Practical remarks on gout, rheumatic fever, and chronic rheumatism of the joints : being the substance of the Croonian Lectures for the present year, delivered at the College of Physicians

Front matter

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YALE MEDICAL LIBRARY

HISTORICAL LIBRARY

Section I

Importance of studying the Natural History of Disease, 1. Illustrated by reference to Typhus Fever, 4; to the Exanthemata, 8; and to Syphilis, 9. Ignorance of the Natural History of Disease leads to endless mistakes in practice, 10. Object of these Lectures, 12. Gout and Rheumatic Fever are Diseases of the Blood, 12. Definition of Blood- Diseases, 13. Characters of Blood-Diseases, 14. Examples of Blood-Diseases, 16. Glanders, 18. Purulent Infection, 19. Lead Cachexy, 21. Lead found in the Brain and Lungs, 22. Diabetes, 24. Bright's Disease, 26.

Section II

General Review of the Natural History of Gout, 30. Gouty Diathesis, 31. The Paroxysm of Gout, 33. Gout at first shows a predilection for small joints, 33. Gout affecting large joints simultaneously, frequently confounded with Rheumatic Fever, 34. The natural tendency of the Paroxysm to a spontaneous Resolution, 34. Local effects of the fit of Gout, 35. Gouty Concretions, 36. The situations

CONTENTS.

at which the elimination of this substance takes place, 37. Gout affecting internal parts, 38. Stomach most frequently attacked, 38. The Heart and Brain sometimes affected, 38. The Urethra and Bladder generally become affected prior to the developement of Gout in the Joints, 38. Gouty Bronchitis and Cough, 39. Dr. Graves' examples of Diseases of the Spinal Cord connected with Gout, 39. Gouty Ophthalmia, 41.

Section III

A low or depressed state of the system favourable to the developement of the Gouty Paroxysm, 42. This fact proved by reference to cases, 43. Deficiency of the Lithates in this form of Gout, 54. Cautions to be learned from these cases, 54.

Section IV

Resemblance of the Phenomena of Gout to Blood- Diseases, 55. Theory of Gout, 55. Gout always at first connected with defective assimilation and imperfect excretion, 58. Gout hereditary, 60. The silent influence of contamination of the System of the Parent upon the Offspring, 62. A Solido- Humoral Pathology most consistent with the laws of the Nutritive Process, 65. Is the Lithic Acid Diathesis the cause of Gout ? 65. Liebig's Theory of Gout, 68. Arguments against this Theory, 69.

CONTENTS. xi

Urine of Birds and Insects, 71. The Gouty Matter probably first derived from the Stomach and Duodenum, 73. Nature of the Gouty Matter, 73.

Section V

Treatment of the Gouty Diathesis, 75. Proofs that it admits of favourable modification, 76. Quantity of the Food, 78. Connexion between the functions of the Stomach and Liver, 78. Use of Diluents, 80. Importance of attending to the Action of the Skin, 81. Nature of the Cutaneous Secretions, 83. Entozoon folliculorum, 85. Mode of counteracting the formation of Lithic Acid, 86. Dr. Philip's Experiments, 87. Effects of a Vegetable Diet, 89. Object of Magendie's Enquiries, 91. Cases, 92. The Lithic Diathesis not referrible simply to the Influence of Food, 94. Magendie's, Philip's, and Liebig's Error, 94. The True Source of Lithic Acid, 95. Cases of Lithic Acid Deposits connected with Malignant Disease, 96. Diet most suitable to Persons of Gouty Diathesis, 98. Beer, 99. Treatment of the Paroxysm of Gout, 100. Mercurial and Saline Purgatives most useful, 101. Local Treatment, 102. Colchicum, 103. Two-fold action of Colchicum, 104. Hints for the guidance of the Practitioner in the Employment of Colchicum, 105. Colchicum chiefly applicable to the Sthenic Form of Gout, 106.

xii CONTENTS.

Section VI

Of Rheumatic Fever, 107. Abuse of the word Rheumatism, 108. The Rheumatic Diathesis, 109. Age at which it occurs, 109. How characterized, 109. Organs liable to become affected, 110, Heart prone to be affected, 111. Cases of Heart-disease connected with the Rheumatic Diathesis, 112. Disease of the Heart frequently associated with Chorea, 115. The Co-existence of Chorea and Rheumatic Diathesis, 116. Note upon Dr. Bright's Cases of Spasmodic Disease connected with affections of the Pericardium, 116. Cardiac Inflammation may be primary, 117.

Section VII

Of the Rheumatic Paroxysm or Fever, 118. Order in which the Joints become affected, 119. The Cause of the Swelling of the Joints, 119. The Fever, 120. The Tongue, the Urine, 120. M. Becquerel's Observations on the Urine, 121. The Character of the Pulse, not sthenic, 121. The Blood, J 21. The Skin, 122. Nature of the Articular Affection, 123. Internal parts liable to be affected, 124. Heart most frequently affected, 124. Affection of the Brain, 125. Patients always liable to Rheumatic Fever after a single attack, 126. Rheumatic Diathesis hereditary, 127.

CONTENTS. Xin

Section VIII

Resemblanceof theltheumatic Diathesis andParoxysm to Blood-Diseases, 128. Puerperal Affections of the Joints difficult to distinguish from Rheumatic Fever, 130. Glanders, 132. Parts symmetrically affected, 133. Rheumatic Fever not symptomatic of Local Disorder, 134. Rheumatic Affection of the Joints different from ordinary Inflammation, 135. Occurrence of Inflammation of the Heart explained, 137. Distinction of Fibrous and Capsular Rheumatism groundless, 138. Characters of the Capsular Rheumatism of Dr. Macleod, 140. Nature of the Rheumatic Matter, 141. Theory of the Rheumatic Diathesis and Fever, 144. Dr. Proufs Views, 144.

Section IX

The unhealthy Secretion of the Uterus a source of Rheumatic Matter, 147. History of a Case in support of this Theory, 1 49. Dysmenorrhoea favourable for the production of unhealthy Secretions of the Uterus, which may contaminate the Blood, 153. Influence of the Chlorotic State upon healthy Sanguification, 154. General Proposition, 156. Dr. Rigby's Remarks relative to this subject, 158. Practical Conclusion, 161.

Section X

Chronic Rheumatism of the Joints, 162. Effects of the Rheumatic Diathesis or Paroxysm on the Joints, 162. Morbid Anatomy of the Joints xiv CONTENTS.

affected, 164. Of the Cartilaginous Bodies found in Rheumatic Joints, 166. The Ivory-like appearance of the Articular Surfaces the result of friction and pressure of the surfaces against each other, 167. These changes in the Joints not fairly attributable to ordinary Chronic Inflammation, 168. Chronic Rheumatism of the Joints a better name than Chronic Rheumatic Arthritis, 169. Researches of Sandifort, Adams, Smith, Cruveilhier, 170. Age at which it occurs, 171. Proofs of its Rheumatic nature, 173. Phenomena of the Disease in the Hip, 173. Phenomena of the Disease in the Hands, 177. Its uterine origin, 178. Cases, 178. Diagnosis from Gout, 181.

Section XI

Difficulties in the treatment of the Rheumatic Diathesis, 192. Rules for the treatment of it, 184. Local treatment of the Joints, 187. Formula for Iodine Paint, 187 Climate, 188. Berri Berri in India, note, 188. Thermal Springs, 189. Principles of the treatment of Rheumatic Fever, 190. Mean duration of the Fever, 190—1. Local treatment, 194. Treatment of the Heart affection, 197. Use of Mercury, 199. Use of Quinine, 201. Tests of the commencement of the period of convalescence,

202. The plan of treatment by large blood-lettings,

203. Bouillaud's Cases, 204. Dr. Macleod's treatment, 207. Dr. Seymour's treatment by Mistura

CONTENTS. xv

Guaiaci, note, 207. Conclusion respecting blood-letting, 208. Opinions of practical writers, note, 209. Does Bleeding favour determination to the Heart? 209. Treatment by Colchicum, 211. Treatment by Opium, Dr. Corrigans plan, 212. Treatment by Calomel and Opium, 2 J 3. Treatment of Chronic Rheumatism, 214.

ON GOUT, RHEUMATIC FEVER,

ETC.

Section I

IMPORTANCE OF STUDYING THE NATURAL HISTORY OP DISEASE, ILLUSTRATED BY REFERENCE TO TYPHUS, THE EXANTHEMATA, AND SYPHILIS— GOUT AND RHEUMATISM ARE BLOOD-DISEASES — DEFINITION OF BLOOD-DISEASES — EXAMPLES ILLUSTRATING THEIR GENERAL CHARACTERS — THE EXANTHEMATA — SYPHILIS

— GLANDERS — PURULENT INFECTION — LEAD CACHEXY

BRIGHT's DISEASE — DIABETES.

The careful study of the natural history of disease, ought always to be an object of paramount importance to physicians. To pursue it with advantage we should observe the natural progress that the various morbid processes make, when unaffected by disturbing causes. It is obvious that the most valuable inferences are deducible from a series of such observations. They would teach us, for instance, whether a given disease tends spontaneously to a fatal result, or to recovery; and what would be its ordinary duration, when not modified by the interference of art. The real state of the various functions, in such a morbid condition of the system, would more completely develop

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2 IMPORTANCE OF A KNOWLEDGE OF

itself, and we should thus be enabled to judge more precisely of the degree to which they may be modified, or changed, through the influence of the disease upon them. Lastly, we should be able to ascertain, with the utmost precision, what are the leading and pathognomonic symptoms of the disease.

Such observations must necessarily throw great light on the pathology and diagnosis of disease; and, indeed, modern improvements are entirely due to observations made in this spirit. They would also be especially useful in enabling us to form a correct judgment as to the real effects of the various remedies which experience or theory lead us to employ. For it must be confessed that there is nothing upon which the physician has often greater difficulty in making up his mind than as to the effects of remedies, and there is nothing upon which a greater discordance of opinion prevails. The whole controversy between the Homoeopath and the Allopath physicians, hinges upon a question as to the effects of certain drugs.

The former gravely tell us, that certain substances, which we are almost daily taking in large quantities without sensible effects, will, if administered to the sick in inconceivably minute doses, produce a manifest change in the

THE NATURAL HISTORY OF DISEASE. 3

actions of the animal economy; whereby morbid processes may be arrested, and disordered functions may be restored to their healthy play. But in a large proportion of the maladies so treated, their natural history shows that they tend spontaneously to a cure; and in the rest, the successful issue is more fairly to be attributed to a certain modification of diet, which indeed, although not flowing from their theory of therapeutics, constitutes the chief treatment of those who profess this system, and by which the causes of disease are often removed or counteracted.

On the other hand, most of the drugs, which the Allopath physician employs, produce obvious effects, when administered in various ways, and in appreciable doses. He knows that mercury salivates, aloes purges, opium causes sleep, in the healthy as well as in the sick. It is clear that the Allopathic mode of treatment must necessarily interfere, more or less, with the ordinary course of a disease, whether for good or for evil, whilst it seems scarcely possible to admit that the Homoeopathic plan, if deprived of its dietary, can do more than enable the conscientious practitioner to observe the natural history of disease, undisturbed by the interference of art.

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4 TYPHUS FEVER.

A brief reference to one or two diseases, will serve to illustrate my position, that a careful attention to the natural history of disease is one of the chief means of advancing medical knowledge, both as regards the diagnostic and the theraupeutic parts.

Let me mention first typhus fever. For how long a time this disease has been the subject of observation by physicians, and to how great an extent their views of it in successive periods were modified by the prevailing physiological doctrine of the day, are sufficiently known to those, even superficially acquainted with the history of medicine. The accumulated experience of years has now given us so great an insight into the natural course of the disease, that we may safely pronounce it to be thoroughly known in all its grades and phases. We know it to be a disease, occurring chiefly in an epidemic form, and restricted to certain limits of place, although apparently little influenced by atmospheric changes, or by local peculiarities. Its causes, therefore, are not in constant or universal operation ; but occur here and there, cease for a time, and recur, according to various circumstances. We know that those, who have intercourse with the sick, are liable to take it, and do suffer in considerable num-

TYPHUS FEVER. 5

bers; and that, by certain precautions, the liability to infection may be considerably diminished. It is also well ascertained that it runs a certain course, and in by far the majority of cases, if the patient's strength be sufficient to enable him to withstand the depressing influence of the morbid processes, it tends to a favourable termination. In the course of the disease, certain vital organs are liable to sympathize with the general system ; and the patient's danger is often greatly increased by the extent to which any of them may suffer.

In some instances the brain becomes affected, and, although organic change in this organ is rare as a consequence of typhus, yet its functions become so impaired, that delirium, or stupor, or coma may be present, complicating and obscuring the other phenomena. Or the bowels may suffer, a complication which, although less formidable in appearance, is yet more serious in reality. We have learned, moreover, that this disease, in its various epidemics, presents much diversity as regards the character and violence of its symptoms, and its fatality to the sufferers. We know that the young and middle-aged are most obnoxious to it ; and it seems also well ascertained, that a person

6 TYPHUS FEVER.

who has once suffered from it, derives, from that first attack, a certain amount of protection against a second.

It is almost self-evident that a disease, to which such a history is applicable, cannot be the result of a mere local inflammation. The anatomical examinations of persons who have died of this malady, prove beyond all question, that no one organ is constantly affected : that frequently all the internal organs are devoid of every appearance of disease, and that the morbid changes which are oftenest met with, are to be regarded as its consequences, rather than as its causes.

In short the concurrent testimony of all physicians, who have carefully studied the phenomena of this disease, unbiassed by pre-conceived theories, confirms, in the strongest manner, the definition of fever long ago given by Fordyce. " Fever," says he, " is a disease which affects the whole system ; it affects the head, trunk, and extremities ; it affects the circulation, absorption, and the nervous system ; it affects the body ; it affects the mind ; it is, therefore, a disease of the whole system in the fullest sense of the term. It does not, however, affect the various parts of the system uniformly and equally, but on the contrary,

TYPHUS FEVER. 7

sometimes one part is more affected than another*."

The good effects of this knowledge of the natural history of typhus fever, are very manifest in the improvement that has taken place in both its prophylaxis and treatment. For the former object, our knowledge of the mode of propagation of the disease, has evidently suggested means to prevent its extension among individuals, or communities; which, wherever they have been carried into effect, have been attended with the best results. And in the treatment, we find that now the diligence of the physician is manifested, not in the administration of drugs, but in watching symptoms as they arise, with a view to interference where necessary; and in carefully estimating the power of the patient to bear up against the depressing influence of the morbid action. Dr. Graves, in his valuable work on Clinical Medicine, lately published, states the remarkable fact, that in the epidemics which raged in Ireland in the years 1816, 17, 18, and 19, it was found by accurate computation, that the rate of mortality was much higher among the rich than among the poor. " Since that period," he adds, " our

* Quoted in Dr. Graves' Clinical Medicine.

8 THE EXANTHEMATA.

practice has greatly improved, and things are much changed ; the preponderance of fatal cases is now to be found among the poor; and the mortality among the rich, or those who have proper medical advice from the commencement, is not one-third of that which is found among the indigent, who are generally neglected at the commencement of the disease." We have further evidence of the good effects of the study of the natural history of disease in our improved knowledge of the exanthemata. Who, now-a-days, would attempt to cut short an attack of small- pox or of measles? No one, surely, who was aware how fixed and determinate are the laws which influence the origin and course of these maladies. We know that they are propagated by contagion — that the poison, when introduced into the system, ere long shows its power in the premonitory fever ; this is relieved by the eruption, which has its periods of maturation and decay ; and the object of the practitioner must ever be, in these diseases, to pilot his patient safely through their various stages, and to guard him from the many dangerous complications which may arise in their course. As well might we think of hastening the progress of the eruptive phenomena in cases

SYPHILIS. 9

where vaccination had been practised, as of cutting short one of the exanthemata. An extensive range of observations and experiments has proved, beyond all question, that mercury, opium, or prussic acid, are not more definite in their action on the animal oeconomy, than the respective poisons of these exanthematous diseases. And here, too, modern practice, guided by a knowledge of the natural history of these diseases, is characterized by the absence of the nimia medici diligentia, and the substitution of a careful watching of phenomena for the officious interference with morbid processes.

In like manner the investigation of the natural history of syphilitic diseases, has led to a much more exact knowledge of those affections than was formerly possessed, and has consequently contributed much to the improved state of modern practice. The routine practice, which used to prevail, of giving mercury in every grade and variety of syphilis, greatly interfered with our obtaining an intimate acquaintance with its natural course, and practitioners were much perplexed to discriminate between the phenomena that were strictly referable to the influence of the venereal poison, and those which were to be attributed

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10 SYPHILIS.

to mercury, or to the combined influence of that mineral and syphilis. It must be confessed that the introduction of the non-mercurial mode of treatment, whatever be its real value for the permanent cure of the disease, has paved the way to a much more rational practice, and has been the means of assigning to mercury its real value as a curative agent, as well as of exonerating it from many heavy charges which its opponents had laid at its door.

On the other hand, it might easily be shown that ignorance of the natural history of disease must lead to endless mistakes in practice. This is particularly striking, when we consider how much men differ as regards their modes of practice even in the same disease, and how highly one man will estimate a remedy, to which another, of not less experience, attaches little or no value. A careful investigation of the natural history of the disease would decide between these discordant opinions, and discriminate what may be ascribed to the natural course of the malady, and what to the course of treatment pursued. The cures for epilepsy are innumerable ; but the natural history of epilepsy tells us that a large number of cases depend on trivial causes, which may be easily

OBJECT OF THE LECTURES. 11

removed, and which sometimes disappear of their own accord, so that almost any remedy may readily acquire a reputation as a means of cure.

These reflections were excited, as I sought to explain the discordance which prevails in the opinions and practice of physicians in reference to two maladies of frequent occurrence, namely, gout and rheumatic fever. Upon neither the nature nor the proper mode of treatment of either of these maladies, but more especially of the latter, can it be said that the views of medical men coincide. We can scarcely ascribe this disagreement of opinion to absolute ignorance of the natural history of these diseases, for they have been long the subjects of close and careful observation ; and the descriptions of the older physicians have not been surpassed by the longioris cevi diligentia. The true cause of the difference seems to consist in an imperfect analysis of their natural history, so that we still stand in need of a careful induction from the facts with which the observations of practical physicians have supplied us, in connexion with the improved state of our knowledge of the phenomena of nutrition in its normal state.

I propose in the present lectures to attempt

12 BLOOD-DISEASES.

to supply this defect, and to offer some comments on the mode of practice in these diseases which have been suggested to me by my own experience.

For the sake of brevity, it will be necessary for me to anticipate the conclusion to which my argument tends, and to affirm, that rheumatic fever and gout are diseases of the blood, a class of maladies which modern pathology has at length enabled us to rescue from the unmerited oblivion into which they had sunk, by reason of the long reign of an exclusive solidism. I believe the phenomena of these diseases to be entirely due to the presence of a morbid element in the blood, generated within it under the influence of particular causes.

It will be advisable that I should give some description of the characters of blood-diseases.

But before proceeding to do so, let me, in order to prevent misunderstanding, separate from blood-diseases those which, originating in some local taint of nutrition, are disseminated by the blood to other and even distant parts of the body. The whole class of malignant diseases may be referred to this category; cancer, fungoid disease, &c, originate in a local derangement of nutrition, as in the stomach, the

BLOOD-DISEASES. 13

lip, the penis, &c, where the peculiar cancercells are first formed. If the local malady be within reach of the surgeon's knife, and can be removed early, the best chance is afforded to the patient of being rescued from its reappearing in some other place ; but if, as is too often the case, the diseased part has been allowed to remain too long, the peculiar cancerous matter makes its way into the blood, and is carried along in the current of the circulation to other organs, where they become the nuclei of new cancerous formations. Such maladies afford examples of diseases of the solids extended and disseminated through the fluids, and serve to demonstrate very strikingly how prejudicial to a sound pathology are exclusive opinions, whether they refer to the solids or to the fluids.

We must also separate those diseases which appear to arise from the deficiency of some element which forms a necessary constituent of the blood, such as purpura, scurvy, and certain states of body characterized by an anaemic condition.

In what I would call the true blood-diseases, a morbid matter is generated by an abnormal chemical action in the blood itself. The morbid element may be formed primarily in the blood, in consequence of some check to one or

14 CHARACTERS OF BLOOD-DISEASES.

more of the ordinary excretions, or from the supply of nutrient material to the blood being too great for the rate at which excretion is carried on ; or it may have been introduced into the blood as a poison, which speedily deranges the normal changes that are continually going on within it. In this last way all contagious diseases are propagated, the matter of contagion having been introduced into the blood ; malarious diseases are also referable to this cause. To either or both of the former causes, I hope to be able to show, that rheumatism and gout are attributable.

All true blood-diseases, whatever their primitive cause may be, exhibit certain characters in common. In all of them we find a greater or less degree of febrile disturbance at an early stage, and this is frequently preceded by a stage of depression and of rigor. Pains in the limbs, or in the joints, sometimes attended with swelling of the latter, and inability to move them freely in consequence of effusions into them, are very commonly met with. The cutaneous function is more or less disturbed, and this disturbance manifests itself either in a harsh, dry, and burning hot skin, or in a profuse perspiration, sometimes exhaling a disagreeable sour odour, or in a cutaneous eruption belong-

CHARACTERS OF BLOOD-DISEASES. 15

ing to one of the multifarious forms which those diseases are prone to assume. The secretions of the liver and the kidney often appear unnatural, the former being too great in quantity or altered in quality; the latter frequently rather diminished than increased, of a high colour, and depositing a brick-dust sediment in greater or less quantity. In some instances internal organs do not escape, but become the seat of an irritation which may entail very serious consequences. Those morbid matters which are introduced from without, and even some of those primarily generated in the blood, are very prone to fix themselves upon particular parts to the exclusion of others, and sometimes the life of the patient is endangered by the destructive influence of such poisonous matter upon the affected organs. As soon as the morbid matter has been eliminated from the system, these symptoms subside, and the organs affected resume their natural state.

To guard myself against the imputation of having stated merely speculative notions, I shall refer briefly to the phenomena of some diseases which are admitted on all hands to arise from the presence of a morbid matter in the blood. In the exanthemata, for instance, we find completely manifest the train of symp-

16 EXAMPLES OF BLOOD-DISEASES.

toms I have enumerated. Fever, pains in the limbs, sometimes affecting the joints, skin eruptions, local affections from the fixation of the poisonous matter in particular parts, as in scarlet fever, the sore throat ; in measles, the pulmonary affection. In syphilis, the poison at first seems limited in its effects to the part through which it was introduced into the system ; but by and by, as it infects the blood more completely, febrile symptoms, sore throat, cutaneous eruptions, pains and swellings of the joints, affections of the eye, show themselves, and often to a fearful extent. And nothing is more remarkable in the natural history of syphilis than the great variety of the eruptions which develope themselves upon the skin. So various are these eruptions, and so frequently do particular groups of symptoms associate themselves with particular forms of them, that Mr. Carmichael was led to advance the ingenious doctrine of a plurality of venereal poisons. The poison of gonorrhoea, too, produces analogous effects, and it is often extremely difficult to cure that severe affection of the joints which, as a secondary consequence of gonorrhoea, is known by the name of gonorrhoeal rheumatism. Several examples are now on record of a disease produced in the human subject by the

EXAMPLES OF BLOOD-DISEASES. 17

accidental inoculation of the morbid secretion from a glandered horse. "Acute glanders in the human subject," says Dr. Williams, " is ushered in by an attack of primary fever, with or without rigors. This is followed by pains in the limbs so severe as often to be mistaken for an attack of acute rheumatism." Abscesses occur in various parts of the body. An eruption of pustules occurs on the face, trunk, limbs, and genital organs. This eruption is preceded and accompanied with profuse foetid sweats.

Let me, by way of illustration, quote a well-stated case from Dr. Williams' able work on morbid poisons.

William Johnson, aetat. 23, was admitted on the 31st of January, 1833, into St. Thomas's Hospital, under the care of Dr. Williams. This patient complained of tightness across the chest, and of pains in the right side and loins, in consequence, as he imagined, of a fall from a horse about three months before. He had also much thirst, a tongue coated with yellow mucus, and a pulse about 90. These symptoms had nothing characteristic, but as the disease advanced, they assumed a peculiarity which caused them to be watched with much anxiety, for without any considerable fever, he

18 GLANDERS.

became incoherent in his answers, and his tongue was tremulous. On the 10th Feb. he was seized with an attack of delirium so furious, that it was necessary to strap him to the bed. He was still, however, capable of giving some account of himself, and complained of gnawing pains in all his limbs, of great difficulty in moving his left arm, every joint of which was painful, and the knuckle of the fore-finger and hand was red, swollen, and painful. There was also a profuse, sour, and offensive perspiration. The disease was now considered to be an attack of acute rheumatism. On the 14th, however, an offensive yellow discharge took place from the right nostril, and a large swelling arose in the middle of the forehead of a purplish hue, and the left eye was nearly closed, and numerous tumefactions took place on the arms and legs, while several phlyzacious pustules were seen on the left side of the neck. The man was now questioned as to his occupation, when he stated that he had been grooming a glandered horse, kept in a stable by itself, and that he remembered the discharge from the nostril had frequently fallen upon his hand, where the scar of a wound was still visible. * * * * On the following day, the 15th, the whole scalp had become tumefied, the forehead purplish,

GLANDERS — PURULENT INFECTION. 19

the eyelids red and shining, the sensation in his throat and nostrils was burning, his thirst intense, and more tumefactions appeared on the extremities and abdomen, while several phlyzacious postules were seen on the left side of the neck. * * * * On the 17th he died.

When the blood is infected with pus, in consequence of its formation in a vein after phlebitis, or by any other means, a train of phenomena very similar to those I have detailed occurs in consequence of this poisonous material being carried to every part of the body in the circulating fluid. It is well known that these serious effects often follow great surgical operations, injuries of the head, or compound fractures, also idiopathic inflammation of a vein, as in some cases on record of inflammation of a sinus of the dura mater ; and I have seen them consequent on the bursting of an abscess, which formed in the septum of the heart. There seems now to be little doubt that at least some forms of puerperal fever may be due to a vitiated state of the blood produced through the uterine veins. In all these instances, pus or other morbific agents formed in, or introduced into the veins, may be carried to every organ.