through the patient's clothes, as not to have entered the wound made in
the flesh. And
4. There may have been no predisposition in the patient to receive the
fever. This is often observed in persons exposed to the plague, yellow
fever, small-pox, and to the infection of the itch, and the venereal
disease.
The hydrophobia, like the small-pox, generally comes on with some
pain, and inflammation in the part in which the infection was infused
into the body, but to this remark, as in the small-pox, there are some
exceptions. As soon as the disease discovers itself, whether by pain or
inflammation in the wounded part, or by any of the symptoms formerly
mentioned, the first remedy indicated is _blood-letting_. All the facts
which have been mentioned, relative to its cause, symptoms, and the
appearances of the body after death, concur to enforce the use of the
lancet in this disease. Its affinity to the plague and yellow fever in
its force, is an additional argument in favour of that remedy. To be
effectual, it should be used in the most liberal manner. The loss of
100 to 200 ounces of blood will probably be necessary in most cases to
effect a cure. The pulse should govern the use of the lancet as in other
states of fever, taking care not to be imposed upon by the absence of
_frequency_ in it, in the supposed absence of fever, and of _tension_
in affections of the stomach, bowels, and brain. This practice, in the
extent I have recommended it, is justified not only by the theory of the
disease, but by its having been used with success in the following cases.
Dr. Nugent cured a woman by two copious bleedings, and afterwards by the
use of sweating and cordial medicines.
Mr. Wrightson was encouraged by Dr. Nugent's success to use the same
remedies with the same happy issue in a boy of 15 years of age[81].
[81] Medical Transactions, vol. ii. p. 192.
Mr. Falconer cured a young woman of the name of Hannah Moore, by
"a copious bleeding," and another depleting remedy to be mentioned
hereafter[82].
[82] Ditto, p. 222.
Mr. Poupart cured a woman by bleeding until she fainted, and Mr. Berger
gives an account of a number of persons being bitten by a rabid animal,
all of whom died, except two who were saved by bleeding[83].
[83] Bibliotheque Choisie de Medecine, tome xv. p. 212.
In the 40th volume of the Transactions of the Royal Society of London,
there is an account of a man being cured of hydrophobia by Dr. Hartley,
by the loss of 120 ounces of blood.
Dr. Tilton cured this disease in a woman in the Delaware state by very
copious bleeding. The remedy was suggested to the doctor by an account
taken from a London magazine of a dreadful hydrophobia being cured by an
accidental and profuse hæmorrhage from the temporal artery[84].
[84] Medical Essays of Edinburgh, vol. i. p. 226.
A case is related by Dr. Innes[85], of the loss of 116 ounces of blood
in seven days having cured this disease. In the patient who was the
subject of this cure, the bleeding was used in the most depressed, and
apparently weak state of the pulse. It rose constantly with the loss of
blood.
[85] Medical Commentaries, vol. iii. p. 496.
The cases related by Dr. Tilton and Dr. Innes were said to be of a
spontaneous nature, but the morbid actions were exactly the same in
both patients with those which are derived from the bite of a rabid
animal. There is but one remote cause of disease, and that is stimulus,
and it is of no consequence in the disease now under consideration,
whether the dread of water be the effect of the saliva of a rabid animal
acting upon the fauces, or of a morbid excitement determined to those
parts by any other stimulus. The inflammation of the stomach depends
upon the same kind of morbid action, whether it be produced by the
miasmata of the yellow fever, or the usual remote and exciting causes
of the gout. An apoplexy is the same disease when it arises from a
contusion by external violence, that it is when it arises spontaneously
from the congestion of blood or water in the brain. A dropsy from
obstructions in the liver induced by strong drink, does not differ in
its proximate cause from the dropsy brought on by the obstructions in
the same viscus which are left by a neglected, or half cured bilious
fever. These remarks are of extensive application, and, if duly attended
to, would deliver us from a mass of error which has been accumulating
for ages in medicine: I mean the nomenclature of diseases from their
remote causes. It is the most offensive and injurious part of the
rubbish of our science.
I grant that bleeding has been used in some instances in hydrophobia
without effect, but in all such cases it was probably used out of time,
or in too sparing a manner. The credit of this remedy has suffered in
many other diseases from the same causes. I beg it may not be tried in
this disease, by any physician who has not renounced our modern systems
of nosology, and adopted, in their utmost extent, the principles and
practice of Botallus and Sydenham in the treatment of malignant fevers.
Before I quit the subject of blood-letting in hydrophobia, I have to
add, that it has been used with success in two instances in dogs that
had exhibited all the usual symptoms of what has been called madness.
In one case, blood was drawn by cutting off the tail, in the other,
by cutting off the ears of the diseased animal. I mention these facts
with pleasure, not only because they serve to support the theory and
practice which I have endeavoured to establish in this disease, but
because they will render it unnecessary to destroy the life of a useful
and affectionate animal in order to prevent his spreading it. By curing
it in a dog by means of bleeding, we moreover beget confidence in the
same remedy in persons who have been bitten by him, and thus lessen
the force of the disease, by preventing the operation of fear upon the
system.
2. Purges and glysters have been found useful in the hydrophobia. They
discharge bile which is frequently vitiated, and reduce morbid action in
the stomach and blood-vessels. Dr. Coste ascribes the cure of a young
woman in a convent wholly to glysters given five or six times every day.
3. Sweating after bleeding completed the cure of the boy whose case is
mentioned by Mr. Wrightson. Dr. Baumgarten speaks highly of this mode
of depleting, and says further, that it has never been cured "but by
evacuations of some kind."
4. All the advantages which attend a salivation in common malignant
fevers, are to be expected from it in the hydrophobia. It aided
blood-letting in two persons who were cured by Mr. Falconer and Dr. Le
Compt.
There are several cases upon record in which musk and opium have
afforded evident relief in this disease.
A physician in Virginia cured it by large doses of bark and wine. I have
no doubt of the efficacy of these remedies when the disease is attended
with a moderate or feeble morbid action in the system, for I take it for
granted, it resembles malignant fevers from other causes in appearing
in different grades of force. In its more violent and common form,
stimulants of all kinds must do harm, unless they are of such a nature,
and exhibited in such quantities, as to exceed in their force the
stimulus of the disease; but this is not to be expected, more especially
as the stomach is for the most part so irritable as sometimes to reject
the mildest aliments as well as the most gentle medicines.
After the morbid actions in the system have been weakened, tonic
remedies would probably be useful in accelerating the cure.
Blisters and stimulating cataplasms, applied to the feet, might probably
be used with the same advantage in the declining state of the disease,
that they have been used in the same stage of other malignant fevers.
The cold bath, also long immersion in cold water, have been frequently
used in this disease. The former aided the lancet, in the cure of the
man whose case is related by Dr. Hartley. There can be no objection
to the cold water in either of the above forms, provided no dread is
excited by it in the mind of the patient.
The reader will perceive here that I have deserted an opinion which I
formerly held upon the cause and cure of the tetanus. I supposed the
hydrophobia to depend upon debility. This debility I have since been
led to consider as partial, depending upon abstraction of excitement
from some, and a morbid accumulation of it in other parts of the
body. The preternatural excitement predominates so far, in most cases
of hydrophobia, over debility, that depleting remedies promise more
speedily and safely to equalize, and render it natural, than medicines
of an opposite character.
In the treatment of those cases of hydrophobia which are not derived
from the bite of a rabid animal, regard should always be had to its
remote and exciting causes, so as to accommodate the remedies to them.
The imperfection of the present nomenclature of medicine has become the
subject of general complaint. The mortality of the disease from the bite
of a rabid animal, has been increased by its name. The terms hydrophobia
and canine madness, convey ideas of the symptoms of the disease only,
and of such of them too as are by no means universal. If the theory I
have delivered, and the practice I have recommended, be just, it ought
to be called the hydrophobic state of fever. This name associates it at
once with all the other states of fever, and leads us to treat it with
the remedies which are proper in its kindred diseases, and to vary them
constantly with the varying state of the system.
In reviewing what has been said of this disease, I dare not say that I
have not been misled by the principles of fever which I have adopted;
but if I have, I hope the reader will not be discouraged by my errors
from using his reason in medicine. By contemplating those errors, he
may perhaps avoid the shoals upon which I have been wrecked. In all his
researches, let him ever remember that there is the same difference
between the knowledge of a physician who prescribes for diseases as
limited by genera and species, and of one who prescribes under the
direction of just principles, that there is between the knowledge we
obtain of the nature and extent of the sky, by viewing a few feet of it
from the bottom of a well, and viewing from the top of a mountain the
whole canopy of heaven.
Since the first edition of the foregoing observations, I have seen a
communication to the editors of the Medical Repository[86], by Dr.
Physick, which has thrown new light upon this obscure disease, and
which, I hope, will aid the remedies that have been proposed, in
rendering them more effectual for its cure. The doctor supposes death
from hydrophobia to be the effect of a sudden and spasmodic constriction
of the glottis, inducing suffocation, and that it might be prevented
by creating an artificial passage for air into the lungs, whereby life
might be continued long enough to admit of the disease being cured
by other remedies. The following account of a dissection is intended
to show the probability of the doctor's proposal being attended with
success.
[86] Volume V.
On the 13th of September, 1802, I was called, with Dr. Physick, to
visit, in consultation with Dr. Griffitts, the son of William Todd,
Esq. aged five years, who was ill with the disease called hydrophobia,
brought on by the bite of a mad dog, on the 6th of the preceding month.
The wound was small, and on his cheek, near his mouth, two circumstances
which are said at all times to increase the danger of wounds from rabid
animals. From the time he was bitten, he used the cold bath daily, and
took the infusion, powder, and seeds of the anagallis, in succession,
until the 9th of September, when he was seized with a fever which
at first resembled the remittent of the season. Bleeding, purging,
blisters, and the warm bath were prescribed for him, but without
success. The last named remedy appeared to afford him some relief, which
he manifested by paddling and playing in the water. At the time I saw
him he was much agitated, had frequent twitchings, laughed often; but,
with this uncommon excitement in his muscles and nerves, his mind was
unusually correct in all its operations.
He discovered no dread of water, except in one instance, when he turned
from it with horror. He swallowed occasionally about a spoon full of
it at a time, holding the cup in his own hand, as if to prevent too
great a quantity being poured at once into his throat. The quick manner
of his swallowing, and the intervals between each time of doing so,
were such as we sometimes observe in persons in the act of dying of
acute diseases. Immediately after swallowing water, he looked pale, and
panted for breath. He spoke rapidly, and with much difficulty. This
was more remarkably the case when he attempted to pronounce the words
_carriage_, _water_, and _river_. After speaking he panted for breath
in the same manner that he did after drinking. He coughed and breathed
as patients do in the moderate grade of the cynanche trachealis. The
dog that had bitten him, Mr. Todd informed me, made a similar noise
in attempting to bark, a day or two before he was killed. We proposed
making an opening into his windpipe. To this his parents readily
consented; but while we were preparing for the operation, such a change
for the worse took place, that we concluded not to perform it. A cold
sweat, with a feeble and quick pulse, came on; and he died suddenly, at
12 o'clock at night, about six hours after I first saw him. He retained
his reason, and a playful humour, till the last minute of his life. An
instance of the latter appeared in his throwing his handkerchief at
his father just before he expired. The parents consented to our united
request to examine his body. Dr. Griffitts being obliged to go into the
country, and Dr. Physick being indisposed, I undertook this business
the next morning; and, in the presence of Dr. John Dorsey (to whom I
gave the dissecting knife), and my pupil Mr. Murduck, I discovered the
following appearances. All the muscles of the neck had a livid colour,
such as we sometimes observe, after death, in persons who have died of
the sore throat. The muscles employed in deglutition and speech were
suffused with blood. The epiglottis was inflamed, and the glottis so
thickened and contracted, as barely to admit a probe of the common size.
The trachea below it was likewise inflamed and thickened, and contained
a quantity of mucus in it, such as we observe, now and then, after
death from cynanche trachealis. The [oe]sophagus exhibited no marks
of disease; but the stomach had several inflamed spots upon it, and
contained a matter of a brown appearance, and which emitted an offensive
odour.
From the history of this dissection, and of many others, in which much
fewer marks appeared of violent disease, in parts whose actions are
essential to life, it is highly probable death is not induced in the
ordinary manner in which malignant fevers produce it, but by a sudden
or gradual suffocation. It is the temporary closure of this aperture
which produces the dread of swallowing liquids: hence the reason why
they are swallowed suddenly, and with intervals, in the manner that has
been described; for, should the glottis be closed during the time of
two swallows, in the highly diseased state of the system which takes
place in this disease, suffocation would be the immediate and certain
consequence. The same difficulty and danger attend the swallowing
saliva, and hence the symptom of spitting, which has been so often
taken notice of in hydrophobia. Solids are swallowed more easily than
fluids, only because they descend by intervals, and because a less
closure of the glottis is sufficient to favour their passage into the
stomach. This remark is confirmed by the frequent occurrence of death
in the very act of swallowing, and that too with the common symptoms of
suffocation. To account for death from this cause, and in the manner
that has been described, it will be necessary to recollect, that fresh
air is more necessary to the action of the lungs in a fever than in
health, and much more so in a fever of a malignant character, such
as the hydrophobia appears to be, than in fevers of a milder nature.
An aversion from swallowing liquids is not peculiar to this disease.
It occurs occasionally in the yellow fever. It occurs likewise in
the disease which has prevailed among the cats, both in Europe and
America, and probably, in both instances, from a dread of suffocation
in consequence of the closure of the glottis, and sudden abstraction of
fresh air.
The seat of the disease, and the cause of death, being, I hope,
thus ascertained, the means of preventing death come next under
our consideration. Tonic remedies, in all their forms, have been
administered to no purpose. The theory of the disease would lead us
to expect a remedy for it in blood-letting. But this, though now and
then used with success, is not its cure, owing, as we now see, to the
mortal seat of the disease being so far removed from the circulation, as
not to be affected by the loss of blood in the most liberal quantity.
As well might we expect the inflammation and pain of a paronychia, or
what is called a felon on the finger, to be removed by the same remedy.
Purging and sweating, though occasionally successful, have failed in
many instances; and even a salivation, when excited (which is rarely the
case), has not cured it. An artificial aperture into the windpipe alone
bids fair to arrest its tendency to death, by removing the symptom which
generally induces it, and thereby giving time for other remedies, which
have hitherto been unsuccessful, to produce their usual salutary effects
in similar diseases[87]. In removing faintness, in drawing off the water
in ischuria, in composing convulsions, and in stopping hæmorrhages in
malignant fever, we do not cure the disease, but we prevent death, and
thereby gain time for the use of the remedies which are proper to cure
it. Laryngotomy, according to Fourcroy's advice, in diseases of the
throat which obstruct respiration, should be preferred to tracheotomy,
and the incision should be made in the triangular space between the
thyroid and cricoid cartilages. Should this operation be adopted, in
order to save life, it will not offer near so much violence to humanity
as many other operations. We cut through a large mass of flesh into the
bladder in extracting a stone. We cut into the cavity of the thorax in
the operation for the empyema. We perforate the bones of the head in
trepanning; and we cut through the uterus, in performing the Cæsarian
operation, in order to save life. The operation of laryngotomy is much
less painful and dangerous than any of them; and besides permitting
the patient to breathe and to swallow, it is calculated to serve the
inferior purpose of lessening the disease of the glottis by means of
local depletion. After an aperture has been thus made through the
larynx, the remedies should be such as are indicated by the state of
the system, particularly by the state of the pulse. In hot climates it
is, I believe, generally a disease of feeble re-action, and requires
tonic remedies; but in the middle and northern states of America it
is more commonly attended with so much activity and excitement of the
blood-vessels, as to require copious blood-letting and other depleting
remedies.
[87] The hoarse barking, or the total inability of mad dogs to bark,
favours still further the idea that the mortal seat of the
disease is in the glottis, and that the remedy which has been
proposed is a rational one.
Should this new mode of attacking this furious disease be adopted, and
become generally successful, the discovery will place the ingenious
gentleman who suggested it in the first rank of the medical benefactors
of mankind.
I have only to add a fact upon this subject which may tend to increase
confidence in a mode of preventing the disease which has been
recommended by Dr. Haygarth, and used with success in several instances.
The same dog which bit Mr. Todd's son, bit, at the same time, a cow, a
pig, a dog, and a black servant of Mr. Todd's. The cow and pig died;
the dog became mad, and was killed by his master. The black man, who
was bitten on one of his fingers, exposed the wound for some time,
immediately after he received it, to a stream of pump water, and washed
it likewise with soap and water. He happily escaped the disease, and
is now in good health. That his wound was poisoned is highly probable,
from its having been made eight hours after the last of the above
animals was bitten, in which time there can be but little doubt of such
a fresh secretion of saliva having taken place as would have produced
the hydrophobia, had it not been prevented by the above simple remedy. I
am not, however, so much encouraged by its happy issue in this case as
to advise it in preference to cutting out the wounded part. It should
only be resorted to where the fears of a patient, or his distance from a
surgeon render it impossible to use the knife.
AN ACCOUNT
OF
_THE MEASLES_,
AS THEY
APPEARED IN PHILADELPHIA,
IN THE SPRING OF 1789.
The weather in December, 1788, and in January, 1789, was variable, but
seldom very cold. On the first of February, 1789, at six o'clock in the
morning, the mercury in Fahrenheit's thermometer fell 5° below 0, in the
city of Philadelphia. At twenty miles from the city, on the Schuylkill,
it fell 12° below 0, at the same hour. On the 19th and 20th of this
month, there fell a quantity of snow, the depth of which, upon an
average, was supposed to be about eight or ten inches. On the 23d, 24th,
25th, and 27th, the weather was very cold. The mercury fluctuated during
these days between 4° and 10° above 0.
In the intervals between these cold days, the weather frequently
moderated, so that the Delaware was frozen and thawed not less than
four times. It was not navigable till the 8th of March. There were in
all, during the winter and month of March, sixteen distinct falls of
snow.
In April and May there were a few warm days; but upon the whole, it was
a very cold and backward spring. The peaches failed almost universally.
There were no strawberries or cherries on the 24th of May, and every
other vegetable product was equally backward. A country woman of 84
years of age informed me, that it was the coldest spring she had ever
known. It was uncomfortable to sit without fire till the first of June.
The measles appeared first in the Northern Liberties, in December.
They spread slowly in January, and were not universal in the city till
February and March.
This disease, like many others, had its _precursor_. It was either a
gum-boil, or a sore on the tongue. They were both very common, but not
universal. They occurred, in some instances, several days before the
fever, but in general they made their appearance during the eruptive
fever, and were a sure mark of the approaching eruption of the measles.
I was first led to observe this fact, from having read Dr. Quin's
accurate account of the measles in Jamaica. I shall now proceed to
mention the symptoms of the measles as they appeared in the different
parts of the body.
1. In the _head_, they produced great pain, swelling of the eye-lids, so
as to obstruct the eye-sight, tooth-ach, bleeding at the nose, tinnitus
aurium, and deafness; also coma for two days, and convulsions. I saw the
last symptom only in one instance. It was brought on by a stoppage of a
running from the ear.
2. In the _throat_ and _lungs_, they produced a soreness and hoarseness,
acute or dull pains in the breast and sides, and a painful or
distressing cough. In one case, this cough continued for two hours
without any intermission, attended by copious expectoration. In two
cases, I saw a constant involuntary discharge of phlegm and mucus from
the mouth, without any cough. One of them terminated fatally. Spitting
of blood occurred in several instances. The symptoms of pneumonia
vera notha and typhoides were very common. I saw two fatal cases from
pneumonia notha, in both of which the patients died with the trunk of
the body in an erect posture. I met with two cases in which there was
no cough till the eruption made its appearance on the fourth day, and
one which was accompanied by all the usual symptoms of the cynanche
trachealis.