Medical Inquiries and Observations, Vol. 2 / The Second Edition, Revised and Enlarged by the Author

AN INQUIRY
INTO THE
CAUSES AND CURE
OF THE
INTERNAL DROPSY OF THE BRAIN.

Having, for many years, been unsuccessful in all the cases, except two, of internal dropsy of the brain, which came under my care, I began to entertain doubts of the common theory of this disease, and to suspect that the effusion of water should be considered only as the effect of a primary disease in the brain.

I mentioned this opinion to my colleague, Dr. Wistar, in the month of June, 1788, and delivered it the winter following in my lectures. The year afterwards I was confirmed in it, by hearing that the same idea had occurred to Dr. Quin. I have since read Dr. Quin's treatise on the dropsy of the brain with great pleasure, and consider it as the first dawn of light which has been shed upon it. In pursuing this subject, therefore, I shall avail myself of Dr. Quin's discoveries, and endeavour to arrange the facts and observations I have collected in such a manner, as to form a connected theory from them, which I hope will lead to a new and more successful mode of treating this disease.

I shall begin this inquiry by delivering a few general propositions.

1. The internal dropsy of the brain is a disease confined chiefly to children.

2. In children the brain is larger in proportion to other parts of the body, than it is in adults; and of course a greater proportion of blood is sent to it in childhood, than in the subsequent periods of life. The effects of this determination of blood to the brain appear in the mucous discharge from the nose, and in the sores on the head and behind the ears, which are so common in childhood.

3. In all febrile diseases, there is a preternatural determination of blood to the brain. This occurs in a more especial manner in children: hence the reason why they are so apt to be affected by convulsions in the eruptive fever of the small-pox, in dentition, in the diseases from worms, and in the first paroxysm of intermitting fevers.

4. In fevers of every kind, and in every stage of life, there is a disposition to effusion in that part to which there is the greatest determination. Thus, in inflammatory fever, effusions take place in the lungs and in the joints. In the bilious fever they occur in the liver, and in the gout in every part of the body. The matter effused is always influenced by the structure of the part in which it takes place.

These propositions being premised, I should have proceeded to mention the remote causes of this disease; but as this inquiry may possibly fall into the hands of some gentlemen who may not have access to the description of it as given by Dr. Whytt, Dr. Fothergill, and Dr. Quin, I shall introduce a history of its symptoms taken from the last of those authors. I prefer it to the histories by Dr. Whytt and Dr. Fothergill, as it accords most with the ordinary phenomena of this disease in the United States.

“In general, the patient is at first languid and inactive, often drowsy and peevish, but at intervals cheerful and apparently free from complaint. The appetite is weak, a nausea, and, in many cases, a vomiting, occurs once or twice in the day, and the skin is observed to be hot and dry towards the evenings: soon after these symptoms have appeared, the patient is affected with a sharp head-ach, chiefly in the fore-part, or, if not there, generally in the crown of the head: it is sometimes, however, confined to one side of the head, and, in that case, when the posture of the body is erect, the head often inclines to the side affected. We frequently find, also, that the head-ach alternates with the affection of the stomach; the vomiting being less troublesome when the pain is most violent, and vice versâ; other parts of the body are likewise subject to temporary attacks of pain, viz. the extremities, or the bowels, but more constantly the back of the neck, and between the scapulæ; in all such cases the head is more free from uneasiness.

“The patient dislikes the light at this period; cries much, sleeps little, and when he does sleep, he grinds his teeth, picks his nose, appears to be uneasy, and starts often, screaming as if he were terrified; the bowels are in the majority of cases very much confined, though it sometimes happens that they are in an opposite state: the pulse in this early stage of the disorder, does not usually indicate any material derangement.

“When the symptoms above-mentioned have continued for a few days, subject as they always are in this disease to great fluctuation, the axis of one eye is generally found to be turned in towards the nose; the pupil on this side is rather more dilated than the other; and when both eyes have the axes directed inwards (which sometimes happens), both pupils are larger than they are observed to be in the eyes of healthy persons: the vomiting becomes more constant, and the head-ach more excruciating; every symptom of fever then makes its appearance, the pulse is frequent, and the breathing quick; exacerbations of the fever take place towards the evening, and the face is occasionally flushed; usually one cheek is much more affected than the other; temporary perspirations likewise break forth, which are not followed by any alleviation of distress; a discharge of blood from the nose, which sometimes appears about this period, is equally inefficacious.

“Delirium, and that of the most violent kind, particularly if the patient has arrived at the age of puberty, now takes place, and with all the preceding symptoms of fever, continues for a while to increase, until about fourteen days, often a much shorter space of time, shall have elapsed since the appearance of the symptoms, which were first mentioned in the above detail.

“The disease then undergoes that remarkable change, which sometimes suddenly points out the commencement of what has been called its second stage: the pulse becomes slow but unequal, both as to its strength, and the intervals between the pulsations; the pain of the head, or of whatever part had previously been affected, seems to abate, or at least the patient becomes apparently less sensible of it; the interrupted slumbers, or perpetual restlessness which prevailed during the earlier periods of the disorder, are now succeeded by an almost lethargetic torpor, the strabismus, and dilatation of the pupil increase, the patient lies with one, or both eyes half closed, which, when minutely examined, are often found to be completely insensible to light; the vomiting ceases; whatever food or medicine is offered is usually swallowed with apparent voracity; the bowels at this period generally remain obstinately costive.

“If every effort made by art fails to excite the sinking powers of life, the symptoms of what has been called the second stage are soon succeeded by others, which more certainly announce the approach of death. The pulse again becomes equal, but so weak and quick, that it is almost impossible to count it; a difficulty of breathing, nearly resembling the stertor apoplecticus, is often observed; sometimes the eyes are suffused with blood, the flushing of the face is more frequent than before, but of shorter duration, and followed by a deadly paleness; red spots, or blotches, sometimes appear on the body and limbs; deglutition becomes difficult, and convulsions generally close the scene. In one case, I may observe, the jaws of a child of four years of age were so firmly locked for more than a day before death, that it was impossible to introduce either food or medicine into his mouth; and, in another case, a hemiplegia, attended with some remarkable circumstances, occurred during the two days preceding dissolution.

“Having thus given as exact a history of apoplexia hydrocephalica as I could compile from the writings of others, and from my own observations, I should think myself guilty of imposition on my readers, if I did not caution them that it must be considered merely as a general outline: the human brain seems to be so extremely capricious (if the expression may be allowed) in the signals it gives to other parts of the system, of the injury it suffers throughout the course of this disease, that although every symptom above-mentioned does occasionally occur, and indeed few cases of the disease are to be met with, which do not exhibit many of them; yet it does not appear to me, that any one of them is constantly and inseparably connected with it.”

To this history I shall add a few facts, which are the result of observations made by myself, or communicated to me by my medical brethren. These facts will serve to show that there are many deviations from the history of the disease which has been given, and that it is indeed, as Dr. Quin has happily expressed it, of **LQU]a truly proteiform” nature.

I have not found the dilated and insensible pupil, the puking, the delirium, or the strabismus, to attend universally in this disease.

I saw one case in which the appetite was unimpaired from the first to the last stage of the disease.

I have met with one case in which the disease was attended by blindness, and another by double vision.

I have observed an uncommon acuteness in hearing to attend two cases of this disease. In one of them the noise of the sparks which were discharged from a hiccory[** sic] fire, produced great pain and startings which threatened convulsions.

I have seen three cases in which the disease terminated in hemiplegia. In two of them it proved fatal in a few days; in the third it continued for nearly eighteen months.

I have met with one case in which no preternatural slowness or intermission was ever perceived in the pulse.

I have seen the disease in children of nearly all ages. I once saw it in a child of six weeks old. It was preceded by the cholera infantum. The sudden deaths which we sometimes observe in infancy, I believe, are often produced by this disease. Dr. Stoll is of the same opinion. He calls it, when it appears in this form, “apoplexia infantalis[46].”

In the month of March, 1771, I obtained a gill of water from the ventricles of the brain of a negro girl of nine years of age, who died of this disease, who complained in no stage of it of a pain in her head or limbs, nor of a sick stomach. The disease in this case was introduced suddenly by a pain in the breast, a fever, and the usual symptoms of a catarrh.

Dr. Wistar informed me, that he had likewise met with a case of internal dropsy of the brain, in which there was a total absence of pain in the head.

Dr. Carson informed me, that he had attended a child in this disease that discovered, for some days before it died, the symptom of hydrophobia.

Dr. Currie obtained, by dissection, seven ounces of water from the brain of a child which died of this disease; in whom, he assured me, no dilatation of the pupil, strabismus, sickness, or loss of appetite had attended, and but very little head-ach.

The causes which induce this disease, act either directly on the brain, or indirectly upon it, through the medium of the whole system.

The causes which act directly on the brain are falls or bruises upon the head, certain positions of the body, and childish plays which bring on congestion or inflammation, and afterwards an effusion of water in the brain. I have known it brought on in a child by falling into a cellar upon its feet.

The indirect causes of this disease are more numerous, and more frequent, though less suspected, than those which have been mentioned. The following diseases of the whole system appear to act indirectly in producing an internal dropsy of the brain.

1. Intermitting, remitting, and continual fevers. Of the effects of these fevers in inducing this disease, many cases are recorded by Lieutaud[47].

My former pupil, Dr. Woodhouse, has furnished me with a dissection, in which the disease was evidently the effect of the remitting fever. That state of continual fever which has been distinguished by the name of typhus, is often the remote cause of this disease. The languor and weakness in all the muscles of voluntary motion, the head-ach, the inclination to rest and sleep, and the disposition to be disturbed, or terrified by dreams, which are said to be the precursors of water in the brain, I believe are frequently symptoms of a typhus fever which terminates in an inflammation, or effusion of water in the brain. The history which is given of the typhus state of fever in children by Dr. Butter[48], seems to favour this opinion.

2. The rheumatism. Of this I have known two instances. Dr. Lettsom has recorded a case from the same cause[49]. The pains in the limbs, which are supposed to be the effect, I suspect are frequently the cause of the disease.

3. The pulmonary consumption. Of the connection of this disease with an internal dropsy of the brain, Dr. Percival has furnished us with the following communication[50]: “Mr. C——'s daughter, aged nine years, after labouring under the phthisis pulmonalis four months, was affected with unusual pains in her head. These rapidly increased, so as to occasion frequent screamings. The cough, which had before been extremely violent, and was attended with stitches in the breast, now abated, and in a few days ceased almost entirely. The pupils of the eyes became dilated, a strabismus ensued, and in about a week death put an end to her agonies. Whether this affection of the head arose from the effusion of water or of blood, is uncertain, but its influence on the state of the lungs is worthy of notice.” Dr. Quin likewise mentions a case from Dr. Cullen's private practice, in which an internal dropsy of the brain followed a pulmonary consumption. Lieutaud mentions three cases of the same kind[51], and two, in which it succeeded a catarrh[52].

4. Eruptive fevers. Dr. Odier informs us[53], that he had seen four cases in which it had followed the small-pox, measles, and scarlatina. Dr. Lettsom mentions a case in which it followed the small-pox[54], and I have seen one in which it was obviously the effects of debility induced upon the system by the measles.

5. Worms. Notwithstanding the discharge of worms gives no relief in this disease, yet there is good reason to believe, that it has, in some instances, been produced by them. The morbid action continues in the brain, as in other cases of disease, after the cause which induced it, has ceased to act upon the body.

6. From the dissections of Lieutaud, Quin, and others, it appears further, that the internal dropsy of the brain has been observed to succeed each of the following diseases, viz. the colic, palsy, melancholy, dysentery, dentition, insolation, and scrophula, also the sudden healing of old sores. I have seen two cases of it from the last cause, and one in which it was produced by the action of the vernal sun alone upon the system.

From the facts which have been enumerated, and from dissections to be mentioned hereafter, it appears, that the disease in its first stage is the effect of causes which produce a less degree of that morbid action in the brain which constitutes phrenitis, and that its second stage is the effect of a less degree of that effusion, which produces serous apoplexy in adults. The former partakes of the nature of the chronic inflammation of Dr. Cullen, and of the asthenic inflammation of Dr. Brown. I have taken the liberty to call it phrenicula, from its being a diminutive species or state of phrenitis. It bears the same relation to phrenitis, when it arises from indirect causes, which pneumonicula does to pneumony; and it is produced nearly in the same manner as the pulmonary consumption, by debilitating causes which act primarily on the whole system. The peculiar size and texture of the brain seem to invite the inflammation and effusions which follow debility, to that organ in childhood, just as the peculiar structure and situation of the lungs invite the same morbid phænomena to them, after the body has acquired its growth, in youth and middle life. In the latter stage which has been mentioned, the internal dropsy of the brain partakes of some of the properties of apoplexy. It differs from it in being the effect of a slow, instead of a sudden effusion of water or blood, and in being the effect of causes which are of an acute instead of a chronic nature. In persons advanced beyond middle life, who are affected by this disease, it approaches to the nature of the common apoplexy, by a speedy termination in life or death. Dr. Cullen has called it simply by the name of “apoplexia hydrocephalica.” I have preferred for its last stage the term of chronic apoplexy, for I believe with Dr. Quin, that it has no connection with a hydropic diathesis of the whole system. I am forced to adopt this opinion, from my having rarely seen it accompanied by dropsical effusions in other parts of the body, nor a general dropsy accompanied by an internal dropsy of the brain. No more occurs in this disease than takes place when hydrothorax follows an inflammation of the lungs, or when serous effusions follow an inflammation of the joints. I do not suppose that both inflammation and effusion always attend in this disease; on the contrary, dissections have shown some cases of inflammation, with little or no effusion, and some of effusion without inflammation. Perhaps this variety may have been produced by the different stages of the disease in which death and the inspection of the brain took place. Neither do I suppose, that the two stages which have been mentioned, always succeed each other in the common order of inflammation and effusion. In every case where the full tense, slow and intermitting pulse occurs, I believe there is inflammation; and as this state of the pulse occurs in most cases in the beginning of the disease, I suppose the inflammation, in most cases, to precede the effusion of water. I have met with only one case in which the slow and tense pulse was absent; and out of six dissections of patients whom I have lost by this disease, the brains of four of them exhibited marks of inflammation.

Mr. Davis discovered signs of inflammation, after death from this 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.

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.

III. Blisters have been uniformly recommended by all practical writers upon this disease. I have applied them to the head, neck, and temples, and generally with obvious relief to the pain in the head. They should be omitted in no stage of the disease; for even in its inflammatory stage, the discharge they occasion from the vessels of the head, greatly overbalances their stimulating effects upon the whole system.

IV. Mercury was long considered as the only remedy, which gave the least chance of a recovery from a dropsy of the brain. Out of all the cases in which I gave it, before the year 1790, I succeeded in but two: one of them was a child of three years old, the other was a young woman of twenty-six years of age. I am the more convinced that the latter case was internal dropsy of the brain, from my patient having relapsed, and died between two or three years afterwards, of the same disease. Since I have adopted the depleting remedies which have been mentioned, I have declined giving mercury altogether, except when combined with some purging medicine, and I have given it in this form chiefly with a view of dislodging worms. My reasons for not giving it as a sialagogue are the uncertainty of its operation, its frequent inefficacy when it excites a salivation, and, above all, its disposition to produce gangrene in the tender jaws of children. Seven instances of its inducing death from that cause, in children between three and eight years of age, and with circumstances of uncommon distress, have occurred in Philadelphia since the year 1795.

V. Linen cloths, wetted with cold vinegar, or water, and applied to the forehead, contribute very much to relieve the pain in the head. In the case of Mr. Cypher's son[57], the solution of ice in the vinegar appeared to afford the most obvious relief of this distressing symptom.

A puncture in the brain has been proposed by some writers to discharge the water from its ventricles. If the theory I have delivered be true, the operation promises nothing, even though it could always be performed with perfect safety. In cases of local injuries, or of inflammation from any cause, it must necessarily increase the disease; and in cases of effusion only, the debilitated state of the whole system forbids us to hope for any relief from such a local remedy.

Bark, wine, and opium promise much more success in the last stage of the disease. I can say nothing in their favour from my own experience; but from the aid they afford to mercury in other diseases, I conceive they might be made to accompany it with advantage.

Considering the nature of the indirect causes which induce the disease, and the case of a relapse, which has been mentioned, after an interval of near three years, as well as the symptoms of slow convalescence, manifested by the pulse, which occurred in the first and seventh cases, I submit it to the consideration of physicians, whether the use of moderate exercise, and the cold bath, should not be recommended to prevent a return of the disease in every case, where it has yielded to the power of medicine.

I have great pleasure in adding, that the theory of this disease, which I have delivered, has been adopted by many respectable physicians in Philadelphia, and in other parts of the United States, and that it has led to the practice that has been recommended, particularly to copious blood-letting; in consequence of which, death from a dropsy of the brain is not a more frequent occurrence, than from any other of the acute febrile diseases of our country.

OBSERVATIONS
UPON
THE NATURE AND CURE
OF THE
GOUT.

In treating upon the gout, I shall deliver a few preliminary propositions.

1. The gout is a disease of the whole system. It affects the ligaments, blood-vessels, stomach, bowels, brain, liver, lymphatics, nerves, muscles, cartilages, bones, and skin.

2. The gout is a primary disease, only of the solids. Chalk-stones, abscesses, dropsical effusions into cavities, and cellular membrane, and eruptions on the skin, are all the effects of a morbid action in the blood-vessels. The truth of this proposition has been ably proved by Dr. Cullen in his First Lines.

3. It affects most frequently persons of a sanguineous temperament; but sometimes it affects persons of nervous and phlegmatic temperaments. The idle and luxurious are more subject to it, than the labouring and temperate part of mankind. Women are said to be less subject to it than men. I once believed, and taught this opinion, but I now retract it. From the peculiar delicacy of the female constitution, and from the thin covering they wear on their feet and limbs, the gout is less apt to fall upon those parts than in men, but they exhibit all its other symptoms, perhaps more frequently than men, in other parts of the body. The remote causes of gout moreover to be mentioned presently, act with equal force upon both sexes, and more of them I believe upon women, than upon men.

It generally attacks in those periods of life, and in those countries, and seasons of the year, in which inflammatory diseases are most common. It seldom affects persons before puberty, or in old age, and yet I have heard of its appearing with all its most characteristic symptoms in this city in a child of 6, and in a man above 80 years of age. Men of active minds are said to be most subject to it, but I think I have seen it as frequently in persons of slender and torpid intellects, as in persons of an opposite character. I have heard of a case of gout in an Indian at Pittsburg, and I have cured a fit of it in an Indian in this city. They had both been intemperate in the use of wine and fermented liquors.

4. It is in one respect a hereditary disease, depending upon the propagation of a similar temperament from father to son. When a predisposition to the gout has been derived from ancestors, less force in exciting causes will induce it than in those habits where this has not been the case. This predisposition sometimes passes by children, and appears in grand-children. There are instances likewise in which it has passed by the males, and appeared only in the females of a family. It even appears in the descendants of families who have been reduced to poverty, but not often where they have been obliged to labour for a subsistence. It generally passes by those children who are born before the gout makes its appearance in a father. It is curious to observe how extensively the predisposition pervades some families. An English gentleman, who had been afflicted with the gout, married a young woman in Philadelphia many years ago, by whom he had one daughter. His wife dying three weeks after the birth of this child, he returned to England, where he married a second wife, by whom he had six children, all of whom except one died with the gout before they attained to the usual age of matrimony in Great Britain. One of them died in her 16th year. Finally the father and grandfather died with the same disease. The daughter whom this afflicted gentleman left in this city, passed her life subject to the gout, and finally died under my care in the year 1789, in the 68th year of her age. She left a family of children, two of whom had the gout. One of them, a lady, has suffered exquisitely from it.

5. The gout is always induced by general predisposing debility.

6. The remote causes of the gout which induce this debility, are, indolence, great bodily labour, long protracted bodily exercise, intemperance in eating, and in venery, acid aliments and drinks, strong tea and coffee, public and domestic vexation, the violent, or long continued exercise of the understanding, imagination, and passions in study, business, or pleasure, and, lastly, the use of ardent, and fermented liquors. The last are absolutely necessary to produce that form of gout which appears in the ligaments and muscles. I assert this, not only from my own observations, but from those of Dr. Cadogan, and Dr. Darwin, who say they never saw a case of gout in the limbs in any person who had not used spirits or wine in a greater or less quantity. Perhaps this may be another reason why women, who drink less of those liquors than men, are so rarely affected with this disease in the extreme parts of their bodies. Wines of all kinds are more disposed to produce this form of gout than spirits. The reason of this must be resolved into the less stimulus in the former, than in the latter liquors. Wine appears to resemble, in its action upon the body, the moderate stimulus of miasmata which produce a common remitting fever, or intermitting fever, while spirits resemble that violent action induced by miasmata which passes by the blood-vessels, ligaments, and muscles, and invades at once the liver, bowels, and brain. There is one symptom of the gout in the extremities which seems to be produced exclusively by ardent spirits, and that is a burning in the palms of the hands, and soles of the feet. This is so uniform, that I have sometimes been able to convict my patients of intemperance in the use of spirits, when no other mark of their having taken them in excess, appeared in the system.

I have enumerated among the remote causes of the gout, the use of strong tea. I infer its predisposing quality to that disease, from its frequency at Japan, where tea is used in large quantities, and from the gout being more common among that sex in our country who drink the most, and the strongest tea.

7. The exciting causes of the gout are frequently a greater degree, or a sudden application of its remote and predisposing causes. They act upon the accumulated excitability of the system, and by destroying its equilibrium of excitement, and regular order of actions, produce convulsion, or irregular morbid and local excitement. These exciting causes are either of a stimulating, or of a sedative nature. The former are violent exercise, of body or mind, night-watching, and even sitting up late at night, a hearty meal, a fit of drunkenness, a few glasses of claret or a draught of cyder, where those liquors have not been habitual to the patient, a sudden paroxysm of joy, anger, or terror, a dislocation of a bone, straining of a joint, particularly of the ankle, undue pressure upon the foot, or leg, from a tight shoe or boot, an irritated corn, and the usual remote causes of fever. The latter exciting causes are sudden inanition from bleeding, purging, vomiting, fasting, cold, a sudden stoppage of moisture on the feet, fear, grief, excess in venery, and the debility left upon the system by the crisis of a fever. All these causes act more certainly when they are aided by the additional debility induced upon the system in sleep. It is for this reason that the gout generally makes its first attack in the night, and in a part of the system most remote from the energy of the brain, and most debilitated by exercise, viz. in the great toe, or in some part of the foot. In ascribing a fit of the gout to a cause which is of a sedative nature, the reader will not suppose that I have departed from the simplicity and uniformity of a proposition I have elsewhere delivered, that disease is the effect of stimulus. The abstraction of a natural and habitual impression of any kind, by increasing the force of those which remain, renders the production of morbid and excessive actions in the system as much the effect of preternatural or disproportioned stimulus, as if they were induced by causes that are externally and evidently stimulating. It is thus in many other of the operations of nature, opposite causes produce the same effects.

8. The gout consists simply in morbid excitement, accompanied with irregular action, or the absence of all action from the force of stimulus. There is nothing specific in the morbid excitement and actions which take place in the gout different from what occur in fevers. It is to be lamented that a kind of metastasis of error has taken place in pathology. The rejection of a specific acrimony as the cause of each disease, has unfortunately been followed by a belief in as many specific actions as there are different forms and grades of disease, and thus perpetuated the evils of our ancient systems of medicine. However varied morbid actions may be by their causes, seats, and effects, they are all of the same nature, and the time will probably come when the whole nomenclature of morbid actions will be absorbed in the single name of disease.

I shall now briefly enumerate the symptoms of the gout, as they appear in the ligaments, the blood-vessels, the viscera, the nervous system, the alimentary canal, the lymphatics, the skin, and the bones of the human body, and here we shall find that it is an epitome of all disease.

I. The ligaments which connect the bones are the seats, of what is called a legitimate or true gout. They are affected with pain, swelling, and inflammation. The pain is sometimes so acute as to be compared to the gnawing of a dog. We perceive here the sameness of the gout with the rheumatism. Many pages, and indeed whole essays, have been composed by writers to distinguish them, but they are exactly the same disease while the morbid actions are confined to this part of the body. They are, it is true, produced by different remote causes, but this constitutes no more difference in their nature, than is produced in a coal of fire, whether it be inflamed by a candle, or by a spark of electricity. The morbid actions which are induced by the usual causes of rheumatism affect, though less frequently, the lungs, the trachea, the head, the bowels, and even the heart, as well as the gout. Those actions, moreover, are the means of a fluid being effused, which is changed into calcareous matter in the joints and other parts of the body, exactly like that which is produced by the gout. They likewise twist and dislocate the bones in common with the gout, in a manner to be described hereafter. The only difference between what are called gouty, and rheumatic actions, consists in their seats, and in the degrees of their force. The debility which predisposes to the gout, being greater, and more extensively diffused through the body than the debility which precedes rheumatism, the morbid actions, in the former case, pass more readily from external to internal parts, and produce in both more acute and more dangerous effects. A simile derived from the difference in the degrees of action produced in the system by marsh miasmata, made use of upon a former occasion, will serve me again to illustrate this part of our subject. A mild remittent, and a yellow fever, are different grades of the same disease. The former, like the rheumatism, affects the bones chiefly with pain, while the latter, like the gout, affects not only the bones, but the stomach, bowels, brain, nerves, lymphatics, and all the internal parts of the body.

II. In the arterial system the gout produces fever. This fever appears not only in the increased force or frequency of the pulse, but in morbid affections of all the viscera. It puts on all the different grades of fever, from the malignity of the plague, to the mildness of a common intermittent. It has moreover its regular exacerbations and remissions once in every four and twenty hours, and its crisis usually on the fourteenth day, in violent cases. In moderate attacks, it runs on from twenty to forty days in common with the typhus or slow chronic state of fever. It is common for those persons who consider the gout as a specific disease, when it appears in the above forms, to say, that it is complicated with fever; but this is an error, for there can exist but one morbid action in the blood-vessels at once, and the same laws are imposed upon the morbid actions excited in those parts of the body by the remote causes of the gout, as by the common causes of fever. I have seen two instances of this disease appearing in the form of a genuine hectic, and one in which it appeared to yield to lunar influence, in the manner described by Dr. Balfour. In the highly inflammatory state of the gout, the sensibility of the blood-vessels far exceeds what is seen in the same state of fever from more common causes. I have known an instance in which a translation of the gouty action to the eye produced such an exquisite degree of sensibility, that the patient was unable to bear the feeble light which was emitted from a few coals of fire in his room, at a time too when the coldness of the weather would have made a large fire agreeable to him. It is from the extreme sensibility which the gout imparts to the stomach, that the bark is so generally rejected by it. I knew a British officer who had nearly died from taking a spoonful of the infusion of that medicine, while his arterial system was in this state of morbid excitability, from a fit of the gout. It is remarkable that the gout is most disposed to assume a malignant character, during the prevalence of an inflammatory constitution of the atmosphere. This has been long ago remarked by Dr. Huxham. Several instances of it have occurred in this city since the year 1793.

III. The gout affects most of the viscera. In the brain it produces head-ach, vertigo, coma, apoplexy, and palsy. In the lungs it produces pneumonia vera, notha, asthma, hæmoptysis, pulmonary consumption, and a short hecking cough, first described by Dr. Sydenham. In the throat it produces inflammatory angina. In the uterus it produces hæmorrhagia uterina. It affects the kidneys with inflammation, strangury, diabetes, and calculi. The position of the body for weeks or months on the back, by favouring the compression of the kidneys by the bowels, is the principal reason why those parts suffer so much in gouty people. The strangury appears to be produced by the same kind of engorgement or choking of the vessels of the kidneys, which takes place in the small-pox and yellow fever. Four cases of it are described in the 3d volume of the Physical and Literary Essays of Edinburgh, by Dr. David Clerk. I have seen one instance of death in an old man from this cause. The catheter brought no water from his bladder. The late Mr. John Penn, formerly governor of Pennsylvania, I have been informed by one of his physicians, died from a similar affection in his kidneys from gout. The catheter was as ineffectual in giving him relief, as it was in the case of my patient. The neck of the bladder sometimes becomes the seat of the gout. It discovers itself by spasm, and a suppression of urine in some cases, and occasionally by a habitual discharge of mucus through the urethra. This disease has been called, by Lieutaud, “a catarrh of the bladder.” Dr. Stoll describes it, and calls it “hæmorrhoids of the bladder.” But of all the viscera, the liver suffers most from the gout. It produces in it inflammation, suppuration, melena, schirrus, gall-stones, jaundice, and a habitual increased secretion and excretion of bile. These affections of the liver appear most frequently in southern countries, and in female habits. They are substitutes for a gout in the ligaments, and in the extremities of the body. They appear likewise in drunkards from ardent spirits. It would seem that certain stimuli act specifically upon the liver, probably for the wise purpose of discharging such parts of the blood from the body, as are vitiated by the rapidity of its circulation. I shall, in another place[58], take notice of the action of marsh miasmata upon the livers of men and beasts. It has been observed that hogs that live near brewhouses, and feed upon the fermented grains of barley, always discover enlarged or diseased livers. But a determination of the blood to the liver, and an increased action of its vessels, are produced by other causes than marsh miasmata, and fermented and distilled liquors. They appear in the fever which accompanies madness and the malignant sore-throat, also in contusions of the brain, and in the excited state of the blood-vessels which is produced by anger and exercise. I have found an attention to these facts useful in prescribing for diseases of the liver, inasmuch as they have led me from considering them as idiopathic affections, but as the effects only of morbid actions excited in other parts of the body.

IV. The gout sometimes affects the arterial and nervous systems jointly, producing in the brain, coma, vertigo, apoplexy, palsy, loss of memory, and madness, and in the nerves, hysteria, hypochondriasis, and syncope. It is common to say the gout counterfeits all these diseases. But this is an inaccurate mode of speaking. All those diseases have but one cause, and they are exactly the same, however different the stimulus may be, from which they are derived. Sometimes the gout affects the brain and nerves exclusively, without producing the least morbid action in the blood-vessels. I once attended a gentleman from Barbadoes who suffered, from this affection of his brain and nerves, the most intolerable depression of spirits. It yielded to large doses of wine, but his relief was perfect, and more durable, when a pain was excited by nature or art, in his hands or feet.

The muscles are sometimes affected by the gout with spasm, with general and partial convulsions, and lastly with great pain. Dr. Stoll describes a case of opisthotonos from it. The angina pectoris, or a sudden inability to breathe after climbing a hill, or a pair of stairs, and after a long walk, is sometimes a symptom of the gout. There is a pain which suddenly pervades the head, breast, and limbs, which resembles an electric shock. I have known two instances of it in gouty patients, and have taken the liberty of calling it the “aura arthritica.” But the pain which affects the muscles is often of a more permanent nature. It is felt with most severity in the calves of the legs. Sometimes it affects the muscles of the head, breast, and limbs, exciting in them large and distressing swellings. But further; the gout in some cases seizes upon the tendons, and twists them in such a manner as to dislocate bones in the hands and feet. It even affects the cartilages. Of this I once saw an instance in colonel Adams, of the state of Maryland. The external parts of both his ears were so much inflamed in a fit of the gout, that he was unable to lie on either of his sides.

V. The gout affects the alimentary canal, from the stomach to its termination in the rectum. Flatulency, sickness, acidity, indigestion, pain, or vomiting, usually usher in a fit of the disease. The sick head-ach, also dyspepsia, with all its train of distressing evils, are frequently the effects of gout concentrated in the stomach. I have seen a case in which the gout, by retreating to this viscus, produced the same burning sensation which is felt in the yellow fever. The patient who was the subject of this symptom died two days afterwards with a black vomiting. It was Mr. Patterson, formerly collector of the port of Philadelphia, under the British government. I was not surprised at these two uncommon symptoms in the gout, for I had long been familiar with its disposition to affect the biliary secretion, and the actions of the stomach. The colic and dysentery are often produced by the gout in the bowels. In the southern states of America, it sometimes produces a chronic diarrhœa, which is known in some places by the name of the “downward consumption.” The piles are a common symptom of gout, and where they pour forth blood occasionally, render it a harmless disease. I have known an instance in which a gouty pain in the rectum produced involuntary stools in a gentleman in this city, and I have heard from a southern gentleman, who had been afflicted with gouty symptoms, that a similar pain was excited in the same part to such a degree, whenever he went into a crowded room lighted by candles, as to oblige him to leave it. In considering the effects of the gout upon this part, I am led to take notice of a troublesome itching in the anus which has been described by Dr. Lettsom, and justly attributed by him to this disease[59]. I have known several cases of it. They always occurred in gouty habits. A distressing collection of air in the rectum, which renders frequent retirement from company necessary to discharge it, is likewise a symptom of gout. It is accompanied with frequent, and small, but hard stools.

Of the above morbid affections of the nerves, stomach, and bowels, the hysteria, the sick head-ach, and the colic, appear much oftener in women than in men. I have said that dyspepsia is a symptom of gout. Out of more than 500 persons who were the patients of the Liverpool infirmary and dispensary, in one year, Dr. Currie informs us, “a great majority were females[60].”

VI. The gout affects the glands and lymphatics. It produced a salivation of a profuse nature in major Pearce Butler, which continued for two days. It produced a bubo in the groin in a citizen of Philadelphia. He had never been infected with the venereal disease, of course no suspicion was entertained by me of its being derived from that cause. I knew a lady who had periodical swellings in her breasts, at the same season of the year in which she had before been accustomed to have a regular fit of the gout. The scrophula and all the forms of dropsy are the effects in many cases of the disposition of the gout to attack the lymphatic system. There is a large hard swelling without pain, of one, or both the legs and thighs, which has been called a dropsy, but is very different from the common disease of that name. It comes on, and goes off suddenly. It has lately been called in England the dumb gout. In the spring of 1798 I attended colonel Innes, of Virginia, in consultation with my Edinburgh friend and fellow-student, Dr. Walter Jones, of the same state. The colonel had large anasarcous swellings in his thighs and legs, which we had reason to believe were the effects of an indolent gout. We made several punctures in his feet and ancles, and thereby discharged a large quantity of water from his legs and thighs. A day or two afterwards his ancles exhibited in pain and inflammation, the usual form of gout in those parts. In the year 1794 I attended Mrs. Lloyd Jones, who had a swelling of the same kind in her foot and leg. Her constitution, habits, and the sober manners of her ancestors, gave me no reason to suspect it to arise from the usual remote causes of gout. She was feverish, and her pulse was tense. I drew ten ounces of blood from her, and gave her a purge. The swelling subsided, but it was succeeded by an acute rheumatic pain in the part, which was cured in a few days. I mention these facts as an additional proof of the sameness of the gout and rheumatism, and to show that the vessels in a simple disease, as well as in malignant fevers, are often oppressed beyond that point in which they emit the sensation of pain.

Under this head I shall include an account of the mucous discharge from the urethra, which sometimes takes place in an attack of the gout, and which has ignorantly been ascribed to a venereal gonorrhæa. There is a description of this symptom of the gout in the 3d volume of the Physical and Literary Essays of Edinburgh, by Dr. Clark. It was first taken notice of by Sauvages by the name of “gonorrhæa podagrica,” in a work entitled Pathologia Methodica. I have known three instances of it in this city. In the visits which the gout pays to the genitals, it sometimes excites great pain in the testicles. Dr. Whytt mentions three cases of this kind. One of them was attended with a troublesome itching of the scrotum. I have seen one case in which the testicles were affected with great pain, and the penis with an obstinate priapism. They succeeded a sudden translation of the gout from the bowels.

From the occasional disposition of the gout to produce a mucous discharge from the urethra in men, it is easy to conceive that it is the frequent cause of the fluor albus in women, for in them, the gout which is restrained from the feet, by a cause formerly mentioned, is driven to other parts, and particularly to that part which, from its offices, is more disposed to invite disease to it, than any other. The fluor albus sometimes occurs in females, apparently of the most robust habits. In such persons, more especially if they have been descended from gouty ancestors, and have led indolent and luxurious lives, there can be no doubt but the disease is derived from the gout, and should be treated with remedies which act not only upon the affected part, but the whole system. An itching similar to that I formerly mentioned in the anus, sometimes occurs in the vagina of women. Dr. Lettsom has described it. In all the cases I have known of it, I believe it was derived from the usual causes of the gout.

VII. There are many records in the annals of medicine of the gout affecting the skin. The erysipelas, gangrene, and petechiæ are its acute, and tetters, and running sores are its usual chronic forms when it appears in this part of the body. I attended a patient with the late Dr. Hutchinson, in whom the whole calf of one leg was destroyed by a mortification which succeeded the gout. Dr. Alexander, of Baltimore, informed me that petechiæ were among the last symptoms of this disease in the Rev. Mr. Oliver, who died in the town of Baltimore, about two years ago. In the disposition of the gout to attack external parts, it sometimes affects the eyes and ears with the most acute and distressing inflammation and pain. I hesitate the less in ascribing them both to the gout, because they not only occur in gouty habits, but because they now and then effuse a calcareous matter of the same nature with that which is found in the ligaments of the joints.

VIII. Even the bones are not exempted from the ravages of this disease. I have before mentioned that the bones of the hands and feet are sometimes dislocated by it. I have heard of an instance in which it dislocated the thigh bone. It probably produced this effect by the effusion of that part of the blood which constitutes chalk-stones, or by an excrescence of flesh in the cavity of the joint. Two instances have occurred in this city of its dislodging the teeth, after having produced the most distressing pains in the jaws. The long protracted, and acute pain in the face, which has been so accurately described by Dr. Fothergill, probably arises wholly from the gout acting upon the bones of the part affected.