venesection, or preferred to it, where the whole
arterial system does not sympathize with the disease in the brain.
II. A second remedy to be used in the second stage of this disease is
_purges_. I have constantly observed all the patients whose cases have
been related, to be relieved by plentiful and repeated evacuations from
the bowels. I was led to the use of frequent purges, by having long
observed their good effects in palsies, and other cases of congestion
in the brain, where blood-letting was unsafe, and where it had been
used without benefit. In the Leipsic Commentaries[56], there is an
account of a case of internal dropsy of the brain, which followed the
measles, being cured by no other medicines than purges and diuretics. I
can say nothing in favour of the latter remedy, in this disease, from
my own experience. The foxglove has been used in this city by several
respectable practitioners, but, I believe, in no instance with any
advantage.
[56] Vol. xxix. p. 139.
III. _Blisters_ have been uniformly recommended by all practical writers
upon this disease. I have applied them to the head, neck, and temples,
and generally with obvious relief to the pain in the head. They should
be omitted in no stage of the disease; for even in its inflammatory
stage, the discharge they occasion from the vessels of the head, greatly
overbalances their stimulating effects upon the whole system.
IV. _Mercury_ was long considered as the only remedy, which gave the
least chance of a recovery from a dropsy of the brain. Out of all the
cases in which I gave it, before the year 1790, I succeeded in but two:
one of them was a child of three years old, the other was a young woman
of twenty-six years of age. I am the more convinced that the latter
case was internal dropsy of the brain, from my patient having relapsed,
and died between two or three years afterwards, of the same disease.
Since I have adopted the depleting remedies which have been mentioned,
I have declined giving mercury altogether, except when combined with
some purging medicine, and I have given it in this form chiefly with a
view of dislodging worms. My reasons for not giving it as a sialagogue
are the uncertainty of its operation, its frequent inefficacy when
it excites a salivation, and, above all, its disposition to produce
gangrene in the tender jaws of children. Seven instances of its inducing
death from that cause, in children between three and eight years of
age, and with circumstances of uncommon distress, have occurred in
Philadelphia since the year 1795.
V. _Linen cloths_, wetted with cold vinegar, or water, and applied to
the forehead, contribute very much to relieve the pain in the head. In
the case of Mr. Cypher's son[57], the solution of ice in the vinegar
appeared to afford the most obvious relief of this distressing symptom.
[57] Case II.
A puncture in the brain has been proposed by some writers to discharge
the water from its ventricles. If the theory I have delivered be true,
the operation promises nothing, even though it could always be performed
with perfect safety. In cases of local injuries, or of inflammation from
any cause, it must necessarily increase the disease; and in cases of
effusion only, the debilitated state of the whole system forbids us to
hope for any relief from such a local remedy.
Bark, wine, and opium promise much more success in the last stage of
the disease. I can say nothing in their favour from my own experience;
but from the aid they afford to mercury in other diseases, I conceive
they might be made to accompany it with advantage.
Considering the nature of the indirect causes which induce the disease,
and the case of a relapse, which has been mentioned, after an interval
of near three years, as well as the symptoms of slow convalescence,
manifested by the pulse, which occurred in the first and seventh cases,
I submit it to the consideration of physicians, whether the use of
moderate exercise, and the cold bath, should not be recommended to
prevent a return of the disease in every case, where it has yielded to
the power of medicine.
I have great pleasure in adding, that the theory of this disease,
which I have delivered, has been adopted by many respectable physicians
in Philadelphia, and in other parts of the United States, and that it
has led to the practice that has been recommended, particularly to
copious blood-letting; in consequence of which, death from a dropsy of
the brain is not a more frequent occurrence, than from any other of the
acute febrile diseases of our country.
OBSERVATIONS
UPON
THE NATURE AND CURE
OF THE
_GOUT_.
In treating upon the gout, I shall deliver a few preliminary
propositions.
1. The gout is a disease of the whole system. It affects the ligaments,
blood-vessels, stomach, bowels, brain, liver, lymphatics, nerves,
muscles, cartilages, bones, and skin.
2. The gout is a primary disease, only of the solids. Chalk-stones,
abscesses, dropsical effusions into cavities, and cellular membrane, and
eruptions on the skin, are all the effects of a morbid action in the
blood-vessels. The truth of this proposition has been ably proved by Dr.
Cullen in his First Lines.
3. It affects most frequently persons of a sanguineous temperament; but
sometimes it affects persons of nervous and phlegmatic temperaments.
The idle and luxurious are more subject to it, than the labouring and
temperate part of mankind. Women are said to be less subject to it than
men. I once believed, and taught this opinion, but I now retract it.
From the peculiar delicacy of the female constitution, and from the thin
covering they wear on their feet and limbs, the gout is less apt to fall
upon those parts than in men, but they exhibit all its other symptoms,
perhaps more frequently than men, in other parts of the body. The remote
causes of gout moreover to be mentioned presently, act with equal force
upon both sexes, and more of them I believe upon women, than upon men.
It generally attacks in those periods of life, and in those countries,
and seasons of the year, in which inflammatory diseases are most common.
It seldom affects persons before puberty, or in old age, and yet I have
heard of its appearing with all its most characteristic symptoms in this
city in a child of 6, and in a man above 80 years of age. Men of active
minds are said to be most subject to it, but I think I have seen it as
frequently in persons of slender and torpid intellects, as in persons of
an opposite character. I have heard of a case of gout in an Indian at
Pittsburg, and I have cured a fit of it in an Indian in this city. They
had both been intemperate in the use of wine and fermented liquors.
4. It is in one respect a hereditary disease, depending upon the
propagation of a similar temperament from father to son. When a
predisposition to the gout has been derived from ancestors, less force
in exciting causes will induce it than in those habits where this has
not been the case. This predisposition sometimes passes by children,
and appears in grand-children. There are instances likewise in which it
has passed by the males, and appeared only in the females of a family.
It even appears in the descendants of families who have been reduced
to poverty, but not often where they have been obliged to labour for a
subsistence. It generally passes by those children who are born before
the gout makes its appearance in a father. It is curious to observe
how extensively the predisposition pervades some families. An English
gentleman, who had been afflicted with the gout, married a young woman
in Philadelphia many years ago, by whom he had one daughter. His wife
dying three weeks after the birth of this child, he returned to England,
where he married a second wife, by whom he had six children, all of whom
except one died with the gout before they attained to the usual age of
matrimony in Great Britain. One of them died in her 16th year. Finally
the father and grandfather died with the same disease. The daughter whom
this afflicted gentleman left in this city, passed her life subject to
the gout, and finally died under my care in the year 1789, in the 68th
year of her age. She left a family of children, two of whom had the
gout. One of them, a lady, has suffered exquisitely from it.
5. The gout is always induced by general predisposing debility.
6. The remote causes of the gout which induce this debility, are,
indolence, great bodily labour, long protracted bodily exercise,
intemperance in eating, and in venery, acid aliments and drinks, strong
tea and coffee, public and domestic vexation, the violent, or long
continued exercise of the understanding, imagination, and passions
in study, business, or pleasure, and, lastly, the use of ardent, and
fermented liquors. The last are absolutely necessary to produce that
form of gout which appears in the ligaments and muscles. I assert this,
not only from my own observations, but from those of Dr. Cadogan, and
Dr. Darwin, who say they never saw a case of gout in the limbs in any
person who had not used spirits or wine in a greater or less quantity.
Perhaps this may be another reason why women, who drink less of those
liquors than men, are so rarely affected with this disease in the
extreme parts of their bodies. Wines of all kinds are more disposed
to produce this form of gout than spirits. The reason of this must
be resolved into the less stimulus in the former, than in the latter
liquors. Wine appears to resemble, in its action upon the body, the
moderate stimulus of miasmata which produce a common remitting fever, or
intermitting fever, while spirits resemble that violent action induced
by miasmata which passes by the blood-vessels, ligaments, and muscles,
and invades at once the liver, bowels, and brain. There is one symptom
of the gout in the extremities which seems to be produced exclusively
by ardent spirits, and that is a burning in the palms of the hands,
and soles of the feet. This is so uniform, that I have sometimes been
able to convict my patients of intemperance in the use of spirits, when
no other mark of their having taken them in _excess_, appeared in the
system.
I have enumerated among the remote causes of the gout, the use of
strong tea. I infer its predisposing quality to that disease, from its
frequency at Japan, where tea is used in large quantities, and from the
gout being more common among that sex in our country who drink the most,
and the strongest tea.